Apgar score

newborn and physician

©iStockphoto.com/Dan Bayley

A rating on a scale of 1 to 10 given a newborn baby, according to criteria published by the pediatrician Virginia Apgar in 1953.¹ A “10” represents the apparently healthiest baby.

Scoring is preferably done by someone other than the person who delivered the baby.² Two scores are recorded: the first at 60 seconds after birth (defined as the moment when the soles of the feet and the top of the head are visible), and the second at 5 minutes after birth. Both scores are based on the same five factors, on each of which the observer may award either 0, 1 or 2 points3:

Factor 0 1 2
(criteria for white baby,
see video for darker skin)
blue pale body pink
extremities blue
completely pink
heart rate absent below 100 over 100
breathing absent slow,
good strong cry
reflexes (response to
stimulation of
sole of foot)
no response grimace cry
muscle tone limp some flexion
of extremities
active motion

An Apgar score is a way of alerting the nursery staff to newborns who may require special attention, but it is primarily a tool for studying the effects of treatments on groups of infants, not individuals. It has been used, for example, in comparing the quality of care in different obstetrical units. Anxious mothers should note first, that a rating of 10 is not often given, and second, Apgar's caution that the score does not “predict neonatal death or survival in individual infants.”4

In 2006 and again in 2015 the major medical associations that deal with childbirth recommended the use of the expanded Apgar form,5 especially in consideration of the original's shortcomings for newborns requiring resuscitation. The expanded form records more data, much of it from more technical analyses, for example, of umbilical arterial blood gas samples.

1. Virginia Apgar.
A proposal for a new method of evaluation of the newborn infant.
Anaesthesia and Analgesia, volume 32, page 260, (1953).

Available online at http://apgar.net/virginia/Apgar_Paper.html

2. Virginia Apgar.
The newborn (Apgar) scoring system. Reflections and advice.
Pediatric Clinics North America, vol. 13, no. 3, pages 645-650 (August 1966).

3. Table adapted from
J. Butterfield and M. J. Covey.
Practical epigram of the Apgar score. (letter to the editor)
JAMA, volume 181, page 353 (28 July 1962).

4. Virginia Apgar and L. S. James.
Further observations on the newborn scoring system.
American Journal of the Diseases of Children, volume 104, page 419 (1962).

5. American Academy of Pediatrics Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists Committee on Obstetric Practice.
The Apgar Score.
Policy Statement from the American Academy of Pediatrics
Pediatrics, September 2015.
Available online at http://pediatrics.aappublications.org/content/early/2015/09/22/peds.2015-2651

This policy statement is an expansion and reaffirmation of one from the same committees that appeared in Pediatrics, vol 117, no. 4 (April 2006).

for further reading

Brian M. Casey, M.D., Donald D. McIntire, Ph.D., and Kenneth J. Leveno, M.D.
The Continuing Value of the Apgar Score for the Assessment of Newborn Infants.
New England Journal of Medicine, 344, pages 467-471 (February 15, 2001)
doi: 10.1056/NEJM200102153440701

Atul Gawande
The Score. How childbirth went industrial.
The New Yorker, October 9, 2006.
Available online at www.newyorker.com/magazine/2006/10/09/the-score

A physician who is a gifted writer describes childbirth.

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