According to the Apgar Scale, What Score Represents the Healthiest Newborns?

Number 644 (Replaces Commission Opinion Number 333, May 2006. Reaffirmed 2021)

Committee on Obstetric Practise

American Academy of Pediatrics—Committee on Fetus and Newborn

This certificate reflects emerging clinical and scientific advances every bit of the date issued and is discipline to modify. The data should not be construed every bit dictating an sectional course of treatment or procedure to be followed. This document reflects emerging concepts on patient safety and is subject area to change. The data should not be construed as dictating an sectional course of treatment or procedure to be followed.

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ABSTRACT: The Apgar score provides an accepted and user-friendly method for reporting the status of the newborn infant immediately after nascency and the response to resuscitation if needed. The Apgar score alone cannot be considered to exist show of or a event of asphyxia, does not predict individual neonatal mortality or neurologic outcome, and should non be used for that purpose. An Apgar score assigned during a resuscitation is non equivalent to a score assigned to a spontaneously animate babe. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting grade that accounts for concurrent resuscitative interventions.

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Introduction

In 1952, Dr. Virginia Apgar devised a scoring arrangement that was a rapid method of assessing the clinical status of the newborn babe at i infinitesimal of historic period and the need for prompt intervention to establish breathing i. A 2nd report evaluating a larger number of patients was published in 1958 2. This scoring organization provided a standardized assessment for infants later delivery. The Apgar score comprises five components: 1) color, 2) heart charge per unit, iii) reflexes, four) musculus tone, and 5) respiration, each of which is given a score of 0, 1, or 2. Thus, the Apgar score quantitates clinical signs of neonatal depression such as cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or gasping respirations. The score is reported at 1 infinitesimal and five minutes after birth for all infants, and at 5-minute intervals thereafter until 20 minutes for infants with a score less than 7 3. The Apgar score provides an accepted and convenient method for reporting the condition of the newborn baby immediately after nascence and the response to resuscitation if needed; however, it has been inappropriately used to predict private adverse neurologic result. The purpose of this statement is to identify the Apgar score in its proper perspective. This argument revises the 2006 College Committee Opinion and AAP Policy Statement to include updated guidance from Neonatal Encephalopathy and Neurologic Outcome, 2nd Edition, along with new guidance on neonatal resuscitation.

The Neonatal Resuscitation Program guidelines state that the Apgar score is

useful for conveying information about the newborn's overall condition and response to resuscitation. However, resuscitation must exist initiated before the 1-minute score is assigned. Therefore, the Apgar score is not used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to use them iii.

An Apgar score that remains 0 beyond 10 minutes of age may, nonetheless, be useful in determining whether continued resuscitative efforts are indicated because very few infants with an Apgar score of 0 at x minutes have been reported to survive with a normal neurologic outcome iii 4 5. In line with this, the 2011 Neonatal Resuscitation Program guidelines land that "if yous can confirm that no center rate has been detectable for at least 10 minutes, discontinuation of resuscitative efforts may exist appropriate" 3.

Neonatal Encephalopathy and Neurologic Consequence, 2d Edition, published in 2014 by the Higher in collaboration with the AAP, defines a 5-minute Apgar score of 7–10 equally reassuring, a score of 4–6 every bit moderately aberrant, and a score of 0–3 as low in the term baby and late-preterm infant 6. That document considers an Apgar score of 0–3 at 5 minutes or more than every bit a nonspecific sign of illness, which "may be 1 of the beginning indications of encephalopathy" 6. Withal, a persistently depression Apgar score solitary is not a specific indicator for intrapartum compromise. Further, although the score is used widely in consequence studies, its inappropriate use has led to an erroneous definition of asphyxia. Asphyxia is divers as the marked impairment of gas commutation leading, if prolonged, to progressive hypoxemia, hypercapnia, and significant metabolic acidosis. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should not be applied to nascence events unless specific testify of markedly impaired intrapartum or firsthand postnatal gas exchange tin be documented based on laboratory testing 6.

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Limitations of the Apgar Score

It is important to recognize the limitations of the Apgar score. The Apgar score is an expression of the infant'due south physiologic condition at ane point in fourth dimension, which includes subjective components. There are numerous factors that can influence the Apgar score, including maternal sedation or anesthesia, built malformations, gestational age, trauma, and interobserver variability 6. In add-on, the biochemical disturbance must be significant before the score is affected. Elements of the score such every bit tone, color, and reflex irritability can be subjective, and partially depend on the physiologic maturity of the infant. The score likewise may be afflicted by variations in normal transition. For example, lower initial oxygen saturations in the first few minutes need non prompt immediate supplemental oxygen administration; the Neonatal Resuscitation Program targets for oxygen saturation are 60–65% at i minute and 80–85% at 5 minutes iii. The healthy preterm infant with no prove of asphyxia may receive a low score only considering of immaturity 7 8. The incidence of low Apgar scores is inversely related to birth weight, and a low score cannot predict morbidity or mortality for any individual infant 8 ix. As previously stated, it likewise is inappropriate to utilize an Apgar score solitary to diagnose asphyxia.

