Apgar Score

The Apgar score is a rapid clinical assessment of a newborn's condition, scored at 1 minute, 5 minutes and 10 minutes after birth. Five components are each scored 0, 1 or 2: heart rate, respiratory effort, muscle tone, reflex irritability and skin colour.

The score summarises the infant's condition at the time of assessment. It informs the need for resuscitation and continued observation, but it is not a predictor of neurological outcome on its own.

Usage. It is used at every birth, and it is recorded at 10 minutes when the score is low at 5 minutes.

Heart rate. Absent scores 0, below 100 beats per minute scores 1, and at or over 100 scores 2.

Respiratory effort. Absent scores 0, slow or irregular scores 1, and good crying scores 2.

Muscle tone. Limp scores 0, some flexion scores 1, and active movement scores 2.

Reflex irritability. No response to stimulation scores 0, grimace scores 1, and cry or cough scores 2.

Skin colour. Blue or pale all over scores 0, body pink with blue extremities scores 1, and completely pink scores 2.

Interpretation.

• A total of 7 to 10 is reassuring.
• A total of 4 to 6 is moderately abnormal and requires close observation and support.
• A total of 0 to 3 is severely abnormal and requires immediate resuscitation.
• A score at 10 minutes that remains below 7 requires continued assessment and specialist review.

Causes of a low score. Preterm birth, intrapartum hypoxia, maternal opioid or sedative exposure, neuromuscular disease, congenital anomaly, and infection.

Critical values and findings needing immediate action.

• A score of 0 to 3 at 5 minutes requires continued resuscitation and specialist neonatal review.
• Absent heart rate requires immediate neonatal resuscitation.

Limitations and artefacts. The score is subjective, and inter-observer variability is significant. Preterm infants score lower because of immaturity. The score does not reliably predict cerebral palsy or long term neurological outcome.

Follow up tests. Umbilical cord blood gas analysis, blood glucose, neonatal examination, and neonatal neurological assessment where the score remained low.

Special groups. Preterm and low-birth-weight infants are scored with awareness of their immaturity. Maternal drugs affecting the newborn are considered when interpreting muscle tone and respiratory effort.