What Is an Apgar Score?
An Apgar score is a quick way for health care professionals to determine if a newborn is in need of immediate medical care. The test evaluates a baby’s skin color, heart rate, reflexes, muscle tone, and breathing rate/effort.
The Apgar test is usually performed twice: at one minute and then again five minutes after a baby is born. The Apgar score range is 0 to 10, with a score of 7 or above considered normal.
If, at 5 minutes, the score is a 7, the Apgar test is repeated again in another 5 minutes until 8 is reached. A 7 usually requires respiratory intervention and/or continued monitoring.
The Apgar test rates the following five factors on a scale of 0 to 2:
- Appearance (skin color)
- Pulse (heart rate)
- Grimace response (reflexes)
- Activity (muscle tone)
- Respiration (breathing rate and effort)
The scores for each component are added together to get the total Apgar score. The higher the score, the better a baby is doing with their transition outside of the womb.
Dr. Virginia Apgar introduced the Apgar score in 1952. In 1963, APGAR became a helpful acronym for “Appearance, Pulse, Grimace, Activity, and Respiration,” which are the five components examined during the Apgar test.
Factors in Apgar Scoring
Pulse and respiration are critical factors, but all are interconnected. For example, a baby with weak reflexes and tone is unlikely to have a strong heart rate and respiratory effort.
Usually, if a low heart rate is resolved or independent respiratory effort is achieved, other issues will also resolve. However, all of the factors are important because together, they give a fuller picture of the severity of a situation.
Although the maximum score is 10, few babies score this high. The most commonly scored Apgar is 8/9. Usually, this score means a blue skin color that becomes pink as proper oxygenation is achieved independently and without intervention over 5 minutes.
At the 5-minute mark, most often, the infant’s hands and feet will still have a blue hue to them, which is why one point is taken off (score of 9). Generally, points are taken off for an infant’s color.
A lower-than-average Apgar score could mean your baby needs medical intervention to address breathing issues or heart trouble.
It is important to understand that the Apgar test is not designed to predict your child’s long-term health or intelligence. However, there is a link between lower-than-average Apgar scores and medical conditions such as cerebral palsy, epilepsy, and hypoxic-ischemic encephalopathy (HIE).
How Is the Apgar Test Performed?
Doctors, nurses, or midwives perform the Apgar test. These health professionals visually observe the baby’s skin to look for signs of discoloration. They test for normal newborn reflexes, such as startle and grasp reflexes, during a nurse’s assessment. They also check to see if the muscles are floppy.
To assess heart rate and clear lungs, they use a stethoscope to listen to the chest. Respiratory rate and effort are assessed visually, looking for normal effort, increased muscle effort, or no effort at all.
Why Is the Apgar Test Performed?
The Apgar test is performed to determine whether a newborn needs extra attention or immediate medical care.
Apgar scores look for signs of the following conditions:
- Apnea (when breathing stops and starts repeatedly)
- Bradycardia (slow heart rate)
- Cyanosis (bluish skin)
- Hypotonia (muscle weakness)
- Respiratory depression (slow and shallow breathing)
What Is the Purpose of Apgar Scoring?
Apgar scoring at one minute following birth gives health care professionals an immediate assessment of how well the baby tolerated the birthing process. It is then performed again at five minutes to determine how a newborn is adjusting to life outside of the womb.
While these baby scores can help medical professionals get a snapshot of a newborn’s health at a specific point in time, they do not predict the baby’s future health.
What is Apgar Score? The Apgar score is a system used to determine if a newborn needs extra medical care and monitoring. New parents should understand the importance of the Apgar score as well as its limitations.
The medical community initially used the Apgar test to determine whether a baby needed resuscitation. However, recent evidence suggests this usage may be unreliable since most cases of oxygen deprivation require resuscitation to begin before the first one-minute Apgar score is determined.
Because of this, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) both recommend an expanded Apgar reporting form that accounts for interventions like CPR and chest compressions.
Although Apgar scores alone cannot detect or prove conditions such as neonatal asphyxia, which can happen when blood flow is blocked or restricted, they may play a role in the overall diagnosis.
What Does a Low Apgar Score Mean?
A low Apgar score (anything below 7) means that your baby may need extra medical care soon after birth. This could include suctioning their airways or providing oxygen to help them breathe better. On its own, a low Apgar score does not mean your baby is unhealthy.
