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Apgar Test

Osher Ben Or, Certified Midwife
13 June 2024

The Apgar test is a quick and methodical tool for assessing a newborn's medical condition. The test is conducted twice: one minute and five minutes after birth.

While the Apgar score helps assessing the general and specific clinical condition of a newborn, if immediate assistance is required at birth, the medical staff does not wait for the Apgar score and instead takes immediate actions to help the newborn, in accordance with a structured protocol tailored to the newborn's specific needs. In that case, the Apgar score is determined during the treatment for the newborn.

The indices examined in an Apgar test:

  • Respiratory effort.
  • Skin color.
  • Pulse.
  • Reflexes.
  • Muscle tone.

The total score (from 1 to 10 points) is the Apgar score.

The Apgar test is a quick and methodical means of assessing a newborn's medical condition. The test is conducted twice: one minute and five minutes after birth. In some cases, and according to the medical staff’s judgment, an additional Apgar test will be performed 10 minutes after birth.

The Apgar test plays a role in assessing a newborn's condition. However, if an infant is born with a need for immediate assistance, the medical staff does not wait for the Apgar score and instead takes immediate actions to help the newborn, in accordance with a structured protocol tailored to the newborn's specific needs.

The Apgar test comprises five indices, and a score is given for each of them. Consequently, the overall condition of the newborn is assessed, then it is determined whether intervention is necessary and for which specific indices.

Most newborns who receive a low Apgar score at the age of one minute will typically show a normal score after five and ten minutes. If a newborn receives a low Apgar score at birth, that newborn will be transferred to monitoring and care, which may involve neonatal intensive care if necessary.

Who determines the Apgar score

The Apgar score is given by the caregiver of the newborn. If a pediatrician is present during labor, including both regular and cesarean section deliveries, the pediatrician will determine the score. In the absence of a physician, the midwife is responsible for determining the score.

The indices examined in the Apgar test

The Apgar test is named after the doctor who created it in 1952, Dr. Virginia Apgar. In addition, the English letters in the word Apgar represent the examined indices:

  • Appearance (skin tone).
  • Pulse (heart rate).
  • Grimace response (reflexes).
  • Activity (muscle tone).
  • Respiration (breathing rate and effort).

  • A newborn who is born pale or pale blue does not get a score for color.
  • If a newborn's body is pink but the color of the extremities is pale blue, the score for appearance is 1. It is important to note that most newborns are born with slightly bluish extremities, and within a few minutes after birth, the skin color transitions from pale blue to pink. This is why the maximum Apgar score one minute after birth is typically 9 and not 10.
  • When the body color is completely pink, the for appearance score is 2.

In the absence of a detectable pulse, the infant will not get a score for pulse. A newborn with a pulse of less than 100 heartbeats per minute receives a score of 1, while a newborn with a pulse of 100 or more heartbeats per minute receives a score of 2.

Grimace response is examined by touching the infant, using a gentle brushing movement on the back or feet to elicit a reaction.

  • If the newborn does not react, the score will be 0 for grimace response.
  • If the newborn reacts with a facial movement (grimace) that resembles an attempted cry, the score will be 1 for grimace response.
  • If the newborn cries, the score will be 2 for the grimace response.

While some newborns encounter breathing difficulties during labor, most promptly recover within a few seconds after being dried, stimulated, and warmed.

  • A newborn who cries and screams immediately after labor receives a score of 2 for respiration.
  • A newborn who struggles to breathe receives a score of 1 for respiration.

The muscle tone examination assesses the newborn's extremity movements to evaluate their muscle tone.

  • If the infant moves the extremities vigorously, a score of 2 will be given for muscle tone.
  • For partial movement, a score of 1 is given for muscle tone.
  • If the infant fails to move the limbs entirely, the score will be 0 for muscle tone.

Total score

The total Apgar score ranges from 1 to 10. In each examination session (at the age of 1 minute and 5 minutes), the scores that the newborn receives for each index are summed up, and the total score is the Apgar score. In most cases, when a newborn's condition is normal, the Apgar score will be 9 after one minute and 10 after five minute.

Low Apgar score

Most low Apgar scores are observed in complex and difficult deliveries, cesarean sections, or in instances of amniotic fluid in the newborn's lungs, among other factors.

The significance of the Apgar score

  • Apgar score of 7, 8, or 9 at the age of one minute: this is considered normal and usually does not necessitate any special intervention, except for stimulation, warming, and drying.
  • Apgar score below 7: this indicates that the newborn requires medical assistance to adapt to life outside the uterus. This medical care may include measures such as physical stimulation, warming, oxygen administration, and suctioning of secretions out of the respiratory tract. In more severe cases, additional advanced treatments may be necessary. The severity of the newborn's condition is proportional to the lower Apgar score.
  • Apgar score below 7 at the age of five minutes: this may necessitate further evaluation and examinations, as determined by the medical staff.

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