APGAR Score Assessment Tool
The APGAR score is a standardized 10-point assessment tool that evaluates five physiological parameters of a newborn at 1 and 5 minutes after birth (and at additional time intervals if needed), with each parameter scored 0-2 points. 1
The Five Components (APGAR Acronym)
Each component is scored 0,1, or 2 points:
- Appearance (Skin Color): Blue/pale (0), body pink with blue extremities (1), completely pink (2) 1
- Pulse (Heart Rate): Absent (0), <100 bpm (1), >100 bpm (2) 1
- Grimace (Reflex Irritability): No response (0), grimace/weak cry (1), vigorous cry/cough/sneeze (2) 1
- Activity (Muscle Tone): Limp (0), some flexion (1), active movement (2) 1
- Respiration (Breathing Effort): Absent (0), slow/irregular/weak cry (1), good/strong cry (2) 1
Total possible score: 0-10 points 1
Timing of Assessment
- Mandatory assessment at 1 minute and 5 minutes after birth 1
- Continue scoring every 5 minutes (at 10,15,20 minutes) if the 5-minute score is ≤5 1
- Scores should be recorded using an expanded reporting form that documents concurrent resuscitative interventions 2
Score Interpretation and Clinical Significance
1-Minute Score
- Does NOT predict individual infant outcomes or guide admission decisions 3, 4
- Primarily reflects the infant's immediate physiologic condition and need for resuscitation 1
- A score of 0-3 should prompt immediate resuscitation but does not predict long-term prognosis 1
5-Minute Score (Most Clinically Important)
- Score ≤5: Requires NICU admission, umbilical arterial blood gas sampling, and consideration of placental pathology examination 3, 4
- Score 0-3: Correlates with neonatal mortality in populations and confers 20-100 fold increased relative risk of cerebral palsy compared to scores 7-10 1, 3, 5
- Score ≥7 with normal fetal heart rate tracing and normal umbilical arterial pH: Generally does not warrant NICU admission based on score alone 3
Extended Scoring (10,15,20 Minutes)
- Score ≤3 at 10 minutes: Associated with 27-67% mortality depending on specific score 3
- Score ≤3 at 20 minutes: Associated with 59% mortality and 57% cerebral palsy in survivors >2500g 3
- Population risk of poor neurologic outcomes increases progressively with persistently low scores 1
Critical Limitations to Understand
The APGAR score alone cannot be considered evidence of asphyxia or predict individual neurologic outcomes. 1, 2
Multiple factors influence the score and must be considered:
- Maternal factors: Sedation, anesthesia, medications 1
- Infant factors: Gestational age, congenital malformations, trauma 1
- Physiologic variations: Normal transition variations (e.g., oxygen saturation targets are 60-65% at 1 minute, 80-85% at 5 minutes per Neonatal Resuscitation Program) 1
- Subjective elements: Tone, color, and reflex irritability depend on physiologic maturity and have interobserver variability 1
Diagnosing Birth Asphyxia Requires ALL of the Following:
An infant with suspected intrapartum hypoxic-ischemic injury must demonstrate:
- Profound metabolic or mixed acidemia (pH <7.00) on umbilical arterial blood sample 6
- APGAR score 0-3 for longer than 5 minutes 6
- Neurologic manifestations (seizures, coma, hypotonia) 6
- Evidence of multisystem organ dysfunction 6
Additional supporting factors include nonreassuring fetal heart rate patterns, neuroimaging abnormalities, neonatal EEG changes, and placental pathology 1
Clinical Pitfalls to Avoid
- Never use the APGAR score alone to diagnose asphyxia or predict individual neurologic disability 1, 2
- Do not compare scores assigned during active resuscitation to scores of spontaneously breathing infants—they are not equivalent 2
- Remember that most infants with low APGAR scores will NOT develop cerebral palsy despite increased population risk 1
- The 1-minute score has minimal predictive value for long-term outcomes 3, 4
- A 5-minute score of ≤5 mandates obtaining umbilical arterial blood gas if possible 1