A low Apgar score (especially at one minute) is common in the following situations:
- Complicated labor and delivery
- Delivery by cesarean section (C-section)
- Fluid in a newborn’s airways
- High-risk pregnancy
- Premature birth
Unfortunately, a low Apgar score could mean your baby suffered a preventable birth injury. This may be especially true for babies with low Apgar scores at five minutes or longer, who are at higher risk of developing severe HIE, brain damage, and cerebral palsy.
A low Apgar score that was caused by a health care professional’s negligence could also mean you are entitled to financial support to help care for your baby. Apgar scores are frequently used as one of many pieces of evidence in medical negligence claims.
If your child was diagnosed with a birth injury like cerebral palsy and you suspect it was the result of medical negligence, talk with one of our registered nurses today to learn what you can do next.
How to Calculate Apgar Score
Apgar score is calculated by adding up the scores of five components: skin color, heart rate, reflex, muscle tone, and breathing. Each of the five components is given a value of 0, 1, or 2 and combined for a total score. This means the Apgar score range is 0 to 10. The higher the Apgar score, the better the baby’s overall health.
The Apgar test is usually performed one minute after birth and then again five minutes after birth. The first score is generally lower and often improves at five minutes.
According to Mount Sinai Hospital, “Very few newborns score a perfect 10 because it takes a while for their hands and feet to warm up and turn pink. About 90% of infants have Apgar scores of 7 to 10.”
What Is a Normal Apgar Score at 1 and 5 Minutes?
A normal Apgar score is anything between 7 and 10. A score of 4 to 6 is considered abnormal, and scores between 0 to 3 are dangerously low. It is common for the one-minute Apgar score to be lower than later scores.
“Most of the time, a low score at 1 minute is near-normal by 5 minutes.”
—Mount Sinai Hospital
Apgar Score Chart
|Appearance (skin color)
|Normal color all over (hands and feet are pink)
|Normal color (but hands and feet are bluish)
|Bluish-gray or pale all over
|Pulse (heart rate)
|Normal (above 100 beats per minute)
|Below 100 beats per minute
|Absent (no pulse)
|Grimace ("reflex irritability')
|Pulls away, sneezes, coughs, or cries with stimulation
|Facial movement only (grimace) with stimulation
|Absent (no response to stimulation)
|Activity (muscle tone)
|Active, spontaneous movement
|Arms and legs flexed with little movement
|No movement, "floppy" tone
|Respiration (breathing rate and effort)
|Normal rate and effort, good cry
|Slow or irregular breathing, weak cry
|Absent (no breathing)
Management of Baby With Low Apgar Score
Although a low Apgar score can be a symptom of certain birth injuries, it doesn’t necessarily mean the baby will have long-term health conditions. In most cases, the baby will only need extra medical care immediately following birth.
The following may be used to treat a baby with a low Apgar score:
- Oxygen: If the baby has trouble breathing, an oxygen mask may be used. They may need a breathing tube if they still aren’t breathing on their own within a few minutes.
- Physical stimulation: Drying off or stimulating the baby can help get their heartbeat to a regular rate, initiate a cry, and increase respiratory effort.
- Suctioning: If the baby’s airways are obstructed by fluid, they may need to be suctioned.
- Other interventions: Medications or fluids may be given through the umbilical cord to help strengthen the baby’s heartbeat.
Managing a low Apgar score with these treatments can help to normalize the baby’s score by the time the five-minute Apgar test is performed.
If your baby still has a low Apgar score after five minutes, they will likely be taken to a special neonatal unit for additional medical care.
If your baby had a low Apgar score when they were born, take our Free Milestones Quiz now to help you determine if they may be falling behind.
IS YOUR CHILD MISSING DEVELOPMENTAL MILESTONES?
Take Our Milestones Quiz
Taking note of your child’s physical, social, and emotional skills can help you determine if they potentially suffered from an injury at birth. An early diagnosis can help your child get the treatment they need as soon as possible.
Q1: How old is your child?
0-2 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child hold their head steadily on their own?
- Q3: Can your child push themselves up when they are lying on their stomach?
- Q4: Has your child started to make smoother movements with their arms and legs?
- Q5: Does your child smile at other people?
- Q6: Can your child bring their hands to their mouth?
- Q7: Does your child turn their head when they hear a noise?
- Q8: Does your child coo or make gurgling noises?
- Q9: Does your child follow things with their eyes?
- Q10: Does your child try to look at their parents or caregivers?
