The Apgar score is a quick assessment of a newborn baby 1 minute and 5 minutes after birth. Healthcare professionals report the newborn’s status based on observation to see if the newborn needs extra medical care.

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Shortly after birth, healthcare professionals evaluate a newborn baby’s ability to adapt and transition to life outside the womb. They examine the newborn for signs of distress and for any apparent abnormalities.

Medical professionals use the Apgar score to rapidly assess a newborn’s overall condition and how they tolerate the birthing process.

This article discusses the Apgar score, its meaning, and how healthcare professionals perform the test. It also explores whether the test can predict a newborn’s health outcomes, as well as the other uses of the Apgar score.

Dr. Virginia Apgar, an anesthesiologist, developed the Apgar test at Columbia University in 1952.

The doctor used her name as a way for healthcare professionals to remember the components they should check for in newborns.

Medical professionals use this scoring system to report an infant’s overall condition. A low score means that the newborn has heart problems or requires breathing support. Some medical professionals also use the Apgar score to evaluate a newborn’s response to resuscitation.

The Apgar score is a mnemonic (a pattern of letters that assists in remembering something) for five categories that reflect the newborn’s general condition at birth:

  • A: appearance (skin color)
  • P: pulse (heart rate)
  • G: grimace (reflexes)
  • A: activity (muscle tone)
  • R: respiration (breathing effort)

A healthcare professional gives the newborn a score of 0, 1, or 2 in each category depending on the newborn’s observed condition. They then add up the scores for all categories to get the total score. An infant can get a total Apgar score of 0–10.

The highest score is 10, but it is rare for newborns to get 10 because their hands and feet are typically blue immediately after birth.

A score of 7–10 is considered reassuring and a sign that the newborn is in good health. A score of 4–7 is moderately abnormal, while a score of 0–3 is low for full-term and late preterm infants.

A score below 7 indicates that the infant requires medical help, such as clearing of their airway or physical stimulation to get their heart to beat faster.

A low Apgar score at 1 minute does not predict long-term health outcomes or adverse clinical outcomes. Most infants with low scores at 1 minute have normal scores at 5 minutes. Most of the time, a low score is a result of:

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A doctor, midwife, or nurse records a score of 0, 1, or 2 for each Apgar component at 1 and 5 minutes after birth.

Then, healthcare professionals add the scores for each component to get a total score of 0–10. They repeat recording these scores every 5 minutes for infants with a 5-minute score of 7 or less and when monitoring newborns requiring resuscitation.

Below is the scoring system per category:

Appearance (skin color)Infant’s skin is pale blue.Infant’s body is pink, while hands and feet are blue.Infant’s entire body is pink.
Pulse (measures heart rate; determines if infant needs resuscitating)Infant has no heartbeat.Infant’s heartbeat is less than 100 beats per minute (bpm).Infant’s heartbeat is greater than 100 bpm.
Grimace (measures infant’s reflex response, typically to a light pinch)Infant shows no response.Infant grimaces.Infant grimaces, cries, coughs, or sneezes.
Activity (muscle tone)Muscles are loose and floppy, without activity.Muscles demonstrate some tone and flexion.Muscles actively move with a flexed tone that resists extension.
Respiration (breathing effort)Infant is not breathing.Infant’s breathing is slow or irregular.Infant cries well.

Low Apgar scores at 5 minutes are associated with an increased risk of health problems and death. However, the American College of Obstetricians and Gynecologists (ACOG) states that a low score alone cannot predict morbidity and mortality in any newborn.

It is important to note that the Apgar score has its limitations. It reflects only an infant’s physiological condition at a point in time, and scores may depend on the infant’s physiological maturity at the time of birth.

Some categories can also be subjective and prone to inter-rater variability, meaning that different healthcare professionals may give an infant differing scores. Moreover, several factors can also influence the Apgar score, including:

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There have also been recent conversations in neonatal health about whether “pink all over” is an accurate indicator of health for newborn babies of color.

A small 2014 study of 61 medical professionals found that many were confused about the Apgar score’s color component, especially for babies of color.

About 34.4% of participants said they considered a baby’s ethnicity when assigning the Apgar score, and 57.4% of those said “pink all over” did not accurately describe the skin color of vigorous African American newborns who would otherwise score a 2. The study authors conclude that this may lower the Apgar score of babies of color.

Some revised versions of the Apgar score state that healthcare professionals should check hands and feet for pinkness, instead of an infant’s entire body.

Learn more about babies and skin color here.

While the score helps gauge a newborn’s response to resuscitation, healthcare professionals do not use Apgar scores — especially not 1-minute scores — to predict infant outcomes.

According to ACOG, having a 0–3 score in a 5-minute Apgar test correlates with neonatal mortality. However, it does not predict an infant’s future neurological dysfunction.

Most infants with low Apgar scores do not develop cerebral palsy, but low scores over time increase the population risk of having poor neurological outcomes. Infants with Apgar scores of less than 3 at 5 and 10 minutes show an increased risk of cerebral palsy.

Specifically, babies with low scores have a 20–100 times increased risk of cerebral palsy compared with infants with an Apgar score of 7–10.

Similarly, a 2018 study found that the risk of epilepsy and cerebral palsy increases with decreasing 5- and 10-minute Apgar scores.

Medical professionals use the change from the 1-minute to the 5-minute Apgar score as a valuable index for resuscitation.

Based on the Neonatal Resuscitation Program guidelines, if a baby’s Apgar score at 5 minutes is less than 7, health professionals should perform continued recording at 5-minute intervals for up to 20 minutes.

The scoring given during resuscitation is not the same as that assigned to an independently or spontaneously breathing infant since resuscitation may alter many of the categories of the score.

It may be appropriate to stop the resuscitative efforts if the Apgar score remains at 0 after 10 minutes.

Learn more about birth asphyxia here.

Apgar scoring can be helpful in individual case reviews, as it may help identify an infant’s specific medical needs and pinpoint areas of improvement in systems of perinatal care.

Analyzing the trends during interventions can provide valuable data for assessing the effect of quality improvement interventions.

Many infants with low Apgar scores do fine after adjusting to life outside the womb.

Parents or caregivers concerned about a newborn’s Apgar score and general condition at birth may ask their healthcare professionals. They may also ask about other tests their baby underwent and what the results mean.

Here are answers to some commonly asked questions about Apgar scores.

What if your baby scores low?

A low 1-minute Apgar score is often not a cause for concern since infants usually get higher scores at 5 minutes. However, infants with low Apgar scores after 5 minutes may require medical assistance for breathing or circulation problems. They may also be at risk of poor neurological outcomes.

How common is an Apgar score of 10?

An Apgar score of 10 is unusual since almost all newborns have blue hands and feet, which will cause them to score a 1 in appearance or skin color.

What does an Apgar score of 6 mean?

An Apgar score of 6 is considered moderately abnormal and suggests that the infant may need some medical help or resuscitation.

What is a poor Apgar score?

An Apgar score of 0–3 at 1 minute is considered low. However, healthcare professionals also regard a score below 7 at 5 minutes as low.

The Apgar test is a quick evaluation tool that health professionals use to describe the general condition of a newborn right after birth. While it is valuable for monitoring and communication between healthcare professionals, the Apgar score alone offers little predictive value for the baby’s long-term health.

Moreover, some of the score’s components can be subjective. Because of this, clinicians often use additional assessment tools to evaluate a newborn’s general condition.