Apgar testing is the assessment of the newborn rating color, heart rate, stimulus response, muscle tone, and respirations on a scale of zero to two, for a maximum possible score of 10. It is performed twice, first at one minute and then again at five minutes after birth.
Apgar scoring was originally developed in the 1950s by the anesthesiologist Virginia Apgar to assist practitioners attending a birth in deciding whether or not a newborn was in need of resuscitation. Using a scoring method fosters consistency and standardization among different practitioners. A February 2001 study published in the New England Journal of Medicine investigated whether Apgar scoring continues to be relevant. Researchers concluded that "The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago."
The five areas are scored as follows:
- Appearance, or color: 2 if the skin is pink all over; 1 for acrocyanosis, where the trunk and head are pink, but the arms and legs are blue; and 0 if the whole body is blue. Newborns with naturally darker skin color will not be pink. However, pallor is still noticeable, especially in the soles and palms. Color is related to the neonate's ability to oxygenate its body and extremities, and is dependent on heart rate and respirations. A perfectly healthy newborn will often receive a score of 9 because of some blueness in the hands and feet.
- Pulse (heart rate): 2 for a pulse of 100+ beats per minute (bpm); 1 for a pulse below 100 bpm; 0 for no pulse. Heart rate is assessed by listening with a stethoscope to the newborn's heart and counting the number of beats.
- Grimace, or reflex irritability: 2 if the neonate coughs, sneezes, or vigorously cries in response to a stimulus (such as the use of nasal suctioning, stroking the back to assess for spinal abnormalities, or having the foot tapped); 1 for a slight cry or grimace in response to the stimulus; 0 for no response.
- Activity, or muscle tone: 2 for vigorous movements of arms and legs; 1 for some movement; 0 for no movement, limpness.
- Respirations: 2 for visible breathing and crying; 1 for slow, weak, irregular breathing; 0 for apnea, or no breathing. A crying newborn can adequately oxygenate its lungs. Respirations are best assessed by watching the rise and fall of the neonate's abdomen, as infants are diaphragmatic breathers.
The combined first letters in these five areas spell Apgar.
No preparation is needed to perform the test. However, while being born the neonate may receive nasal and oral suctioning to remove mucus and amniotic fluid. This may be done when the head of the newborn is safely out, while the mother rests before she continues to push.
Since the test is primarily observational in nature, no aftercare is needed. However, the test may flag the need for immediate intervention or prolonged observation.
The maximum possible score is 10, the minimum is zero. It is rare to receive a true 10, as some acrocyanosis in the newborn is considered normal, and therefore not a cause for concern. Most infants score between 7 and 10. These infants are expected to have an excellent outcome. A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance, or perhaps just suctioning if breathing has been obstructed by mucus. While suctioning is being done, a source of oxygen may be placed near, but not over the newborn's nose and mouth. This form of oxygen is referred to as blow-by. A score in the 4-6 range indicates that the neonate is having some difficulty adapting to extrauterine life. This may be due to medications given to the mother during a difficult labor, or at the very end of labor, when these medications have an exaggerated effect on the neonate.
With a score of 0-3, the newborn is unresponsive, apneic, pale, limp and may not have a pulse. Interventions to resuscitate will begin immediately. The test is repeated at five minutes after birth and both scores are documented. Should the resuscitation effort continue into the five-minute time period, interventions will not stop in order to perform the test. The one-minute score indicates the need for intervention at birth. It addresses survival and prevention of birth-related complications resulting from inadequate oxygen supply. Poor oxygenation may be due to inadequate neurological and/or chemical control of respiration. The five-minute score appears to have a more predictive value for morbidity and normal development, although research studies on this are inconsistent in their conclusions.
Feinbloom, Richard I. Pregnancy, Birth and the Early Months. Cambridge, MA: Perseus Publishing, 2000.
Pillitteri, Adele. Maternal & Child Nursing; Care ofthe Childbearing and Childrearing Family. 3rd ed. Philadelphia: Lippincott, 1999.
Casey, B. M., D. D. McIntire, and K. J. Leveno. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants". New England Journal of Medicine 344 (February 15, 2000): 467-71.
Apgar, Virginia. A Proposal for a New Method of Evaluation of the Newborn Infant. http://www.apgarfamily.com/Apgar_Paper.html.
The National Childbirth Trust. http://www.nctpregnancyandbabycare.com.