Continuing Education Activity

The Apgar score is a standardized assessment of a neonate's status immediately after birth and the response to resuscitation efforts and remains the gold standard for evaluating neonates. Although the Apgar score was initially designed to assess the need for intervention to establish breathing at 1 minute, the Neonatal Resuscitation Program guidelines state that Apgar scores should not be used to determine the initial need for intervention, what interventions are indicated, or when to initiate them, as resuscitation must be commenced before the 1-minute Apgar score is assigned. The Apgar score should not be interpreted in isolation but as part of a complete assessment, with resuscitation always taking precedence over scoring. 

This course delves into the clinical significance and intricacies of Apgar scoring, which involves evaluating 5 vital signs of newborns: color, heart rate, reflexes, muscle tone, and respiration. While a score of 7 to 10 at 1 and 5 minutes is considered reassuring, factors such as gestational age, birth weight, maternal medications, and congenital anomalies can influence scores. Healthcare professionals will better understand Apgar scores in predicting outcomes, emphasizing the need for ongoing monitoring and care beyond the initial scoring period when evaluating and managing newborns.

Objectives:

• Identify the physiological criteria used for calculating the Apgar score.

• Interpret the clinical relevance of the Apgar score.

• Determine the limitations of the Apgar score.

• Apply interprofessional team strategies to improve care coordination and patient outcomes when evaluating newborns using the Apgar score.

Introduction

The Apgar score is a rapid method for assessing a neonate immediately after birth and in response to resuscitation. Apgar scoring remains the accepted assessment method endorsed by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. While originally designed in 1952 by Dr. Virginia Apgar, an anesthesiologist at Columbia University, to assess the need for intervention to establish breathing at 1 minute, the guidelines for the Neonatal Resuscitation Program state that Apgar scores should not be used to determine the initial need for intervention, what interventions are indicated, or when to initiate them, as resuscitation must be commenced before the 1-minute Apgar score is assigned.[1][2][3]

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, including cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression, or apnea. Each element is scored 0, 1, or 2. The score is recorded at 1 minute and 5 minutes after delivery in all infants, with expanded recording at 5-minute intervals for infants who score ≤7 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 because it provides somewhat subjective information about an infant’s physiology at a point in time. 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. 

Indications

Apgar scoring is indicated in all newborn infants at 1 and 5 minutes and should be documented in the clinical record. In infants scoring <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.[4][5][6]

Contraindications

Apgar scoring has no known contraindications in the evaluation of newborns. However, in certain situations (eg, an infant who needs to be paralyzed or undergo surgery at birth), the score may not reflect the underlying physiology.

Equipment

While most auscultation is performed with a stethoscope rather than by palpation, the most accurate method remains an electrocardiogram.[7] No other equipment is required. A pulse oximeter may also be used. Ideally, a radiant warmer and an electrocardiogram should be readily available in the delivery suite to provide the necessary warmth for neonates with hypothermia and to provide a more accurate heart rate if resuscitation is required. Alternatively, warm blankets and a stethoscope could be used.

Personnel

Any trained healthcare professional may calculate the Apgar score depending on the situation, including:

• Neonatologist
• Pediatrician
• Nurse practitioner
• Family physician
• Midwife
• Nurse
• Respiratory Therapist

Technique or Treatment

There are 5 parts to an Apgar score. Each category is weighted evenly and assigned a 0, 1, or 2 value. The components are then added to give a score recorded 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 low in full-term and late preterm infants, at 5 minutes, when an infant has a score of <7, Neonatal Resuscitation Program guidelines recommend continued recording at 5-minute intervals up to 20 minutes. Scoring during resuscitation is not equivalent to an infant not undergoing resuscitation because resuscitative efforts alter several score elements.[8][9]

The score is calculated using the following assessment:

• Breathing effort
  • If the neonate is not breathing, the respiratory score is 0.
  • If respirations are slow and irregular, weak, or gasping, the respiratory score is 1.
  • If the neonate is crying vigorously, the respiratory score is 2.

• Heart rate
  • The heart rate is evaluated with a stethoscope or an electrocardiogram and 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 <100 bpm, the heart rate score is 1.
  • If the heart rate is >100 bpm, the heart rate score is 2.

• Muscle tone
  • In inactive neonates with loose and floppy muscle tone, the score for muscle tone is 0.
  • In neonates demonstrating some tone and flexion, the score for muscle tone is 1.
  • In neonates in active motion with a flexed muscle tone that resists extension, the muscle tone score is 2.

• Grimace response or reflex irritability in response to stimulation
  • In a neonate with no response to stimulation, the reflex irritability response score is 0.
  • A neonate grimacing in response to stimulation has a reflex irritability response score of 1.
  • In a neonate who cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.

• Color
  • Most infants will score 1 for color even at the 5-minute, as peripheral cyanosis is common among normal infants. Color can also be misleading in non-white infants.[10]
  • If the neonate 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 neonate is entirely pink, the score for color is 2.

Clinical Significance

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. While there is some evidence of poor long-term outcomes with a low Apgar score at 1 minute, the change in scores from 1 to 5 minutes and the individual scores at 5 and 10 minutes are more predictive.[11][12][11][13][14][15]

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.[16] Most infants with low Apgar scores do not go on to develop cerebral palsy, but lower scores over time increase the population's risk of poor neurologic outcomes. Scores <5 at 5 and 10 minutes correlate with an increased relative risk of cerebral palsy. Neonates with scores <5 at 5 minutes after delivery should have cord blood gas sampling performed. Apgar scores that remain at 0 after 10 minutes are predictive of a poor outcome, though a significant portion of those babies survive, and many have no neurodevelopmental disabilities.[16][17] Experts no longer recommended that resuscitative efforts be terminated at 10 minutes with an Apgar score of 0.[17]

Enhancing Healthcare Team Outcomes

Physicians, advanced practitioners, midwives, respiratory therapists, and nurses play pivotal roles in Apgar scoring, with consistency in scoring crucial to mitigate inter-rater variability. Interprofessional team members are each instrumental in assessing neonates and promptly communicating any changes in Apgar scores to the attending clinician. Health professionals each play a crucial role in documenting scores at 1 and 5 minutes and working with other clinicians in initial resuscitative measures for low-scored neonates. Interprofessional communication ensures findings are shared with the mother and family, facilitating collaborative care planning. Physicians, advanced practitioners, midwives, and nurses should address family concerns, provide education leaflets, and emphasize patient education for managing neonates with low Apgar scores. This collaborative approach fosters optimal patient-centered care, enhancing outcomes and safety through effective team performance.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses looking after newborns should know the Apgar score and its significance. Nurses should understand that a score between 7-10 is average; a score between 4-6 needs proper reevaluation. A score of less than 3 is never good, and immediate attention is mandatory. In this situation, the nurse should immediately call a code and inform the clinician.

Nursing, Allied Health, and Interprofessional Team Monitoring

• Apgar scoring at 1 and 5 minutes
• The general condition of the neonate
• Vital signs of the newborn
• Umbilical cord pH
• Arterial blood gases of the newborn