Apgar score

Image:Apgar score.png

Various members of the healthcare team, including midwives, nurses, or physicians, may be involved in the Apgar scoring of a neonate. The test is generally done at one and five minutes after birth and may be repeated later if the score is and remains low. Scores of seven and above are generally normal; four to six, fairly low; and three and below are generally regarded as critically low and cause for immediate resuscitative efforts.{{Cite journal|last1=Newborn|first1=American Academy of Pediatrics Committee on Fetus And|last2=Practice|first2=American College of Obstetricians and Gynecologists Committee on Obstetric|date=2015-10-01|title=The Apgar Score|journal=Pediatrics|language=en|volume=136|issue=4|pages=819–822|doi=10.1542/peds.2015-2651|issn=0031-4005|pmid=26416932|s2cid=31689176|doi-access=free}}

A low score on the one-minute mark may show that the neonate requires medical attention,{{cite journal | vauthors = Casey BM, McIntire DD, Leveno KJ | title = The continuing value of the Apgar score for the assessment of newborn infants | journal = The New England Journal of Medicine | volume = 344 | issue = 7 | pages = 467–71 | date = February 2001 | pmid = 11172187 | doi = 10.1056/NEJM200102153440701 | doi-access = free }} but does not necessarily indicate a long-term problem, particularly if the score improves at the five-minute mark. A constellation of factors may contribute to a low Apgar score value.{{Cite journal|last=Pediatrics|first=American Academy of|date=2014-05-01|title=Neonatal Encephalopathy and Neurologic Outcome, Second EditionReport of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy|journal=Pediatrics|language=en|volume=133|issue=5|pages=e1482–e1488|doi=10.1542/peds.2014-0724|issn=0031-4005|doi-access=free}} An Apgar score that remains below three at five minutes and later times, such as 10, 15, or 30 minutes, does not provide supporting evidence for a specific illness but can sometimes be among the first indicators of neonatal encephalopathy.{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK328263/|title=Care of the baby and woman immediately after birth|date=December 2014|publisher=National Institute for Health and Care Excellence (UK)}} However, the Apgar test's purpose is to determine quickly whether or not a newborn needs immediate medical care. It is not designed to predict long-term health issues.{{cite journal|author-link=Virginia Apgar|vauthors=Apgar V|year=1953|title=A proposal for a new method of evaluation of the newborn infant|url=https://profiles.nlm.nih.gov/ps/access/cpbbkg.pdf|journal=Current Researches in Anesthesia & Analgesia|volume=32|issue=4|pages=260–7|doi=10.1213/00000539-195301000-00041|pmid=13083014}}

A score of 10 is uncommon due to the prevalence of transient cyanosis, and does not substantially differ from a score of nine. Transient cyanosis is common, particularly in babies born at high altitude.{{cite journal | vauthors = Gonzales GF, Salirrosas A | title = Arterial oxygen saturation in healthy newborns delivered at term in Cerro de Pasco (4340 m) and Lima (150 m) | journal = Reproductive Biology and Endocrinology | volume = 3 | pages = 46 | date = September 2005 | pmid = 16156890 | pmc = 1215518 | doi = 10.1186/1477-7827-3-46 | doi-access = free }}

File:HumanNewborn.JPG

In cases where a newborn needs resuscitation, it should be initiated before the Apgar score is assigned at the one-minute mark. Therefore, the Apgar score is not used to determine if initial resuscitation is needed, rather it is used to determine if resuscitation efforts should be continued. Variation between the one-minute and five-minute Apgar scores can be used to assess an infant's response to resuscitation. If the score is below seven at the five-minute mark, the Neonatal Resuscitation Program guidelines specify that the infant's Apgar score should be reassessed at five-minute intervals for up to 20 minutes.

Exceedingly few infants who have an Apgar score of 0 at 10 minutes of age survive with intact neurological function. As a result, the 2011 Neonatal Resuscitation Program suggests that if no pulse is appreciable at 10 minutes of life, "discontinuation of resuscitative efforts may be appropriate." However, in a recent retrospective study including 17 infants with an Apgar score of 0 at 10 minutes who received therapeutic hypothermia, 4 of the 8 surviving babies had no neurological abnormalities, and only one infant had severe abnormalities, as assessed through brain MRI.{{Cite journal|last1=Ayrapetyan|first1=Marina|last2=Talekar|first2=Kiran|last3=Schwabenbauer|first3=Kathleen|last4=Carola|first4=David|last5=Solarin|first5=Kolawole|last6=McElwee|first6=Dorothy|last7=Adeniyi-Jones|first7=Susan|last8=Greenspan|first8=Jay|last9=Aghai|first9=Zubair H.|date=April 2019|title=Apgar Scores at 10 Minutes and Outcomes in Term and Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era|journal=American Journal of Perinatology|volume=36|issue=5|pages=545–554|doi=10.1055/s-0038-1670637|issn=0735-1631|pmc=8039809|pmid=30208498}}

During neonatal resuscitation, Apgar scores may not accurately represent the condition of the neonate as resuscitation measures (i.e. positive pressure ventilation and chest compressions) may artificially elevate scores. As a result, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage the use of an expanded Apgar score report, which records resuscitation efforts utilized at each time point.

