Apgar score

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Apgar score
Virginia Apgar.jpg
Virginia Apgar, creator of the Apgar score

The Apgar score is a quick way for doctors to evaluate the health of all newborns at 1 and 5 minutes after birth and in response to resuscitation.[1] It was originally developed in 1952 by an anesthesiologist at Columbia University, Virginia Apgar, as way to address the need for a standardized way to evaluate infants shortly after birth.[2]

Today, the categories developed by Apgar used to assess the health of a newborn remain largely the same as in 1952, though the way they are implemented and used has evolved over the years.[3] The score is determined through the evaluation of the newborn in five criteria: activity (tone), pulse, grimace, appearance, and respiration. For each criterion, newborns can receive a score from 0 to 2.[1][3][4] The list of criteria is a backronym of Apgar's surname.

History and development of the Apgar score[edit]

Apgar originally thought up the criteria as way to address the lack of a standardized way to assess the need for assistive breathing procedures for newborns. In 1952, after some refinement of her initial system, Apgar presented the Apgar score at a joint meeting between the International Anesthesia Research Society (IARS) and the International College of Anesthetist, and it was then published in Anesthesia and Analgesia in 1953.[2]

In 1955, efforts to establish a scientific basis to the score increased. Alongside Duncan Holaday and Stanley James,[2] Apgar published a research paper using the scores of 15,348 infants to establish the association between a low Apgar score (0-2) and laboratory findings characteristics of asphyxia.[5]

As previously mentioned, in its infancy the Apgar score was developed to be used on newborns at 1 minute after birth. However, today the Apgar score is not utilized as a way to determine the need for newborn resuscitation because supportive measures must be implemented prior to 1 minute after birth.[4]

Today, the Apgar score is a method of assessment endorsed by the American College of Obstetricians and Gynecologist and the American Academy of Pediatrics.[3]


The five criteria of the Apgar score:[4]
Score of 0 Score of 1 Score of 2 Component of backronym
Skin color blue or pale all over blue at extremities,
body pink
no cyanosis
body and extremities pink
Pulse rate absent < 100 beats per minute ≥ 100 beats per minute Pulse
Reflex irritability grimace no response to stimulation grimace on suction or aggressive stimulation cry on stimulation Grimace
Muscle Tone none some flexion flexed arms and legs that resist extension Activity
Respiratory effort absent weak, irregular, gasping strong, robust cry Respiration

Interpretation of scores[edit]

Mind map showing summary for the Apgar score

Various members of the healthcare team, including midwives, nurses, or physicians, may be involved in the Apgar scoring of a neonate.[3] The test is generally done at one and five minutes after birth and may be repeated later if the score is and remains low. Scores of seven and above are generally normal; four to six, fairly low; and three and below are generally regarded as critically low and cause for immediate resuscitative efforts.[6]

A low score on the one-minute mark may show that the neonate requires medical attention,[7] but does not necessarily indicate a long-term problem, particularly if the score improves at the five-minute mark. A constellation of factors may contribute to a low Apgar score value.[8] An Apgar score that remains below three at five minutes and later times, such as 10, 15, or 30 minutes, does not provide supporting evidence for a specific illness but can sometimes be among the first indicators of neonatal encephalopathy.[8][6][9] However, the Apgar test's purpose is to determine quickly whether or not a newborn needs immediate medical care. It is not designed to predict long-term health issues.[10]

A score of 10 is uncommon, due to the prevalence of transient cyanosis, and does not substantially differ from a score of nine. Transient cyanosis is common, particularly in babies born at high altitude.[11]

Implementation of scores[edit]

In cases where a newborn needs resuscitation, it should be initiated before the Apgar score is assigned at the one-minute mark. Therefore, the Apgar score is not used to determine if initial resuscitation is needed, rather it is used to determine if resuscitation efforts should be continued. Variation between the one-minute and five-minute Apgar scores can be used to assess an infant's response to resuscitation. If the score is below seven at the five-minute mark, the Neonatal Resuscitation Program guidelines specify that the infant's Apgar score should be reassessed at five-minute intervals for up to 20 minutes.[4]

Exceedingly few infants who have an Apgar score of 0 at 10 minutes of age survive with intact neurological function. As a result, the 2011 Neonatal Resuscitation Program suggests that if no pulse is appreciable at 10 minutes of life, neonatal resuscitation may be terminated.[6] However, in a recent study including 17 infants with an Apgar score of 0 at 10 minutes who received therapeutic hypothermia, 41% showed no evidence neurological abnormalities on brain MRI scan.[12] Therefore, the decision of whether or not resuscitation efforts should continue beyond 10 minutes should be decided on a case-by-case basis.

