Apgar Score

Introduction

• In 1952, Dr. Virginia Apgar, an obstetric anesthesiologist at Columbia University, NY, created the Apgar scoring system to standardize the rapid assessment of newborns in the first minute of life.^1,2 Although the Apgar score is commonly thought of as an acronym, it was originally named after Dr. Apgar.
• The Apgar scoring system quantifies the clinical signs of neonatal distress, including bradycardia, pallor, hypotonia, apnea, respiratory depression, and cyanosis.^1,2
• The Apgar scoring system is widely used as an assessment tool and is endorsed by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology (ACOG).^1,2

Components and Timing

Timing

The Apgar scores are performed at 1 and 5 minutes of life. If a newborn infant’s Apgar score at 5 minutes is less than 7, it should be repeated every 5 minutes until 20 minutes of life.^1,2

Interpretation of Apgar Scores

• The Apgar score only reflects a newborn infant’s clinical status at one point in time and includes subjective components. It should not be used to guide resuscitative efforts.¹
• A low Apgar score at 1 minute does not predict adverse clinical outcomes as it will likely improve by 5 minutes.
• Apgar scores alone should not be used to establish a diagnosis of asphyxia.¹
• The ACOG Task Force on Neonatal Encephalopathy defines the 5-minute Apgar score of 0-3 as low and concerning, 4-6 as moderately abnormal, and 7-10 as reassuring.³
• The Apgar score does not predict individual neonatal mortality or neurologic outcomes. Most newborn infants with low Apgar scores do not go on to develop cerebral palsy.^1-3 However, based on population studies, Apgar scores less than 5 at 5 and 10 minutes confer an increased relative risk of cerebral palsy in large populations. This increased risk is as high as 20- to 100-fold higher than infants with 5-minute Apgar scores of 7-10.¹
•  A recent population-based cohort study in Sweden found an increased risk of cerebral palsy and seizures with lower Apgar scores at 5 and 10 minutes.⁴
• When a newborn infant has an Apgar score of 5 or more at 5 minutes, an umbilical arterial blood sample from a clamped section of the umbilical cord should be obtained, if possible.¹
• An Apgar score that remains 0 beyond 10 minutes may be useful in determining if the termination of resuscitation efforts is appropriate, as very few newborn infants with an Apgar score of 0 at 10 minutes survive with normal neurologic outcomes.^1,2

Clinical Use and Limitations

• The Apgar score is a rapid method for evaluating a newborn infant after birth at 1 and 5 minutes of life. It evaluates the effectiveness of resuscitation efforts started before the first minute of life.²
• The Apgar score should not be used to determine the initial need for intervention, as the Neonatal Resuscitation Program states that resuscitation efforts must be initiated before the 1-minute Apgar score is assigned.²
• There are several limitations of the Apgar score:^1,2
  • The Apgar score is a snapshot of the newborn infant’s physiologic condition at one point in time.
  • Apgar scores may vary with gestational age, birth weight, congenital anomalies, maternal sedation or general anesthesia, trauma, etc.
  • Several components of the Apgar score are subjective and are prone to inter-rater variability.