Apgar Scoring Performing

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NURSING
PRACTICE &
SKILL
Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Reviewers
Amy Hurst, RN, MSN
Cinahl Information Systems, Glendale, CA
Darlene Strayer, RN, MBA
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
April 28, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Apgar Scoring: Performing
What is Apgar Scoring?
› The Apgar scoring system is an assessment tool used to assess the newborn at 1 and 5
minutes after birth by quantifying five physiologic signs: pulse rate, respiratory effort,
muscle tone, reflex irritability (i.e., response to stimulation), and skin color. The score
recorded at 1 minute gives an indication of the newborn’s tolerance of labor and delivery
and how well he/she is initially adapting to life outside of the uterus. The score recorded
at 5 minutes provides a more accurate indication of the newborn’s overall health. If the
5-minute score is less than 7, additional scoring should be performed every 5 minutes
thereafter for up to 20 minutes
• What: Each of the 5 physiologic signs that are evaluated using the Apgar scoring system
is assigned a score of 0–2for a maximum total sum of 10 (for details, see the table
below). A total score of 7–10 indicates good physiologic status, a score of 4–6 indicates
fair condition (i.e., moderate difficulty adjusting to extrauterine life), and a score of 0–3
indicates that the newborn’s clinical condition is poor (i.e., the newborn is in severe
distress). If neonatal resuscitation is necessary at the time of delivery, it should be
initiated as soon as possible without waiting for the first Apgar score to be obtained at 1
minute. According to the 2010 neonatal resuscitation guidelines issued by the American
Heart Association (AHA) and the American Academy of Pediatrics (AAP), the decision
to initiate resuscitation should not be made based on the newborn’s Apgar score. (For
more information, seeWhat You Need to Know Before Apgar Scoring and Nursing
Practice and Skill ... Neonatal Resuscitation (Birth throughout Initial Hospitalization):
Performing)
• How: When performing Apgar scoring, the clinician observes standard precautions and
adheres to facility/unit protocols regarding care of the newborn. Apgar scoring coincides
with the completion of other critical postnatal tasks, including drying and warming the
newborn, stimulating the newborn in order to promote normal respiration and heart rate,
and providing resuscitation, if indicated. An Apgar timer (i.e., a hand-held, electronic
device that is preset to signal the clinician at 1-, 5-, and 10-minuteintervals) can be used
to alert the clinician when it is time to assess the Apgar scores
• Where: Apgar scoring is performed in childbirth settings (e.g., delivery rooms and
birthing suites of inpatient healthcare facilities, free standing birth centers, home
birth settings). In the inpatient setting, scoring may be repeated after the initial 1- and
5-minute assessment in the newborn nursery or neonatal intensive care unit (NICU),
particularly if the infant had low initial scores, the delivery was traumatic, or extensive
resuscitation was required
• Who: Apgar scoring is performed by appropriately trained neonatal clinicians (e.g.,
physicians, registered nurses, midwives, nurse practitioners). To avoid bias, the Apgar
score should be obtained by a clinician who was not directly involved in providing care
for the mother during labor and delivery. Apgar scoring is commonly performed in the
presence of the newborn’s parents and others who were present during delivery
What is the Desired Outcome of Apgar Scoring?
› The desired outcome of Apgar scoring is to obtain accurate data regarding the newborn’s
clinical status and initial adjustment to extrauterine life
Why is Apgar Scoring Important?
› The Apgar score is a standardized tool for rapid assessment of the newborn. Although the Apgar score was introduced
approximately 60 years ago as the first neonatal assessment tool, its use continues to be an important part of modern neonatal
care
• Because the Apgar scoring system is limited to 5 physiologic parameters, an experienced clinician can assign an Apgar
score quickly and proceed to other important postnatal tasks
• Apgar score documentation comprises an essential element of the newborn’s medical record and can be accessed in the
future if needed for medical or legal purposes as evidence of the newborn’s clinical status at the time of birth and response
to interventions provided
Facts and Figures
› The Apgar score was developed in the early 1950s by anesthesiologist Dr. Virginia Apgar (National Library of Medicine,
n.d.)