During neonatal resuscitation, Apgar scores may not accurately represent the condition of the neonate as resuscitation measures (i.e. positive pressure ventilation and chest compressions) may artificially elevate scores. As a result, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage the use of an expanded Apgar score report, which records resuscitation efforts utilized at each time point.[6]

A systematic review that analyzed the relationship between umbilical cord pH and neonatal outcomes found that low cord pH is strongly correlated with mortality, morbidity and cerebral palsy in childhood.[13] To reduce the risk of negative outcomes, it is recommended to obtain a sample of the umbilical artery blood gas when a newborn has an Apgar score of five or less at the five-minute mark.[4]

Newborn crying right after birth

Recognizing the importance of skin to skin contact (SSC), the World Health Organization (WHO), as part of the Baby Friendly Hospital Initiative, recommends that the Apgar score should be done while SSC is underway whenever possible.[14] This recommendation was adopted by the American Academy of Pediatrics in 2009.[14]


There are numerous factors that contribute to the Apgar score, several of which are subjective. Examples of subjective factors include but are not limited to color, tone, and reflex irritability.[15] Preterm infants may receive a lower score in these categories due to lack of maturity rather than asphyxia. Other factors that may contribute to variability among infants are birth defects, sedation of the mother during labor, gestational age or trauma. Inappropriately using the Apgar score has led to errors in diagnosing asphyxia.[4]

Various studies have shown that the Apgar score has variability between individual medical providers. A study was done in which health care providers were assigned to give Apgar scores to a group of infants.[16] Results showed that health care provider had a consistency of 55% to 82% when it came to assigning scores when compared with one another.[16][17] Ideally, to limit variability and bolster consistency, it is preferred that the same individual determine the 1-minute and 5-minute Apgar scores.[3]


Some ten years after initial publication,[18][citation needed] a backronym for APGAR was coined in the United States as a mnemonic learning aid: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration.

  • Spanish: Apariencia, Pulso, Gesticulación, Actividad, Respiración;
  • Portuguese: Aparência, Pulso, Gesticulação, Atividade, Respiração;
  • French: Apparence, Pouls, Grimace, Activité, Respiration;
  • German: Atmung, Puls, Grundtonus, Aussehen, Reflexe, representing the same tests but in a different order (respiration, pulse, muscle tone, appearance, reflex).
  • Czech: Adaptace kůže, Pulz, Grimasy, Aktivita svalů, Respirace;[19]

Another eponymous backronym from Virginia Apgar's name is American Pediatric Gross Assessment Record.

Another mnemonic for the test is "How Ready Is This Child?", which summarizes the test criteria as Heart rate, Respiratory effort, Irritability, Tone, and Color.[20]

See also[edit]


