Continuing Education Activity
In 1952, Dr. Virginia Apgar, an anesthesiologist at Columbia University, developed the Apgar score. Serendipitously, APGAR is also a useful mnemonic to describe the components of the score: appearance, pulse, grimace, activity, and respiration. The score is a rapid method for evaluating neonates immediately after birth and in response to resuscitation. Apgar scoring remains the accepted method of assessment and is endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). While originally designed to assess the need for intervention to establish breathing at 1 minute, the guidelines for the Neonatal Resuscitation Program (NRP) state that Apgar scores do not determine the initial need for intervention as resuscitation must be initiated before the 1-minute Apgar score is assigned. This activity reviews the Apgar score and its clinical relevance and highlights the role of the interprofessional team in the evaluation and management of newborns.
- Identify the physiological criteria used for calculating the Apgar score.
- Describe the clinical relevance of the Apgar score.
- Outline the limitations of the Apgar score.
- Explain the importance of coordinated collaboration and effective communication among the interprofessional team members involved in the evaluation and management of newborns using APGAR score in fostering the best possible standard of care to newborns and their families.
In 1952, Dr. Virginia Apgar, an anesthesiologist at Columbia University, developed the Apgar score. The score is a rapid method for assessing a neonate immediately after birth and in response to resuscitation. Apgar scoring remains the accepted method of assessment and is endorsed by both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. While originally designed to assess the need for intervention to establish breathing at 1 minute, the guidelines for the Neonatal Resuscitation Program9NRP) state that Apgar scores do not determine the initial need for intervention as resuscitation must be initiated before the 1-minute Apgar score is assigned.
Elements of the Apgar score include color, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression, or apnea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score seven or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.
Apgar scores may vary with gestational age, birth weight, maternal medications, drug use or anesthesia, and congenital anomalies. Several components of the score are also subjective and prone to inter-rater variability. Thus, the Apgar score is limited in that it provides somewhat subjective information about an infant’s physiology at a point in time. It is useful in gauging the response to resuscitation but should not be used to extrapolate outcomes, particularly at 1 minute as this does not hold any long-term clinical significance. Apgar score alone should not be interpreted as evidence of asphyxia and its significance in outcome studies while widely reported is often inappropriate. Resuscitation should always take precedence over calculating a clinical score.
Apgar scoring is recorded in all newborn infants at 1 minute and 5 minutes. In infants scoring less than 7, expanded Apgar score recording is encouraged by the American College of Obstetrics and Gynecology and the American Academy of Pediatrics as a method of monitoring response to resuscitation.
There are no known contraindications to APGAR scoring in the evaluation of newborns.
Auscultation with a stethoscope rather than by palpitation of a pulse best assesses heart rate. No other equipment is required. Auscultation is a more accurate way to count the pulse as compared to palpation of an umbilical or brachial pulse. A pulse oximeter may also be used. Ideally, radiant warmer should be readily available in the delivery suite, to provide the necessary warmth for neonates with hypothermia. Alternatively, warm blankets could be used.
There are five parts of an Apgar score. Each category is weighted evenly and assigned a value of 0, 1, or 2. The components are then added together to give a total score that is recorded at 1 and 5 minutes after birth. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is deemed to be low in full-term and late preterm infants. At 5 minutes, when an infant has a score of less than 7, Neonatal Resuscitation Program guidelines recommend continued recording at 5-minute intervals up to 20 minutes. It should be noted that scoring during resuscitation is not equivalent to that of an infant not undergoing resuscitation because resuscitative efforts alter several elements of the score.
The score is calculated as follows:
- If the infant is not breathing, the respiratory score is 0.
- If respirations are slow and irregular, weak or gasping, the respiratory score is 1.
- If the infant is crying vigorously, the respiratory score is 2.
- Note, heart rate is evaluated with a stethoscope, and it is the most critical part of the score in determining the need for resuscitation.
