Apgar Score for Newborn Health Assessment

What Is An Apgar Score?

The Apgar score is a simple method of quickly assessing the health and vital signs of a newborn baby. It was created by Dr. Virginia Apgar in 1952.

Crying newborn baby in the hands of a doctor.

What Does APGAR Stand For, And What Does It Measure?

Apgar stands for Appearance, Pulse, Grimace, Activity, and Respiration. Medical teams use this scoring system to make sure babies are healthy right after birth. Each category is score 0, 1, or 2 points, and the total is the Apgar score. A low score ay indicate the baby requires medical intervention.

A – Appearance (skin color)

This is an evaluation of the baby’s skin color. The medical team measures if the baby is blue or pale all over (0 points), blue at the extremities (1 point), or pink all over (2 points).

P – Pulse (heart rate)

During this evaluation, the medical team measures the baby’s heart rate. An absent heart rate scores 0 points. A slow heart rate of less than 100 beats per minute (bpm) scores 1 point. A fast heart rate of more than 100 bpm is considered normal and scores 2 points.

G – Grimace (reflex irritability/response)

To evaluate this category, the medical team checks if the baby lacks a response to stimulation (0 points), responds with a grimace (1 point), or responds by crying and pulling away (2 points).

A – Activity (muscle tone)

During this evaluation, the medical team asks if the baby is limp (0 points), if the baby has some joint movement (1 point), or if the baby shows active motion (2 points).

R – Respiration (breathing ability)

During this step, the medical team asks if the baby is failing to breathe (0 points), if the baby has a weak cry and slow breathing (1 point), or if the baby is breathing well and crying normally (2 points). A baby that has trouble breathing may show signs of respiratory distress syndrome (RDS).

A table showing how the APGAR test is scored.

What Do Apgar Scores Mean?

  • Apgar scores of 0-3 are critically low, especially in term and late-preterm infants
  • Apgar scores of 4-6 are below normal, and indicate that the baby likely requires medical intervention
  • Apgar scores of 7+ are considered normal 

The lower the Apgar score, the more alert the medical team should be to the possibility of the baby requiring intervention. For example, a baby with a low score is more likely than a baby with a high score to need resuscitation (however, it is important to note that in certain cases, resuscitation must be initiated prior to determining the Apgar score).  Some components of the Apgar score are subjective, and there are cases in which a baby requires urgent medical treatment despite having a high Apgar score.

A low one-minute Apgar score immediately after birth may not indicate that the baby will have long-term health complications (1). However, there is evidence to suggest that infants whose Apgar scores remain low at five minutes or later are much more likely to suffer long-term neurological damage. For example, a 2018 study in Sweden found that babies with lower Apgar scores at 5 and 10 minutes were at greater risk for developing cerebral palsy (CP) and seizure disorders, such as epilepsy. A separate 2018 study in the Journal of Clinical Sciences found a significantly increased risk of cerebral palsy in infants who had low Apgar scores at the five-minute mark. This was especially true of children born at a normal birth weight.

Higher Apgar scores, however, do not rule out the possibility that the baby has a brain injury, such as hypoxic-ischemic encephalopathy (HIE). In these cases, physicians must recognize other signs and symptoms of injury and treat them quickly and appropriately.

When Is Apgar Testing Done?

Apgar testing is typically done at one and five minutes after a baby is born, and it may be repeated at 10, 15, and 20 minutes if the score is low. The five criteria are each scored as 0, 1, or 2 (two being the best), and the total score is calculated by then adding the five values obtained.

Doctor using stethoscope on baby.

What Can Cause Low Apgar Scores?

A wide range of pregnancy and birth-related complications can result in low Apgar scores. Importantly, babies who have been deprived of oxygen often perform poorly on the Apgar test (although higher scores do not necessarily indicate a lack of oxygen-deprivation). Listed below are a few of the complications that can cause a baby to become oxygen-deprived, and may manifest in low Apgar scores:

When a child has a brain injury such as HIE or cerebral palsy, it is imperative that experts rely on objective scientific methods and direct observation to determine if the child was exposed to damaging hypoxia/asphyxia around the time of birth. Clinical markers should be examined and all possibilities of causes explored so that the cause and timing of the brain injury can be pinpointed.