A systematic review that analyzed the relationship between umbilical cord pH and neonatal outcomes found that low cord pH is strongly correlated with mortality, morbidity and cerebral palsy in childhood.{{cite journal | vauthors = Malin GL, Morris RK, Khan KS | title = Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis | journal = BMJ | volume = 340 | issue = may13 1 | pages = c1471 | date = May 2010 | pmid = 20466789 | pmc = 2869402 | doi = 10.1136/bmj.c1471 }} To reduce the risk of negative outcomes, it is recommended to obtain a sample of the umbilical artery blood gas when a newborn has an Apgar score of five or less at the five-minute mark.

Recognizing the importance of skin to skin contact (SSC), the World Health Organization (WHO), as part of the Baby Friendly Hospital Initiative, recommends that the Apgar score should be done while SSC is underway whenever possible.{{Cite journal|last1=Feldman-Winter|first1=Lori|last2=Goldsmith|first2=Jay P.|last3=Newborn|first3=Committee on Fetus And|last4=Syndrome|first4=Task Force on Sudden Infant Death|date=2016-09-01|title=Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns|journal=Pediatrics|volume=138|issue=3|pages=e20161889|language=en|doi=10.1542/peds.2016-1889|issn=0031-4005|pmid=27550975|s2cid=19866683|doi-access=free}} This recommendation was adopted by the American Academy of Pediatrics in 2009.

There are numerous factors that contribute to the Apgar score, several of which are subjective. Examples of subjective factors include but are not limited to color, tone, and reflex irritability.{{Cite web |title=Apgar score: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/003402.htm |access-date=2022-11-18 |website=medlineplus.gov |language=en}} Preterm infants may receive a lower score in these categories due to lack of maturity rather than asphyxia. Other factors that may contribute to variability among infants are birth defects, sedation of the mother during labor, gestational age or trauma. Inappropriately using the Apgar score has led to errors in diagnosing asphyxia.

Various studies have shown that the Apgar score has variability between individual medical providers. One study was done in which several health care providers were assigned to give Apgar scores to the same infants. Results showed an Apgar score consistency of 55% to 82% between health care providers.{{Cite journal|last=Montgomery|first=Kristen S.|date=2000|title=Apgar Scores: Examining the Long-term Significance|journal=The Journal of Perinatal Education|volume=9|issue=3|pages=5–9|doi=10.1624/105812400X87716|issn=1058-1243|pmc=1595023|pmid=17273212}}{{Cite journal|last=Livingston|first=Jacquelynn|date=1990-11-01|title=Interrater reliability of the apgar score in term and premature infants|journal=Applied Nursing Research|volume=3|issue=4|pages=164–165|doi=10.1016/S0897-1897(05)80139-9|pmid=2252404|issn=0897-1897}} Ideally, to limit variability and bolster consistency, it is preferred that the same individual determine the 1-minute and 5-minute Apgar scores.

A 2023 paper of nine million babies, found that non-white babies were given lower Apgar scores than white babies, as their darker skin color often results in lower scores on the appearance measure, making them more likely to receive medical care that might not be needed.Rabin, Roni Caryn. [https://www.nytimes.com/2024/07/13/health/apgar-score-black-infants.html "Why Does a Routine Test of Newborns Reward 'Pink' Skin? The Apgar test grades infants in five areas, including skin tone. Babies of color score lower, and may be subjected to unnecessary treatment."], The New York Times, July 15, 2024. Accessed July 16, 2024. "Dr. Grünebaum led a study that analyzed the Apgar scores of more than nine million American babies born between 2016 and 2019. Overall, he found, only 2.6 percent of newborns got a perfect score. But the odds for a Black baby to do so were less than half those of a white infant: 3.3 percent of white babies scored a perfect 10, compared with 1.4 percent of Black newborns, the study found.... But critics of the Apgar score’s reliance on skin color fear that it is resulting in extra medical treatment being heaped on babies of color who are healthy, potentially sending them to intensive care unnecessarily."