- Q11: Does your child show boredom, cry, or fuss when engaged in an activity that hasn’t changed in a while?
3-4 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child hold their head steadily on their own?
- Q3: Does your child push down on their legs when their feet are on a flat surface?
- Q4: Has your child started to roll over from their stomach to their back?
- Q5: Can your child hold and shake a toy such as a rattle?
- Q6: Does your child bring their hands to their mouth?
- Q7: Does your child play with people and start to cry when the playing stops?
- Q8: Does your child smile spontaneously, especially at people?
- Q9: Does your child copy some movements and facial expressions of other people?
- Q10: Does your child babble with expressions and copy sounds they hear?
- Q11: Does your child cry in different ways to show hunger, pain, or tiredness?
- Q12: Does your child respond to affection like hugging or kissing?
- Q13: Does your child follow moving things with their eyes from side to side?
- Q14: Does your child recognize familiar people at a distance?
5-6 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child roll over on both sides (front to back/back to front)?
- Q3: Has your child begun to sit without support?
- Q4: Does your child rock back and forth?
- Q5: Can your child support their weight on their legs (and perhaps bounce) when standing?
- Q6: Has your child begun to pass things from one hand to the other?
- Q7: Does your child bring objects such as toys to their mouth?
- Q8: Does your child know if someone is not familiar to them and is a stranger?
- Q9: Does your child respond to other people’s emotions, such as a smile or a frown?
- Q10: Does your child enjoy looking at themselves in the mirror?
- Q11: Does your child look at things around them?
- Q12: Does your child respond to sounds they hear by making sounds themselves?
- Q13: Does your child make sounds to show joy or displeasure?
- Q14: Does your child respond to their own name?
- Q15: Has your child started to string vowels together, such as "ah," "eh," or "oh," or started to say consonant sounds such as "m" or "b"?
- Q16: Has your child begun to laugh?
7-9 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child crawl?
- Q3: Can your child stand while holding on to something to support them?
- Q4: Can your child sit without support?
- Q5: Can your child pull themselves up to stand?
- Q6: Does your child play peekaboo?
- Q7: Can your child move things from one hand to the other?
- Q8: Can your child pick small things up, such as a piece of cereal, with their thumb and index finger?
- Q9: Does your child look for things that they see you hide?
- Q10: Does your child watch the path of something as it falls?
- Q11: Does your child show fear when around strangers?
- Q12: Does your child become clingy with adults who are familiar to them?
- Q13: Does your child have favorite toys?
- Q14: Does your child use their fingers to point?
- Q15: Does your child understand “no”?
- Q16: Does your child make a lot of repetitive sounds, such as “mamama” or “bababa”?
- Q17: Does your child copy the sounds and gestures of other people?
10-12 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child stand alone with no support?
- Q3: Does your child walk while holding on to furniture?
- Q4: Can your child take a few steps without holding on to anything?
- Q5: Can your child get into a sitting position without any help?
- Q6: Does your child bang two things together when playing?
- Q7: Does your child poke with their index finger?
- Q8: Has your child started to use things like hairbrushes or drinking cups correctly?
- Q9: Does your child find hidden objects easily?
- Q10: Does your child play peekaboo or pat-a-cake?
- Q11: Does your child become shy or nervous around strangers?
- Q12: Does your child repeat actions or sounds to get attention?
- Q13: Does your child put out an arm or leg to help when getting dressed?
- Q14: Does your child cry when a parent leaves the room?
- Q15: Does your child show that they have favorite things or people?
- Q16: Does your child show fear?
- Q17: Does your child say things such as “mama,” “dada,” or “uh-oh”?
- Q18: Does your child try to say the words you say?
- Q19: Has your child started to use gestures like waving or shaking their head “no”?
13-18 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child walk by themselves?
- Q3: Does your child walk up stairs and run?
- Q4: Does your child pull toys while walking?
- Q5: Can your child drink from a cup on their own?
- Q6: Can your child eat with a spoon on their own?
- Q7: Can your child help undress themselves?
- Q8: Does your child have occasional temper tantrums?
- Q9: Does your child show affection to familiar people?
- Q10: Does your child become clingy in new situations?
- Q11: Does your child explore their environment alone with parents close by?
- Q12: Can your child say several single words?
- Q13: Can your child say and shake their head “no”?
- Q14: Does your child point to show things to other people?
- Q15: Does your child scribble?
- Q16: Does your child know what ordinary products such as phones, spoons, and brushes are used for?