What Happens If My Baby Has a Low Apgar Score?

Some babies with low Apgar scores at birth go on to be perfectly healthy, although they likely require medical intervention shortly after birth (1). Oftentimes, infants with low Apgar scores or other risk factors will be moved to the neonatal intensive care unit (NICU) in order to receive appropriate care. Common medical interventions for newborns with low Apgar scores may include resuscitation, hypothermia therapy (in cases of HIE), or other preventative treatments.

Does a Low Apgar Score Mean Medical Malpractice Occurred?

A low Apgar score does not necessarily mean that medical malpractice occurred. In many circumstances, however, low Apgar scores are associated with birth injury, which may have stemmed from medical malpractice. In addition, if physicians fail to act on low Apgar scores and provide the appropriate treatments, this may be considered negligence. If injury occurs as a result of this negligence, it is medical malpractice.

What Is An Assisted Apgar Score?

Apgar scores assigned during resuscitation cannot accurately be compared to scores from infants who are breathing spontaneously, because the resuscitation will change the variables under consideration.

In such cases, an “assisted” Apgar score must be used to take into account the resuscitation. The American College of Obstetricians and Gynecologists (ACOG) recognizes this concept and recommends using an “expanded Apgar score report form.”

How Was The Apgar Test Developed?

At the time Dr. Virginia Apgar began her career, women had great difficulty entering the field of medicine. As Erin Blakemore noted in a piece for Time Magazine, “Women who did attain a medical degree were often shunted into obscure specialties or discouraged by their male colleagues, and it was no different for Apgar.” In her case, that obscure specialty was anesthesiology. Apgar began studying how anesthesia could impact mothers and babies. One day, a medical student asked her how to evaluate the health of a newborn baby, and she simply scribbled a list of what she considered to be the most important signs. Then she realized that those signs could be combined into a formal assessment tool to indicate whether a baby requires medical intervention. Apgar tested this method, and found it to be effective.

Legal Help | ABC Law Centers: Birth Injury Lawyers

When delivery complications arise, it is the responsibility of the medical team to act quickly and appropriately to minimize the risks to the mother and baby.  Failure to appreciate the significance of a low Apgar score, or to provide interventions that a baby needs, is negligence. If this negligence results in injury to the baby, it is medical malpractice.

Due to the complex nature of birth injury (infant malpractice) cases, it is essential to work with an attorney or attorneys that have a lot of experience in the field and are skillful at reading lengthy and complex medical records. In addition, the attorney should be very knowledgeable about the science involved in birth injury cases. Jesse Reiter has decades of relevant experience, and his practice focuses exclusively on birth injury. He has helped numerous families whose children have HIE, cerebral palsy, and other health issues. Many of his cases involve the use of Apgar scoring.

With over 130 years of joint legal experience, the ABC Law Centers: Birth Injury Lawyers (Reiter & Walsh, P.C.) attorneys have the education, qualifications, results, and accomplishments necessary to succeed. To begin your free, confidential birth injury case evaluation, contact us in any of the following ways. Our team is available to speak with you 24/7.

  • Free Case Review
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What should I expect right after my baby is born?

Attorney Rebecca Walsh explains what a baby should look like right after birth. A baby that is born looking blue, limp or floppy, and unresponsive may have very low Apgar scores.

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Helpful resources

  1. Women’s Health Care Physicians. (n.d.). Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/The-Apgar-Score.
  2. Blakemore, E. (2016, August 29). Virginia Apgar & the Apgar Score-The Doctor Who Saved Babies. Retrieved from http://time.com/4460720/virginia-apgar/.
  3. Apgar score: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from https://medlineplus.gov/ency/article/003402.htm.
  4. (n.d.). Retrieved from https://www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant#H3.
  5. Persson, M., Razaz, N., Tedroff, K., Joseph, K. S., & Cnattingius, S. (2018). Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden. bmj, 360, k207.
  6. Aliyu, I., Lawal, T. O., & Onankpa, B. (2018). Hypoxic-ischemic encephalopathy and the Apgar scoring system: The experience in a resource-limited setting. Journal of Clinical Sciences, 15(1), 18.