What Is an Apgar Score?

The Apgar score is the result of an observation done soon after birth that gives a numerical representation of how well a newborn baby is adjusting to life outside the womb. It is done in delivery rooms around the world, and was developed to provide a standardized way to judge how a baby is coping with birth to predict survival and cue medical staff to a newborn's potential healthcare needs.

Why It's Important

Birth is a monumental, sometimes tough, transition. Going from being in the uterus to the outside world not only involves a tight squeeze but also requires a baby to move from dependency on their mom for their basic bodily needs to full independence.

The Apgar score provides a way to quickly ascertain how a baby is doing and what (if any) extra medical care is needed. The test also provides doctors an accurate and helpful barometer of a newborn's likelihood of survival.

Types of Apgar Score

There are two main types of Apgar scores. The first is the Conventional Apgar (or simply Apgar) test, which is the original scoring system. The second is the Combined Apgar, which is a modification that includes both the original score as well as a score relating to any interventions that were used to support the newborn's vital signs.

Conventional Apgar

The Conventional Apgar score was developed by Dr. Virginia Apgar, an anesthesiologist and the first woman to become a full professor at Columbia University College of Physicians and Surgeons. She used her research on obstetrical anesthesia (studying the impact medicines given to the mother had on the newborn) to create the scoring system, which she published in 1953.

Dr. Apgar used her last name as the acronym for the score:

• A = Activity
• P = Pulse
• G = Grimace
• A = Appearance
• R = Respiration

Combined Apgar

In the decades following the launch of the Apgar system, the American College of Obstetricians and Gynecologists (ACOG) sought to develop tests that would more accurately account for medical interventions given to newborns and their responses to treatment, as well as other parameters that the original test was not as sensitive to measuring.

Several reconfigured tests emerged, which have been researched for efficacy. The Combined Apgar score offers a more comprehensive and precise scoring system that has been shown to paint a more specific picture of a newborn's condition, including the need for interventions and the likelihood of adverse outcomes. However, it is not commonly used.

What to Look For

Apgar scoring is done by the midwife, nurse, or doctor at one minute and five minutes after the birth. Your baby may also be given an Apgar score at 10 minutes if the first scores were low. Apgar scores are given in all birth settings: hospital, birth center, and home.

The Apgar score ranges from 0 to 10, with 10 being the highest (and best) score a baby can get. Gestational age, maturity, reflexes, responsiveness, color, and other factors are considered to make up the score. The newborn is given points in five categories:

• Heart rate
• Muscle tone
• Reflex irritability
• Respiratory effort
• Skin color

In each of the categories, a baby can earn 0, 1, or 2 points. The points from each of the categories are added together for the total score.

What Scores Mean

The ACOG defines the 5-minute Apgar scores in the following way:

• 7–10: Reassuring
• 4–6: Moderately abnormal
• 0–3: Low 

A score of 7 or higher (the optimal range) indicates a baby is in good health. Scores of 6 or below suggest a newborn needs medical care (0 to 3 is the most concerning range), which can include physical stimulation, oxygen, and clearing of airways, among other treatments.

When the Combined Apgar test is used, an additional score is created evaluating interventions used based on seven possible criteria. One point or zero points are given based on the use of interventions corresponding to each category. These results are tallied for a total between 0 (all interventions used) and 7 (no interventions) and the result is listed before the basic Apgar score.

The Combined Apgar scoring system is also represented by an acronym, which stands for typical neonatal interventions, as follows:

• C: Continuous positive airway pressure
• O: Oxygen
• M-B: Mask and bag ventilation
• I: Intubation and ventilation
• N: Neonatal chest compression
• E: Exogenous surfactant
• D: Drugs

For example, if a newborn who got a 6 on the Conventional Apgar receives oxygen and medication but no other interventions (for a total of 5), their Combined Apgar score would read 5/6. If no interventions (7) are used on a baby who got 10 on the traditional scale, they would get a score of 7/10, which is the best possible score.

Tips on Interpretation

While Apgar scores do not account for every variable, they are an effective tool in quickly establishing the health of a newborn and their need for extra care. However, don't panic if your baby's first reading is low. It's important to know that it's not uncommon for readings at one minute to be below the optimal range of 7 to 10 but to then speedily rebound into the "reassuring" range at the five-minute test.

The Five-Minute Mark

In the intervening minutes between tests, medical interventions can be done to vastly improve your newborn's outlook. Also, sometimes, a baby just needs some time to acclimate. Apgar scores are not absolutes in terms of your baby's ability to survive or thrive. Medical professionals simply use the Apgar score as a tool to uniformly and quickly inform their treatment protocol for your newborn.

Low Score

Sometimes, low Apgar scores indicate more complex and potentially dangerous issues Research shows that adverse scores on the Combined Apgar are particularly telling on this front. They may predict specific neonatal medical conditions, including birth asphyxia, hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage (IVH), and neonatal seizure.

Skin-to-Skin Contact

With increasing prioritization of skin-to-skin time in many hospitals and birth centers, some parents wonder if this might interfere with Apgar testing and how it will be done. While your baby is skin-to-skin, you will have a nurse or doctor assigned to watch your baby. This is done while standing next to you. Typically, the goal is only to separate or disturb your skin-to-skin time if you or your baby need medical help.

A Word From Verywell

High Apgar scores mean your newborn is doing well. Lower scores indicate that something could be wrong. So it makes sense to feel stressed and alarmed to hear your doctors report a lower-than-optimal score. This is why being in a hospital with a fully-equipped neonatal unit is so important for high-risk births, as mere minutes can be life-saving for your baby.

Sadly, some newborns will have neonatal problems that need swift, and possibly long-term, attention—and some will not survive. However, in most cases, the birthing team is able to use the information the Apgar tool provides to quickly get your baby any care they may need.