› The American College of Obstetricians and Gynecologists (ACOG) recommends against general application of Apgar scores
alone to predict long-termhealth outcomes such as cerebral palsy and other neurologic disabilities (ACOG, 2006)
› Although questions exist regarding the predictive value of the Apgar score, investigators of individual studies maintain that it
is an effective marker for
• neonatal mortality
–In low birth weight infants (i.e., infants weighing 1,500–2,499 grams at delivery), an Apgar score at 5 minutes of < 5 is a
good predictor of neonatal mortality (Mori et al., 2008)
–Very low Apgar scores (e.g., 0–3) at 5 and 10 minutes after delivery are associated with increased risk of cerebral palsy,
neonatal seizures, and neonatal death (Chen et al., 2010)
–In preterm infants born at 24 weeks of gestation, the 5 minute Apgar score was the most useful predictor for survival
without severe brain damage (Forsblad et al., 2008)
• disease in childhood and adulthood
–Apgar score history combined with other assessment data can be used to guide the development of individualized
preventive care interventions for avoidance or early detection and treatment of illness
–Risk of developing childhood cancer, particularly before 6 months of age, is substantially higher in children whose
5-minute Apgar scores was ≤ 5 compared with children who had higher scores according to investigators of a
population-based study of 5 million children in Norway and Sweden. After adjusting for maternal factors (e.g., age,
history of smoking during pregnancy) and neonatal characteristics (e.g., sex, birth weight, gestational age), newborns
whose 5-minute Apgar scores were 5 or less were 6 times more likely than newborns with Apgar scores of 9–10 to be
diagnosed with Wilms’ tumor, retinoblastoma, and other common childhood cancers (Li et al., 2012)
–Risk of attention deficit hyperactivity disorder (ADHD) is 75% higher in children who had Apgar scores of 1–4 at 5
minutes compared with children who had scores of 9 or 10 (Li et al., 2011)
–Children who had an Apgar score of < 8 at 5 minutes are more likely to develop dental caries in primary teeth than
children who had scores of 9 or 10 (Sanders et al., 2010)
–An Apgar score of < 7 at 5 minutes was found to be consistently associated with increased prevalence of neurologic
disability and low cognitive function in early adulthood (Ehrenstein et al., 2009)
› Because it is a semi-objective assessment tool that relies partially on clinician observation, Apgar scoringis subject to
variability in interobserver agreement. This is particularly true in the assessment of preterm newborns, who generally
demonstrate lower Apgar scores as a result of physiologic immaturity. In a study by the AAP, 335 neonatal clinicians (75%
of whom reported having more than 12 years of clinical experience in the delivery room) participated in a video-based study
in which they were asked to assign Apgar scores to newborns in four video clips at 1, 5, and 10 minutes after birth. High
interobserver agreement was demonstrated in scoring the healthy, full-term infant, but considerable variability was found
when scoring the three preterm infants except at times when the infants showed indisputable signs of extreme sickness (e.g.,
apnea, complete lack of response to stimulation) (Bashambu et al., 2012)
What You Need to Know Before Apgar Scoring
› The Apgar scoring system evaluates and assigns a score of 0, 1, or 2 for each of 5 physiologic signs as shown below. The
Apgar score is measured at one minute and five minutes after birth; if the 5-minute score is < 7, scoring typically continues
every five minutes until the newborn’s condition stabilizes or until 20 minutes have passed since birth. APGAR has been
used as a mnemonic device representing A ppearance, P ulse, G rimace, A ctivity, R espiratory effort, but this is not
the order in which the newborn’s status is assessed. The correct order of assessment, beginning with pulse, is indicated in the
table below
› .
SIGN SCORE (assign points based on response)
0 1 2
Pulse rate Absent < 100 ≥ 100
Respiratory effort:
Breathing
Absent Slow, irregular,
gasping; weak cry
Good; strong cry
Activity: Muscle
tone
None; flaccid Some flexion of
extremities
Active motion;
flexed arms and
legs which resist
extension
Grimace: Reflex
irritability
No response to
stimulation
Feeble cry when
stimulated
Strong cry; pulls
away or sneezes
when stimulated
with catheter in nare
Appearance: Skin
color
Pallor, cyanosis Pink body, blue
extremities
Completely pink
.
