The Apgar score is a number assigned to a baby right after birth to help the medical team quickly assess the baby’s health. The score is used to help indicate how likely it is that the newborn will need medical intervention.
- Scores of 7+ are typically considered normal (but not always).
- Scores of 4 – 6 are below normal. A low score means the baby will likely need medical intervention, which may include resuscitation. The lower the score, the more alert the team should be to the possibility of intervention.
- Scores of 1 – 3 are critically low.
How is Apgar score determined?
A member of the medical team quickly examines the baby and assigns numbers for the different Apgar criteria, so some of the numbers can be largely based on opinion and therefore may not accurately reflect the health of the baby. There certainly are cases in which a baby has a high score but needs urgent medical treatment nonetheless due to birth asphyxia or other birth injuries. In spite of the subjectivity of the Apgar score, however, hospitals universally use it.
The five factors used to determine the baby’s Apgar score are:
- Appearance/complexion: Is the baby’s body blue or pale all over, blue at the extremities, or entirely pink?
- Pulse rate: Is the baby’s heart rate absent, slow (<100 beats per minute [bpm]) or fast (>100 bpm)?
- Reflex irritability: Does the baby have no response to stimulation, does the baby grimace and cry feebly, or does the baby cry and pull away when stimulated?
- Activity: Does the baby exhibit no activity, have some flexion (joint movement), or have flexed arms and legs that resist extension?
- Respiratory effort: Is the baby breathing, does the baby have a weak, irregular respiratory effort, or is the baby’s cry really strong?
Apgar score assessment is typically done at one and five minutes after birth and may be repeated later if the score remains low. If the score is low at ten, fifteen, or thirty minutes after birth, there is a significant risk that the baby will suffer long-term brain damage. There is also a significant increase in the risk of the child having cerebral palsy. Higher Apgar scores, however, do not rule out the possibility that the newborn may have a brain injury such as hypoxic-ischemic encephalopathy (HIE). It is important to note that the purpose of the Apgar score is to quickly determine whether a baby needs immediate medical attention; the Apgar score was not devised to make long-term predictions about the newborn’s health.
What Can Cause a Low Apgar Score?
Listed below are events that can occur during or near the time of birth that, if mismanaged, can cause newborns to have low Apgar scores. It is important to note that these conditions can injure a baby even without causing low Apgar scores.
- Umbilical cord problems, such as a prolapsed cord (cord exits in front of the baby and the baby’s body impinges on it), nuchal cord (cord is wrapped around the baby’s neck), short umbilical cord, or true knot.
- Placental abruption (when part or all of the placenta tears away from the uterus).
- Uterine rupture (when the wall of the uterus tears open).
- Trauma to the baby’s head and intracranial hemorrhages (brain bleeds) can occur if forceps or vacuum extractors are used to help deliver the baby. Also, macrosomia (large baby), cephalopelvic disproportion (mother’s pelvis is too small for the size of the baby), a malpositioned baby (such as breech or face presentation), or the shoulder getting stuck on the mother’s pelvic bone (shoulder dystocia) all increase the likelihood of head trauma and brain bleeds during delivery.
- Excessive uterine activity (hyperstimulation) can occur when Pitocin or Cytotec are used during labor; the medication can cause very strong and frequent contractions that deprive the baby of oxygen.
- Improperly treated maternal infections, such as chorioamnionitis, Group B Strep (GBS) and herpes simplex virus (HSV). Premature rupture of the membranes (PROM) can cause a maternal infection to travel to the baby at birth and can also cause preterm birth.
- Severe preeclampsia (high maternal blood pressure).
- Anesthesia mistakes can cause the mother’s blood pressure to get really low, causing a decrease in the amount of oxygen-rich blood going to the baby.
- Delayed emergency C-section when fetal distress is evident on the fetal heart monitor.
- Oligohydramnios (low amniotic fluid)
- Premature birth, which puts a baby at risk of having brain bleeds, respiratory distress, and other significant problems at birth.
- Amniotic fluid embolism, which is a condition in which amniotic fluid, fetal cells, or other debris enters the mother’s bloodstream. This triggers an allergic reaction, causing cardiorespiratory collapse in the mother, which in turn causes rapid deterioration of the baby).
Conditions that Cause Low Apgar Scores Can Indicate the Presence of Birth Injury
Birth injuries are injuries in a baby caused by an event that occurs during or near the time of delivery. A lack of oxygen to the baby’s brain (birth asphyxia) is the most common cause of birth injuries. Birth injuries and birth trauma are associated with permanent brain damage and conditions such as the following:
- Hypoxic-ischemic encephalopathy (HIE)
- Neonatal encephalopathy (NE)
- Periventricular leukomalacia (PVL – usually seen in premature babies)
- Hydrocephalus (fluid in the brain)
- Intracranial hemorrhage, intraventricular hemorrhage (brain bleeds)
- Seizure disorder
- Cerebral palsy
A common birth injury that does not involve the brain is called a brachial plexus injury or Erb’s palsy. This occurs when the baby’s shoulder gets caught on the mother’s pelvis during delivery and the physician applies too much force to the baby’s head in an attempt to remove her from the birth canal. Excessive force can cause the baby’s nerves to stretch or tear, resulting in extreme weakness or paralysis of the affected arm. Sometimes the baby is stuck for too long in the birth canal, causing head trauma, brain bleeds and/or oxygen deprivation and HIE.
Reiter & Walsh, P.C. | Legal Advocates for Children with Birth Injuries
The nationally-recognized birth injury lawyers at Reiter & Walsh ABC Law Centers have been helping children with birth injuries and cerebral palsy throughout the nation for almost 3 decades. Our firm is unique in that we focus solely on birth injury law. Reiter & Walsh ABC Law Centers is currently recognized as being one of the best medical malpractice law firms in the nation by U.S. News and World Report, and the partners of the firm, Jesse Reiter and Rebecca Walsh, were recently recognized as being two of the best medical malpractice lawyers in America by U.S. News and World Report. In fact, U.S. News and World Report has given Jesse the honor of being one of the “Best Lawyers in America” every year since 2008.
Birth injury is a difficult area of law to pursue due to the complex nature of the medical records. The birth injury lawyers at Reiter & Walsh have decades of experience with birth injury, hypoxic-ischemic encephalopathy and cerebral palsy cases. To find out if you have a case, contact our firm to speak with one of our award-winning birth injury attorneys. We have numerous multi-million dollar verdicts and settlements that attest to our success, and no fees are ever paid to our firm until we win your case. Email or call us at 888-419-2229. Our firm’s attorneys are available 24/7 to speak with you.
Free Case Review | Available 24/7 | No Fee Until We Win