- Q17: Can your child follow one-step commands such as “sit down” or “stand up”?
- Q18: Does your child play with a doll or stuffed animal by pretending to feed it?
19-23 MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Has your child begun to run?
- Q3: Has your child kicked a ball?
- Q4: Can your child climb down and onto furniture on their own?
- Q5: Can your child walk up and down stairs while holding on?
- Q6: Can your child stand on their tiptoes?
- Q7: Has your child thrown a ball overhand?
- Q8: Does your child copy others, especially people older than them?
- Q9: Does your child get excited around other children?
- Q10: Has your child shown more independence as they've aged?
- Q11: Does your child do what they were told not to do and become defiant?
- Q12: Does your child point to things when they are named?
- Q13: Does your child know names of familiar people or body parts?
- Q14: Does your child say 2 to 4-word sentences?
- Q15: Does your child repeat words they hear?
- Q16: Does your child complete sentences and rhymes in familiar books?
- Q17: Does your child name items in books, such as dogs, cats, and birds?
- Q18: Does your child play simple pretend games?
- Q19: Has your child started to use one hand more than the other?
- Q20: Has your child begun to sort shapes and colors?
- Q21: Does your child follow 2-step instructions, such as “pick up your hat and put it on your head?”
24+ MONTHS DEVELOPMENTAL MILESTONES QUIZ
- Q2: Can your child run easily?
- Q3: Can your child climb?
- Q4: Can your child walk up and down stairs with one foot on each step?
- Q5: Can your child dress and undress themselves?
- Q6: Does your child show affection for friends without being told?
- Q7: Does your child take turns when playing games?
- Q8: Does your child show concern when others are crying?
- Q9: Does your child understand the idea of “mine" and "theirs"?
- Q10: Does your child show many different emotions?
- Q11: Does your child copy adults and friends?
- Q12: Does your child separate easily from their parents?
- Q13: Does your child get upset when there is a major change in their routine?
- Q14: Does your child say words such as “I,” “me,” “we,” “you,” and some plural nouns?
- Q15: Can your child say their first name, age, and gender?
- Q16: Can your child carry on a conversation with 2 to 3 sentences?
- Q17: Can your child work toys with buttons and other moving parts?
- Q18: Does your child play pretend with dolls, animals, or people?
- Q19: Can your child finish 3 or 4 piece puzzles?
- Q20: Can your child copy a circle when drawing?
- Q21: Can your child turn pages of a book one page at a time?
- Q22: Can your child turn door handles?
Preventable birth injuries are not always obvious and may even be minimized or covered up by negligent health care providers. Even though the expenses associated with birth complications can leave families financially unprepared, legal help is available.
Get Answers to Your Apgar Score Questions
Apgar scores cannot predict your child’s future health. However, a low Apgar score can be one of the first warning signs that they may face health issues later in life.
If you believe medical negligence was the cause of your baby’s low Apgar score, we may be able to connect you with a top birth injury lawyer. Our national network includes some of the best birth injury law firms from across the country with decades of experience helping families obtain justice and compensation.
Get a free and confidential case review now to find out if you are eligible.
Apgar Score FAQs
What is the purpose of Apgar scoring?
The purpose of Apgar scoring is to determine if a newborn infant needs extra medical care immediately following birth. The Apgar test is usually given at one minute and then again five minutes after a baby is born.
The first test helps health care professionals assess how well the baby tolerated the birthing process. Later tests determine how well the baby is adjusting outside the mother’s womb.
What are the 5 Apgar scores?
There are five elements that make up the total Apgar score:
- Breathing effort
- Heart rate
- Muscle tone
- Skin color
Each element is given a score of 0, 1, or 2 for a total possible score of 10.
What is a normal Apgar score?
A normal Apgar score is 7 or above. However, it is important to remember that a lower score doesn’t mean your child is unhealthy. It means they need immediate or extra care, such as suctioning or oxygen.
What is a poor Apgar score?
A poor Apgar score is 0, 1, 2, or 3. A score of 4 to 6 is considered abnormal and requires intervention. Poor Apgar scores at one minute usually improve once a baby receives appropriate medical treatment.
Does Apgar score measure intelligence?
No, an Apgar score does not measure intelligence. The Apgar test was designed as a convenient method for health care professionals to determine whether a newborn needs extra care soon after they’re born.
However, children born with low Apgar scores may develop neurological conditions that can affect their intellectual development in the long term.