• Total scores are interpreted as follows:
–A score of 0–3 indicates poor clinical status (i.e., severe distress); although the Apgar score is not used to determine the
need for resuscitation, resuscitation should typically already be underway for newborns with scores in this low range
–A score of 4–6 indicates fair status (i.e., moderate difficulty adjusting to extrauterine life); infants with scores in this range
typically receive interventions such as suctioning the airway and physical stimulation (e.g., rubbing the back or flicking
the foot) to achieve a subsequent Apgar score of ≥ 7
–A score of 7–10 indicates minimal or no difficulty adjusting to extrauterine life
• Multiple factors, both neonatal and maternal, affect Apgar scores
–Prematurity is associated with lower Apgar scores due to physiologic underdevelopment (e.g., resulting in reduced tone
and/or reflex irritability)
–Use of medical interventions during labor, cesarean delivery, infection, and congenital abnormalities can result in lower
Apgar scores
–In a study comparing Apgar scores among male infants, investigators found that maternal socioeconomic factors
influenced Apgar scores. Mothers who were self-employed were less likely to have an infant with an Apgar score of <
7 at 5 minutes compared with mothers who worked in manual occupations. Risk of low Apgar scores decreased as the
mother’s level of education increased (Odd et al., 2008)
–Newborns of women who are obese (e.g., body mass index [BMI] of 30–39) or morbidly obese (e.g., BMI ≥ 40) were
more likely to have low Apgar scores (e.g., 4–6) at 5 minutes compared with newborns of normal weight mothers.
Maternal weight was not found to influence risk of very low (e.g., 0–3) Apgar scores (Chen et al., 2010)
• The clinician who performs Apgar scoring must demonstrate competence in physical assessment and neonatal care and
possess knowledge of pediatric advanced life support (PALS) techniques
–The clinician should be well versed in normal neonatal appearance and behavior in the immediate postnatal period and in
the techniques used to obtain scores in each category
- Pulse rate is assessed first, either by auscultation of the apical pulse (pulse is typically counted for 30 seconds and the
rate obtained by multiplying by 2) using a stethoscope, or by palpation of the umbilical cord (pulse is counted for 6
seconds, and the rate is obtained by multiplying by 10) using the fingers of a gloved hand
- For detailed information about apical pulse assessment, see Nursing Practice & Skill ... Apical Pulse: Taking
- Respiratory effort is assessed by counting and assessing the quality of respirations during the course of 1 minute.
The clinician should expect the healthy newborn to have a strong cry and a respiratory rate of 30–60 unassisted (i.e.,
spontaneous) breaths/min
- Muscle tone is assessed by bringing the infant’s limbs out of flexion, which is the normal state for newborns, and
assessing infant resistance to extension; the healthy newborn typically demonstrates resistance to extension with
appropriate flexion of the hips, knees, and elbows
- Reflex irritability is determined by flicking the sole or suctioning the nare and noting the newborn’s response; the
clinician should expect the healthy newborn to cry and/or pull away when stimulated
- The score for skin color is obtained by thorough observation of the infant’s tone on all skin surfaces; if the infant has
dark skin, assessment of the oral mucosa, palms of the hands, and soles of the feet is particularly useful in determining
the presence or absence of cyanosis. At the time of delivery and prior to the first breath, newborns’ normal appearance
is cyanotic; by the 1-minute Apgar score when breathing has been initiated, the skin becomes pink corresponding with
tissue perfusion
- The majority of healthy newborns are not given Apgar scores of 10 because their skin is not completely pink (e.g., the
hands and feet are not yet well-perfused) at the 1-minute marker
-
–Because the clinician who is performing Apgar scoring is typically simultaneously involved in or responsible for
providing immediate care to the newborn, which may include resuscitation, knowledge of AHA/AAP neonatal
resuscitation guidelines and the facility/unit protocol for neonatal resuscitation (which should reflect the most current,
established guidelines)is important
- At the time of delivery, the clinician who is responsible for Apgar scoring conducts a brief assessment of the newborn
