1. Killion, Molly M. MS, RN, CNS

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A new committee opinion from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) (2015) offers further guidance on appropriate use of the Apgar score. The Apgar score was developed in 1952 by Dr. Virginia Apgar to assess the clinical state of a newborn (AAP & ACOG). It includes five assessments (each of which is assigned a score from zero to two): color, heart rate, reflexes, muscle tone, and respirations. An Apgar score is usually assigned at 1 and 5 minutes of life and then at 5-minute intervals until 20 minutes of life for babies with a score less than seven (AAP & ACOG). Although it was designed to quantitatively assess signs of neonatal depression, it should not be used to judge a need for resuscitation, when to start resuscitation, or which steps for resuscitation are required (AAP & American Heart Association, 2011). An Apgar score remaining at zero past 10 minutes of life may be helpful in deciding if resuscitative measures should be stopped (AAP & ACOG). Improvement in the Apgar score from 1 minute to 5 minutes may indicate a favorable response to resuscitation; however, Apgar scores assigned during resuscitation may not correspond to those scores assigned to spontaneously breathing newborns. An accepted standard for assigning Apgar scores during resuscitation has not been developed (AAP & ACOG). There may be utility in using documentation extending past the Apgar score when an infant is undergoing resuscitation that includes the assessment of neonatal response and which resuscitative techniques were used (AAP & ACOG). An example of medical record documentation in this situation is available in the new committee opinion (AAP & ACOG).


As per ACOG and AAP (2014) in Neonatal Encephalopathy and Neurologic Outcome, Apgar scores alone are not accurate predictors of infant outcomes. Hypoxic-ischemic encephalopathy often implies an injury that occurred at or around the time of birth but to label it as such requires a full etiologic examination of cause and timing that includes 5- and 10-minute Apgar scores, umbilical cord arterial blood gases, neuroimaging with magnetic resonance imaging, and presence of multisystem organ failure (ACOG & AAP). If this evaluation is unable to be done, the term neonatal encephalopathy should be used instead (ACOG & AAP). The Apgar score should not be independently used to note evidence of asphyxia (AAP & ACOG, 2015); however, if the 5-minute Apgar score is seven or greater, it is unlikely there was a hypoxic-ischemic event around the time of birth that played a large part in causing neonatal encephalopathy. An Apgar score of 0-3 at 1 minute of life does not predict long-term outcomes, whereas a 5-minute Apgar score of 0-3 does correlate with neonatal mortality, but not future neurologic morbidity (AAP & ACOG). An umbilical arterial cord blood gas should be collected for any newborn with a 5-minute Apgar score of less than six and consideration should be given to sending the placenta for pathologic evaluation (AAP & ACOG). Regardless of the 1-minute Apgar score, a 5-minute score of 7-10 is considered reassuring, 4-6 as moderately abnormal, and 0-3 as concerning (AAP & ACOG).


When the Apgar score is used as intended, it can accurately describe the state of the newborn immediately after birth and how the baby is transitioning to extrauterine life (AAP & ACOG, 2015). Conversely, Apgar scores alone do not accurately predict an individual infant's risk for mortality or neurologic morbidity and most infants with low Apgar scores do not develop cerebral palsy (AAP & ACOG).




American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2015). The Apgar score (Committee Opinion No. 644). Pediatrics, 136(4), 819-822. doi:10.1542/peds.2015-2651 [Context Link]


American Academy of Pediatrics, & American Heart Association. (2011). Textbook of neonatal resuscitation (6th ed.). Elk Grove Village, IL: Authors. [Context Link]


American College of Obstetricians and Gynecologists, & American Academy of Pediatrics. (2014). Neonatal encephalopathy and neurologic outcome (2nd ed.). Washington, DC: Authors. [Context Link]