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Apgar Score and Resuscitation

The v-minute Apgar score, and particularly a change in the score between 1 infinitesimal and 5 minutes, is a useful index of the response to resuscitation. If the Apgar score is less than 7 at v minutes, the Neonatal Resuscitation Plan guidelines state that the assessment should be repeated every 5 minutes for up to twenty minutes 3. However, an Apgar score assigned during a resuscitation is non equivalent to a score assigned to a spontaneously breathing infant 10. There is no accustomed standard for reporting an Apgar score in infants undergoing resuscitation afterward birth because many of the elements contributing to the score are altered past resuscitation. The concept of an assisted score that accounts for resuscitative interventions has been suggested, but the predictive reliability has not been studied. In social club to correctly draw such infants and provide accurate documentation and data collection, an expanded Apgar score report form is encouraged Effigy 1. This expanded Apgar score besides may show to be useful in the setting of delayed cord clamping, where the fourth dimension of birth (complete commitment of the babe), the time of cord clamping, and the time of initiation of resuscitation all tin be recorded in the comments box.

The Apgar score solitary cannot be considered to be testify of or a consequence of asphyxia. Many other factors, including nonreassuring fetal heart rate monitoring patterns and abnormalities in umbilical arterial claret gases, clinical cognitive function, neuroimaging studies, neonatal electroencephalography, placental pathology, hematologic studies, and multisystem organ dysfunction need to be considered in diagnosing an intrapartum hypoxic–ischemic event v. When a Category I (normal) or Category 2 (indeterminate) fetal heart rate tracing is associated with Apgar scores of 7 or college at 5 minutes, a normal umbilical string arterial blood pH (± ane standard divergence), or both, it is not consistent with an acute hypoxic–ischemic event 6.

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Prediction of Outcome

A ane-minute Apgar score of 0–3 does not predict any individual infant's upshot. A v-minute Apgar score of 0–iii correlates with neonatal mortality in large populations 11 12, simply does not predict individual future neurologic dysfunction. Population studies have uniformly reassured u.s.a. that virtually infants with depression Apgar scores volition not develop cerebral palsy. However, a low 5-minute Apgar score clearly confers an increased relative risk of cerebral palsy, reported to be as high every bit 20-fold to 100-fold over that of infants with a 5-minute Apgar score of 7–10 9 xiii 14 15. Although individual take chances varies, the population take chances of poor neurologic outcomes besides increases when the Apgar score is 3 or less at 10 minutes, 15 minutes, and 20 minutes 16. When a newborn has an Apgar score of five or less at 5 minutes, umbilical artery blood gas from a clamped section of the umbilical cord should be obtained, if possible 17. Submitting the placenta for pathologic exam may be valuable.

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Other Applications

Monitoring of depression Apgar scores from a delivery service can exist useful. Individual example reviews tin can place needs for focused educational programs and improvement in systems of perinatal intendance. Analyzing trends allows for the assessment of the effect of quality improvement interventions.

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Conclusions

The Apgar score describes the condition of the newborn infant immediately after birth and, when properly practical, is a tool for standardized assessment eighteen. It as well provides a mechanism to tape fetal-to-neonatal transition. Apgar scores practice not predict individual mortality or adverse neurologic event. Nevertheless, based on population studies, Apgar scores of less than 5 at 5 minutes and 10 minutes clearly confer an increased relative risk of cognitive palsy, and the degree of abnormality correlates with the risk of cerebral palsy. Virtually infants with low Apgar scores, still, will not develop cerebral palsy. The Apgar score is afflicted past many factors, including gestational age, maternal medications, resuscitation, and cardiorespiratory and neurologic conditions. If the Apgar score at five minutes is 7 or greater, it is unlikely that peripartum hypoxia–ischemia acquired neonatal encephalopathy.

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Recommendations

• The Apgar score does not predict private neonatal mortality or neurologic outcome, and should not be used for that purpose.

• Information technology is inappropriate to apply the Apgar score solitary to establish the diagnosis of asphyxia. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should not be applied to birth events unless specific evidence of markedly impaired intrapartum or immediate postnatal gas exchange tin be tin be documented.

• When a newborn has an Apgar score of 5 or less at 5 minutes, umbilical artery blood gas from a clamped section of umbilical cord should be obtained. Submitting the placenta for pathologic examination may be valuable.

• Perinatal wellness care professionals should exist consistent in assigning an Apgar score during resuscitation; therefore, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (the College) encourage employ of an expanded Apgar score reporting grade that accounts for concurrent resuscitative interventions.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score

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