Apgar Score for Newborn Health Assessment | Birth Injury Diagnosis

What Is An Apgar Score?

The Apgar score was developed in 1952 as a simple and repeatable method to quickly assess the health of a baby immediately after birth.  Dr. Apgar, creator of the score, believed that the same signs that were traditionally used by anesthesiologists to monitor a patient’s condition during surgery could be used to assess a baby’s condition after birth and predict the likelihood of survival.  The testing typically is done at one and five minutes after birth, and it may be repeated later if the score remains low.  The Apgar score is calculated by evaluating the baby on five criteria on a scale from 0 to 2, then adding the five values obtained.  The five criteria of the Apgar score are:

  • Appearance/complexion: Is the baby blue or pale all over, is the body pink, or is the baby blue at extremities?
  • 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 she grimace and give a feeble cry, or does she cry and pull away when stimulated?
  • Activity: Does the baby exhibit no activity, have some flexion (joint movement), or does she have flexed arms and legs that resist extension?
  • Respiratory effort: Is the baby breathing, does she have a weak, irregular respiratory effort, or is her cry really strong?

Apgar Scoring System - Diagnosing Cerebral Palsy, HIE and Birth Injuries

What Do Apgar Scores Mean?

Scores of 1-3 are critically low, 4-6 are below normal, and 7+ are normal.  A low score indicates that a baby is likely to need medical intervention; the lower the score, the more alert the medical team should be to the possibility of intervention.  For example, a baby with a low score is more likely than a baby with a high score to need resuscitation.  When a baby requires resuscitation, it means that she needs help for her heart, her blood pressure, and/or she needs help to breathe or to start breathing.  Some components of the Apgar score are subjective and certainly there are cases in which a score is high, but urgent medical treatment for the baby may be needed nonetheless.

If the score remains low at later times, such as at 10, 15, or 30 minutes after birth, there is a risk that the child will suffer long-term neurological damage, and there also is a small but significant increase of the risk of cerebral palsy.  Higher Apgar scores, however, do not rule out the possibility that the baby has a brain injury, such as hypoxic ischemic encephalopathy (HIE).  It is important to remember, though, that the purpose of the Apgar score is to quickly determine whether a newborn needs immediate medical care; it was not devised to make-long term predictions regarding the baby’s health.

Causes of Low Apgar Score

Causes of Low Apgar ScoreIndeed, Dr. Apgar did not intend for the Apgar score to be used as a litigation tool for either establishing or ruling out hypoxia/asphyxia (oxygen deprivation) in the baby that occurred during labor and delivery.  Despite this, the American College of Obstetricians and Gynecologists (ACOG) has routinely included the Apgar score with its published criteria for litigation.  The rationale for utilizing the Apgar score in litigation criteria is based on a scientifically invalid hypothesis: that all newborns who suffer hypoxia or asphyxia around the time of delivery must have low Apgar scores (0-3) at 1, 5, and 10 minutes.  Recent research has shown that ACOG’s criteria does not objectively demonstrate the entire range of cases in which an infant with cerebral palsy suffered damaging fetal or neonatal hypoxia/asphyxia.

Anything that causes a baby to become oxygen deprived can cause the baby to have a low Apgar score after birth.  Listed below are a few of the conditions that can cause a low Apgar score.

  • Umbilical cord problems, such as a prolapsed cord (cord exits in front of the baby and the baby’s body impinges on it) or nuchal cord (cord is wrapped around the baby’s neck)
  • Placental abruption, which occurs when part of the placenta tears away from the uterus.
  • Uterine rupture, which occurs when the wall of the uterus (womb) tears open.
  • Trauma to the baby’s head can occur during labor 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, face, or brow presentation), or the shoulder getting stuck on the mother’s pelvic bone (shoulder dystocia) all can increase the likelihood of head trauma during delivery
  • Excessive uterine activity can occur when Pitocin or Cytotec are used during labor and the medication causes very strong and frequent contractions that deprive the baby of oxygen.
  • Undiagnosed or improperly treated maternal infections, such as chorioamnionitis and villitis, Group B Strep (GBS), and herpes simplex virus (HSV)
  • Severe preeclampsia (high maternal blood pressure)
  • Amniotic fluid embolism, which is a condition in which amniotic fluid, fetal cells, or other debris enters the mother’s blood stream, which triggers an allergic reaction that causes cardiorespiratory collapse in the mother, which then causes rapid deterioration of the baby
  • Excessive vaginal bleeding

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 of the child 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.

How Do You Pronounce Apgar?


Legal Help for Birth Injuries | Reiter & Walsh, P.C.’s Legal Experience and Focus on Birth Injury

Due to the complex nature of birth injury 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 experience in this area, and his practice focuses exclusively on birth injury.  He has helped numerous families whose children have HIE, cerebral palsy, and other birth injuries.  Many of his cases involve the use of Apgar scoring.

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 can lead to failure of the medical team to act quickly.  If the physician or medical team fail to properly monitor a baby or to act skillfully and quickly when complications occur, it is negligence.  If a hospital is ill-prepared to perform resuscitation procedures or the medical team improperly performs the procedures, it also is negligence.  If this negligence results in injury to the baby, it is medical malpractice.


“Jesse Reiter is a remarkable and well experienced birth injury lawyer. We hired Reiter & Walsh after reading about Mr. Reiter’s professional profile and years of experience. We were very happy with the services he provided and admire his professional excellence. He conducted professional and ethical manners; he worked with great dignity. Throughout the legal process, we were informed.

Emily Thomas is an inspiring lawyer with a purpose. Our family was blessed to have her walk us through the legal process that was foreign to us at the time. She worked for us 24/7 and was never too busy to answer all our questions. We absolutely loved working with her!

We wish Reiter & Walsh much strength to serve families that deserve better outcomes, and we shine a light to their lives, just as she did with ours. We are highly satisfied with their professional services and wish them the best of luck.”

-Client review from 10/06/2017

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