to determine whether the infant should be dried, warmed, and assigned an Apgar score at 1 minute or be brought to the
radiant warmer/resuscitation table immediately for resuscitation. Immediate resuscitation prior to the 1-minute Apgar
score is necessary if the newborn does not meet all three of the following criteria at the time of delivery:
- Born at term
- Breathing or crying
- Good tone
- If all criteria are not met, neonatal resuscitation is initiated in accordance with facility/unit protocol. The 2010 AHA/
AAP guidelines recommend providing the following interventions, as needed, in sequence (for details see the previously
referenced Nursing Practice & Skill about neonatal resuscitation):
- Initial stabilization strategies (e.g., suctioning the airway, drying the body, physically stimulating the newborn)
- Ventilation with 40–60 breaths/minute for rescue breathing and 30 breaths/minute for cardiopulmonary resuscitation
(CPR)
- Chest compressions with 3 chest compressions for every breath (3:1 ratio) for a total of 90 compressions/minute during
CPR
- Administration of emergency medication (e.g., EPINEPHrine, volume expanders)
- If at any time during Apgar scoring the newborn’s heart rate is less than 100 beats/minute and/or the newborn is not
breathing, resuscitation should be immediately initiated in accordance with facility/unit protocols
• Preliminary steps that should be performed before initiating Apgar scoring include the following:–Review the facility/unit protocols for newborn assessment and documentation, and for neonatal resuscitation, if these are
available
–Review the treating clinician’s orders and maternal medical record for information about anticipated level of support
necessary at birth (e.g., known maternal or fetal conditions that may warrant immediate resuscitation)
–Verify that all supplies/equipment (e.g., stethoscope, Apgar timer) are clean, ready for immediate use, and in good
working order
• Gather supplies necessary for Apgar scoring, which typically include the following:
–Nonsterile gloves; additional personal protective equipment (PPE; e.g., gown, face mask, eye protection) may be
necessary depending on facility/unit protocol
–Apgar scoring sheet or facility newborn assessment documentation form
–Apgar timer or a clock or watch with a second hand
–Stethoscope that is disinfected with a facility-approved,hospital-grade disinfectant wipe and warmed prior to use
–Facility-approved, hospital-grade disinfectant to wipe stethoscope after use
–Warmed towel
–Radiant warmer, suction equipment, and neonatal resuscitation equipment
How to Perform Apgar Scoring
› Perform hand hygiene; don nonsterile gloves and additional PPE as needed
› If possible, introduce yourself to the parent(s) and other visitors that are present prior to the time of delivery, and briefly
explain your clinical role in newborn resuscitation and Apgar scoring. Assess parent anxiety and for knowledge deficits
regarding Apgar scoring
• If not previously done by the mother’s nurse, determine if the patient/family requires special considerations regarding
communication (e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs if they are
present
–Follow facility protocols for using a professional certified medical interpreter, either in person or by telephone, when a
language barrier exists
› Note the time of delivery in order to perform timely Apgar scoring at 1 and 5 minutes after delivery; if using an Apgar timer,
start the timer at the exact delivery time
› Perform a brief assessment of the newborn to determine whether resuscitation or routine care is appropriate
• If the newborn was born preterm, is not breathing or crying, and/or is not demonstrating good tone (i.e., is “floppy”), place
him/her on the resuscitation table or radiant warmer and begin resuscitation in accordance with facility/unit protocol
› If the newborn was born at term, is breathing or crying, and demonstrates good tone, dry and warm the infant immediately
to prevent heat loss (e.g., place the newborn in skin-to-skin contact with the mother and cover with a dry linen drape) and
proceed with routine care, including Apgar scoring at 1 minute
› At 1 minute after delivery, begin Apgar scoring by assigning a score for the infant’s
• pulse rate
–Assess the heart rate by auscultation of the apical pulse or by palpation of the umbilical cord
- If auscultating the apical pulse, place the stethoscope at the fourth intercostal space lateral to the left midclavicular line.