Apgar originally developed the criteria as a way to address the lack of a standardized way to assess the need for assistive breathing procedures for newborns. In 1952, after some refinement of her initial system, Apgar presented the Apgar score at a joint meeting between the International Anesthesia Research Society and the International College of Anesthetists, and it was then published in Anesthesia & Analgesia in 1953.{{cite journal| author=Apgar V| title=A Proposal for a New Method of Evaluation of the Newborn Infant. Originally published in July 1953, volume 32, pages 250-259. | journal=Anesth Analg | year= 2015 | volume= 120 | issue= 5 | pages= 1056–1059 | pmid=25899272 | doi=10.1213/ANE.0b013e31829bdc5c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25899272 }}

In 1955, efforts to establish a scientific basis to the score increased. Alongside Duncan Holaday and Stanley James, Apgar published a research paper using the scores of 15,348 infants to establish the association between a low Apgar score (0-2) and laboratory findings characteristics of asphyxia.{{Cite journal|last=Apgar|first=Virginia|title=Evaluation of the Newborn Infant-Second Report|date=1958-12-13|url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.1958.03000150027007|journal=Journal of the American Medical Association|language=en|volume=168|issue=15|pages=1985–1988|doi=10.1001/jama.1958.03000150027007|pmid=13598635|issn=0002-9955|url-access=subscription}}

The Apgar score is no longer used as a way to determine the need for newborn resuscitation because supportive measures must be implemented prior to 1 minute after birth, the first time-point at which the Apgar score is determined. However, the Apgar score is a method of assessment endorsed by the American College of Obstetricians and Gynecologist and the American Academy of Pediatrics.

Some ten years after initial publication,{{Cite web |title=What Is a Good Apgar Score? |url=https://my.clevelandclinic.org/health/diagnostics/23094-apgar-score |access-date=2022-11-18 |website=Cleveland Clinic |language=en}} a backronym for APGAR was coined in the United States as a mnemonic learning aid: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration.

• Spanish: Apariencia, Pulso, Gesticulación, Actividad, Respiración;
• Portuguese: Aparência, Pulso, Gesticulação, Atividade, Respiração;
• French: Apparence, Pouls, Grimace, Activité, Respiration;
• German: Atmung, Puls, Grundtonus, Aussehen, Reflexe, representing the same tests but in a different order (respiration, pulse, muscle tone, appearance, reflex).
• Czech: Adaptace kůže, Pulz, Grimasy, Aktivita svalů, Respirace;{{Cite web|url=https://www.maminka.cz/clanek/co-je-to-apgar-skore-a-kdo-ho-vymyslel-podivejte-se-na-video|title=Co je to APGAR skóre a kdo ho vymyslel?|website=www.maminka.cz|access-date=2020-01-12|language=cs}}

Another eponymous backronym from Virginia Apgar's name is American Pediatric Gross Assessment Record.

Another mnemonic for the test is "How Ready Is This Child?", which summarizes the test criteria as Heart rate, Respiratory effort, Irritability, Tone, and Color.{{cite book | vauthors = Klostranec JM, Hong J, Raghuran K | title = The Essential Med Notes for Medical Students | date = 2012 | publisher = University of Toronto Press | location = Toronto, ON }}

• Ballard Maturational Assessment
• Bishop score
• Glasgow Coma Scale
• Midwifery
• Paediatric Glasgow Coma Scale

{{Reflist}}

• {{cite journal | vauthors = Apgar V | title = The newborn (Apgar) scoring system. Reflections and advice | journal = Pediatric Clinics of North America | volume = 13 | issue = 3 | pages = 645–50 | date = August 1966 | pmid = 5946299 | doi = 10.1016/S0031-3955(16)31874-0 | url = http://profiles.nlm.nih.gov/ps/access/CPBBJY.pdf | author-link = Virginia Apgar|ref=none}} (Retrieved from [http://profiles.nlm.nih.gov/ps/retrieve/Collection/CID/CP Profiles in Medicine-The Virginia Apgar Papers])

• [http://www.evidencio.com/models/show/160 Online calculator of the Apgar score]

{{Physical exam}}

{{Medical mnemonics}}

{{Obstetric signs and symptoms}}

{{Authority control}}

{{DEFAULTSORT:Apgar Score}}

Category:American inventions

Category:Diagnostic obstetrics and gynaecology

Category:Infant mortality

Category:Medical scales

Category:Medical assessment and evaluation instruments

Category:Medical mnemonics