  1. ^ a b "The Apgar Score". www.acog.org. Retrieved 2021-09-10.
  2. ^ a b c Calmes, Selma H. (May 2015). "Dr. Virginia Apgar and the Apgar Score: How the Apgar Score Came to Be". Anesthesia & Analgesia. 120 (5): 1060–1064. doi:10.1213/ANE.0000000000000659. ISSN 0003-2999. PMID 25899273. S2CID 41296774.
  3. ^ a b c d e Simon, Leslie V.; Hashmi, Muhammad F.; Bragg, Bradley N. (2021), "APGAR Score", StatPearls, Treasure Island, Florida: StatPearls Publishing, PMID 29262097, retrieved 2021-09-10
  4. ^ a b c d e f "The Apgar Score". www.acog.org. Retrieved 2019-08-01.
  5. ^ Apgar, Virginia (1958-12-13). "Evaluation of the Newborn Infant-Second Report". Journal of the American Medical Association. 168 (15): 1985–1988. doi:10.1001/jama.1958.03000150027007. ISSN 0002-9955. PMID 13598635.
  6. ^ a b c d Newborn, American Academy of Pediatrics Committee on Fetus And; Practice, American College of Obstetricians and Gynecologists Committee on Obstetric (2015-10-01). "The Apgar Score". Pediatrics. 136 (4): 819–822. doi:10.1542/peds.2015-2651. ISSN 0031-4005. PMID 26416932. S2CID 31689176.
  7. ^ Casey BM, McIntire DD, Leveno KJ (February 2001). "The continuing value of the Apgar score for the assessment of newborn infants". The New England Journal of Medicine. 344 (7): 467–71. doi:10.1056/NEJM200102153440701. PMID 11172187.
  8. ^ a b Pediatrics, American Academy of (2014-05-01). "Neonatal Encephalopathy and Neurologic Outcome, Second EditionReport of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy". Pediatrics. 133 (5): e1482–e1488. doi:10.1542/peds.2014-0724. ISSN 0031-4005.
  9. ^ Care of the baby and woman immediately after birth. National Institute for Health and Care Excellence (UK). December 2014.
  10. ^ Apgar V (1953). "A proposal for a new method of evaluation of the newborn infant" (PDF). Current Researches in Anesthesia & Analgesia. 32 (4): 260–7. doi:10.1213/00000539-195301000-00041. PMID 13083014.
  11. ^ Gonzales GF, Salirrosas A (September 2005). "Arterial oxygen saturation in healthy newborns delivered at term in Cerro de Pasco (4340 m) and Lima (150 m)". Reproductive Biology and Endocrinology. 3: 46. doi:10.1186/1477-7827-3-46. PMC 1215518. PMID 16156890.
  12. ^ Ayrapetyan, Marina; Talekar, Kiran; Schwabenbauer, Kathleen; Carola, David; Solarin, Kolawole; McElwee, Dorothy; Adeniyi-Jones, Susan; Greenspan, Jay; Aghai, Zubair H. (April 2019). "Apgar Scores at 10 Minutes and Outcomes in Term and Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era". American Journal of Perinatology. 36 (5): 545–554. doi:10.1055/s-0038-1670637. ISSN 0735-1631. PMC 8039809. PMID 30208498.
  13. ^ Malin GL, Morris RK, Khan KS (May 2010). "Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis". BMJ. 340 (may13 1): c1471. doi:10.1136/bmj.c1471. PMC 2869402. PMID 20466789.
  14. ^ a b Feldman-Winter, Lori; Goldsmith, Jay P.; Newborn, Committee on Fetus And; Syndrome, Task Force on Sudden Infant Death (2016-09-01). "Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns". Pediatrics. 138 (3): e20161889. doi:10.1542/peds.2016-1889. ISSN 0031-4005. PMID 27550975. S2CID 19866683.
  15. ^ "Apgar score: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2022-11-18.
  16. ^ a b Montgomery, Kristen S. (2000). "Apgar Scores: Examining the Long-term Significance". The Journal of Perinatal Education. 9 (3): 5–9. doi:10.1624/105812400X87716. ISSN 1058-1243. PMC 1595023. PMID 17273212.
  17. ^ Livingston, Jacquelynn (1990-11-01). "Interrater reliability of the apgar score in term and premature infants". Applied Nursing Research. 3 (4): 164–165. doi:10.1016/S0897-1897(05)80139-9. ISSN 0897-1897. PMID 2252404.
  18. ^ "What Is a Good Apgar Score?". Cleveland Clinic. Retrieved 2022-11-18.
  19. ^ "Co je to APGAR skóre a kdo ho vymyslel?". www.maminka.cz (in Czech). Retrieved 2020-01-12.
  20. ^ Klostranec JM, Hong J, Raghuran K (2012). The Essential Med Notes for Medical Students. Toronto, ON: University of Toronto Press.

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