Count heartbeats for 30 seconds and multiply this number by 2
-
- If palpating the umbilical cord after it is clamped and cut, place two fingers at the base of the cord for 6 seconds, count
the pulsations, and multiply this number by 10; prior to cord cutting and clamping, pulsations can be observed and
counted at the abdomen
–Assign a score of 0 for no pulse rate, 1 for pulse rate < 100 beats/min, and 2 for pulse rate ≥ 100 beats/min
• respiratory effort
–Observe respirations for 1 minute, noting the respiratory rate and quality of respirations and the strength of the newborn’s
cry
–Assign a score of 0 for absent spontaneous respirations; 1 for shallow, gasping, weak, or slow respirations (e.g., < 30
breaths/min); and 2 for regular spontaneous respirations (e.g., 30–60 breaths/min) or vigorous crying
• muscle tone
–Extend the infant’s limbs outward and observe how they return to normal flexion
–Assign a score of 0 if the infant’s limbs do not return to flexion, 1 if limbs return to partly flexed with little resistance to
extension, and 2 if the limbs rapidly return to flexion and have good resistance to extension
• reflex irritability
–Evaluate reflex irritability by flicking the sole of the foot or by placing a suction catheter in the nare
–Assign a score of 0 if there is no response, 1 for weak cry or grimace, and 2 if the infant emits a strong cry, pulls away, or
sneezes in response to the presence of a suction catheter in the nare
• skin color
–Observe the infant’s overall complexion and the color of the extremities. Observe the oral mucous membranes and
conjunctivae, lips, palms, and soles to assess color in infants with dark skin
–Assign a score of 0 if the infant is pale and extremities are cyanotic, 1 if the torso is of normal color but the extremities
are cyanotic, and 2 if the infant has a completely pink body
› Add each score to obtain the total sum, and document the score on the Apgar scoring sheet or on the newborn assessment
form according to facility protocol
› Repeat Apgar scoring at 5 minutes after delivery
› Disinfect the stethoscope and other equipment according to facility/unit protocol; discard used procedure materials and PPE,
and perform hand hygiene
› Document performing Apgar scoring in the patient’s medical record, including the following information:
• Date and times scoring was performed
• Results of scoring in each category and in total, and details regarding low or very low Apgar scores
• Medical/nursing interventions that were performed in response to low or very low Apgar scores
• Newborn’s response to medical/nursing interventions
• Mother/partner/family member education that was provided, including topics presented, response to education, plan for
follow-upeducation, barriers to communication and learning, and/or techniques that promoted successful communication
and learning
Other Tests, Treatments, or Procedures That May be Necessary Before or After Apgar
Scoring
› If initial scores are low or the infant is at risk for secondary effects of sedation or analgesia, perform additional scoring (e.g.,
every 5 minutes until 20 minutes after delivery) as ordered or as indicated by facility protocol
› Throughout the course of Apgar scoring, perform standard newborn care interventions in accordance with facility/unit
protocol (e.g., airway suctioning, warming strategies, physical stimulation)
What to Expect After Apgar Scoring
› Apgar scoring is performed accurately and efficiently so that the newborn’s clinical status, initial adjustment to extrauterine
life, and need for medical and nursing intervention is assessed in a timely manner
Red Flags
› The Apgar score can be influenced by maternal analgesia or sedation within 4 hours before delivery. Newborns affected by
secondary sedation can have high initial Apgar scores and low subsequent scores that indicate respiratory and neurologic
depression
What Do I Need to Tell the Mother/Spouse/Patient’s Family?
› Prior to delivery, the mother (and spouse/partner, if present) should be informed about what will occur immediately
following delivery, including Apgar scoring. The mother (and spouse/partner) should be reassured that Apgar scoring is a
normal procedure that is performed to assess the baby’s well being
• Educate that an Apgar score of 7–10 indicates good adjustment to extrauterine life, and explain that healthy newborns often
have scores that are less than 10(e.g., due to poor initial perfusion of the hands and feet)
References
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