Apgar testing


The Apgar scoring system evaluates the physical condition of the newborn at one minute after birth and again at five minutes after birth. The newborn receives a total score (Apgar score) that ranges from 0 to 10 based on rating color, heart rate, respiratory effort, muscle tone, and reflex irritability.


Virginia Apgar specialized in anesthesiology and childbirth . She developed the Newborn Scoring System, later called the Apgar score, in 1949 for practitioners to use in deciding whether or not a newborn needed resuscitation. This score provides a uniform method of observation and evaluation of a newborn infant's need for resuscitation immediately after delivery at one minute and again at five minutes. The score is significant because one person in the delivery room evaluates the infant using five signs in an objective, standard and measurable manner. Research published in The New England Journal of Medicine in 2001 concluded that the Apgar scoring system remains as relevant for the prediction of neonatal survival in the early 2000s as it was in 1949.


Five factors are considered in the evaluation of a newborn and the word Apgar can be used as a mnemonic to remember them, i.e., A = Activity (or muscle tone); P = Pulse; G = Grimace (or reflexes to stimuli); A = Appearance (or skin color), and R = Respiration. Scores are given as follows:

  • Activity: Limpness, no movement at all = 0; some flexion of the limbs = 1; active movement, vigorous movements of arms and legs = 2.
  • Pulse: No pulse = 0; pulse below 100 beats per minute (bpm) = 1; pulse over 100 per minute = 2. This is the most important assessment and can be determined by auscultation with a stethoscope or palpation at the junction of the umbilical cord and skin. A newborn heart rate of less than 100 bpm indicates the need for immediate resuscitation.
  • Grimace: No response to stimuli = 0; some response, a slight cry or grimace = 1; active response, coughing, sneezing, or vigorously crying = 2. The stimuli used to evoke a response can be the use of nasal suctioning, stroking the back to assess for spinal abnormalities, having the foot tapped.
  • Appearance: The whole body is blue, gray, or very pale = 0; acrocyanosis, i.e., trunk and head have a pink skin color and hands and feet are blue = 1; pink all over = 2. Newborns with naturally darker skin color will not be pink, but pallor is still noticeable and especially in the soles of the feet and palms of the hands. Skin color is related to the newborn's ability to oxygenate its body and extremities and is dependent on heart rate and respirations.
  • Respiration: No breathing, apnea = 0; slow and irregular respiration = 1; good regular respiration, especially accompanied by crying = 2. Respirations are best assessed by watching the rise and fall of the neonate's abdomen since infants are diaphragmatic breathers.


Essentially no preparation is needed to determine an Apgar score. Clinicians have suctioning equipment available and may use it during the birth process for nasal and oral suctioning to remove mucus and amniotic fluid. This is usually performed when the head of the newborn is safely delivered while the mother rests for her final push. The Apgar score should not be performed by the individual doing the delivery, but by the labor and delivery nurse or nursery nurse.


The Apgar score is primarily observational in nature and its only purpose is to alert the healthcare provider that the baby may need immediate assistance or prolonged observation in the nursery. It provides a means of monitoring the effectiveness of interventions and a process of determining which interventions are valuable.

Normal results

It is important to note that an Apgar score is strictly used to determine a newborn's immediate condition at birth and that it does not necessarily reflect the future health of a baby. The maximum obtainable score is 10 and the minimum is zero. It is quite rare to receive a true 10 as some acrocyanosis is considered normal and not a cause for concern. A score of 7 to 10 is considered normal, and 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 in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen referred to as "blow-by" may be placed near but not directly over the nose and mouth of the neonate during suctioning. A score in the 4–6 range indicates that the neonate is having difficulty adapting to extrauterine life, which in some cases may be related to medications given to the mother during labor, prematurity , or a rapid delivery.

A low Apgar score provides a warning signal that the baby may have hidden health problems, such as breathing difficulties or internal bleeding. With a score of 0–3, the newborn is unresponsive, pale, limp, and may not have a pulse; therefore, an infant with a score of 0—3 needs immediate resuscitation. An ongoing evaluation is continued during resuscitation and documented again at five minutes. In the event of a difficult resuscitation, the Apgar score is done at 10, 15, and 20 minutes as well. A newborn with an Apgar score in this range generally requires advanced medical care and emergency measures, such as assisted breathing, administration of fluids or medications, and observation in a neonatal intensive care unit (NICU) by a neonatologist. An Apgar score of 0–3 at 20 minutes of age, for example, is indicative of high rates of morbidity (disease) and mortality (death).


There are no risks involved with the Apgar scoring process. It is an evaluation of the baby at birth to determine if any resuscitation procedures are needed.


Acrocyanosis —A condition characterized by blueness, coldness, and sweating of the extremities. A slight cyanosis, or blueness, of the hands and feet of the neonate is considered normal. This impaired ability to fully oxygenate the extremities is due to an immature circulatory system which is still in flux.

Amniotic fluid —The liquid in the amniotic sac that cushions the fetus and regulates temperature in the placental environment. Amniotic fluid also contains fetal cells.

Apnea —The temporary absence of breathing. Sleep apnea consists of repeated episodes of temporary suspension of breathing during sleep.

Extrauterine —Occurring outside the uterus.

Neonate —A newborn infant, from birth until 28 days of age.

Neonatologist —A physician (pediatrician) who has special training in the care of newborn infants.

Pallor —Extreme paleness in the color of the skin.

Parental concerns

Parental concerns may be addressed if the Apgar score is low at five minutes and then again at 10 minutes. The healthcare provider should address the possible risks associated with a low score and advise the parents as to follow-up care. A persistently low Apgar score could indicate neurological problems and the parents would want to obtain additional treatment for the baby to ensure appropriate development. Children with cerebral palsy often have neurological damage at birth and the use of physical therapy or speech therapy enhances their outcome.



Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care , 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Tappero, Ellen, and Mary Honeyfield. Physical Assessment of the Newborn , 3rd ed. Santa Rosa, CA: NICU Ink Book Publishers, 2003.


Casey, B. M., et al. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants." New England Journal of Medicine 334 (February 15, 2000): 467–71.


Association of Women's Health, Obstetric, and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: http://www.awhonn.org.

National Association of Neonatal Nurses. 4700 W. Lake Avenue, Glenview, IL 60025–1485. Web site: http://www.nann.org.


"APGAR Scoring for Newborns." Available online at http://www.childbirth.org/articles/apgar.html (accessed November 28, 2004).

"What is the Apgar Score?" KidsHealth. Available online at http://kidshealth.org/parent/pregnancy_newborn/medical_care/apgar.html (accessed November 28, 2004).

Linda K. Bennington, RNC, MSN, CNS

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