- If there is no heartbeat, the heart rate score is 0.
- If the heart rate is less than 100 beats per minute, the heart rate score is 1.
- If the heart rate is more than 100 beats per minute, the heart rate score is 2.
- If the muscle tone is loose and floppy without activity, the score for muscle tone is 0.
- If the infant demonstrates some tone and flexion, the score for muscle tone is 1.
- If the infant is in active motion with a flexed muscle tone that resists extension, the score for muscle tone is 2.
Grimace Response or Reflex Irritability in Response to Stimulation
- If there is no response to stimulation, the reflex irritability response score is 0.
- If there is grimacing in response to stimulation, the reflex irritability response score is 1.
- If the infant cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.
- Note, most infants will score 1 for color as peripheral cyanosis is common among normal infants. Color can also be misleading in non-white infants.
- If the infant is pale or blue, the score for color is 0.
- If the infant is pink, but the extremities are blue, the score for color is 1.
- If the infant is entirely pink, the score for color is 2.
Apgar scores were designed to help identify infants that require respiratory support or other resuscitative measures, not as an outcome measure. The Apgar score alone should not be considered evidence of asphyxia or proof of an intrapartum hypoxic event. A low Apgar score of 0 to 1 at 1 minute is not predictive of adverse clinical outcome or long-term health issues since most infants, even those with very low 1-minute scores will have normal scores by 5 minutes. Low Apgar scores at 5 minutes correlate with mortality and may confer an increased risk of cerebral palsy in population studies but not necessarily with an individual neurologic disability. Most infants with low Apgar scores do not go on to develop cerebral palsy, but lower scores over time increase the population risk of the poor neurologic outcome. Scores less than five at 5 and 10 minutes correlate with an increased relative risk of cerebral palsy. Neonates with scores less than five at 5 minutes should have umbilical artery blood gas sampling performed. Apgar scores that remain at 0 after 10 minutes may indicate that the termination of resuscitative efforts is appropriate as very few infants survive with good neurologic outcomes if no heart rate has been detectable for over 10 minutes.
The Apgar score alone should not be considered as evidence of asphyxia or evidence of an intrapartum hypoxic event. A low Apgar score of 0 to 1 at 1 minute is not predictive of adverse clinical outcome or long-term health issues since most infants, even those with very low 1-minute scores will have normal scores by 5 minutes. Low Apgar scores at 5 minutes correlate with mortality and may confer an increased risk of cerebral palsy in population studies but not necessarily with an individual neurologic disability.
Enhancing Healthcare Team Outcomes
Apgar scoring may be performed by a physician, midwife, or nurse. Inter-rater variability is quite common as some components of the score are subjective, so ideally, the same person should calculate the initial and ongoing scores for consistency. The nurse has a crucial role in evaluating neonates using the APGAR score, and she should inform the clinician of any untoward changes in the APGAR score of the newborn. The nurse should document the findings of the APGAR score at 1 minute and 5 minutes, respectively. The nurse assists the clinician in the initial resuscitative measures of the neonates, particularly if they have low APGAR scores. The interprofessional team should communicate the findings of the resuscitation efforts to the woman and her family and should formulate a care plan to neonates with low APGAR scores. The nurse should collaborate with the clinician to address any concerns, the woman and her family might have. The nurse should provide the woman with the necessary information leaflets about neonatal care. Patient education is key to the successful management of neonates with low APGAR scores. The best possible standard of care could only be achieved through coordinated collaboration and clear communication among the members of the interprofessional team. [level V]
Nursing, Allied Health, and Interprofessional Team Interventions
Nurses looking after newborns should be familiar with the Apgar score. Also, they should know what the score signifies. Nurses should understand that a score between 7-10 is normal; a score between 4-6 needs proper reevaluation as the infant does require monitoring for 5 minutes. A score of less than 3 is never good, and immediate attention is mandatory. The nurse should call a code and inform the clinician immediately.