• Neonatologist
• Nurse practitioner
• Family physician
• Midwife

There are five parts of an Apgar score. Each category is weighted evenly and assigned a value of 0, 1, or 2. The components are then added together to give a total score that is recorded at 1 and 5 minutes after birth. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is deemed to be low in full-term and late preterm infants. At 5 minutes, when an infant has a score of less than 7, Neonatal Resuscitation Program guidelines recommend continued recording at 5-minute intervals up to 20 minutes. It should be noted that scoring during resuscitation is not equivalent to that of an infant not undergoing resuscitation because resuscitative efforts alter several elements of the score.[7][8]

The score is calculated as follows:

Breathing Effort

• If the infant is not breathing, the respiratory score is 0.
• If respirations are slow and irregular, weak or gasping, the respiratory score is 1.
• If the infant is crying vigorously, the respiratory score is 2.

Heart Rate

• Note, heart rate is evaluated with a stethoscope, and it is the most critical part of the score in determining the need for resuscitation.
• If there is no heartbeat, the heart rate score is 0.
• If the heart rate is less than 100 beats per minute, the heart rate score is 1.
• If the heart rate is more than 100 beats per minute, the heart rate score is 2.

Muscle Tone

• If the muscle tone is loose and floppy without activity, the score for muscle tone is 0.
• If the infant demonstrates some tone and flexion, the score for muscle tone is 1.
• If the infant is in active motion with a flexed muscle tone that resists extension, the score for muscle tone is 2.

Grimace Response or Reflex Irritability in Response to Stimulation

• If there is no response to stimulation, the reflex irritability response score is 0.
• If there is grimacing in response to stimulation, the reflex irritability response score is 1.
• If the infant cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.

Color

• Note, most infants will score 1 for color as peripheral cyanosis is common among normal infants. Color can also be misleading in non-white infants.
• If the infant is pale or blue, the score for color is 0.
• If the infant is pink, but the extremities are blue, the score for color is 1.
• If the infant is entirely pink, the score for color is 2.

Apgar scores were designed to help identify infants that require respiratory support or other resuscitative measures, not as an outcome measure. The Apgar score alone should not be considered evidence of asphyxia or proof of an intrapartum hypoxic event. A low Apgar score of 0 to 1 at 1 minute is not predictive of adverse clinical outcome or long-term health issues since most infants, even those with very low 1-minute scores will have normal scores by 5 minutes. Low Apgar scores at 5 minutes correlate with mortality and may confer an increased risk of cerebral palsy in population studies but not necessarily with an individual neurologic disability. Most infants with low Apgar scores do not go on to develop cerebral palsy, but lower scores over time increase the population risk of the poor neurologic outcome. Scores less than five at 5 and 10 minutes correlate with an increased relative risk of cerebral palsy. Neonates with scores less than five at 5 minutes should have umbilical artery blood gas sampling performed. Apgar scores that remain at 0 after 10 minutes may indicate that the termination of resuscitative efforts is appropriate as very few infants survive with good neurologic outcomes if no heart rate has been detectable for over 10 minutes.[9]

The Apgar score alone should not be considered as evidence of asphyxia or evidence of an intrapartum hypoxic event. A low Apgar score of 0 to 1 at 1 minute is not predictive of adverse clinical outcome or long-term health issues since most infants, even those with very low 1-minute scores will have normal scores by 5 minutes. Low Apgar scores at 5 minutes correlate with mortality and may confer an increased risk of cerebral palsy in population studies but not necessarily with an individual neurologic disability.

Apgar scoring may be performed by a physician, midwife, or nurse. Inter-rater variability is quite common as some components of the score are subjective, so ideally, the same person should calculate the initial and ongoing scores for consistency. The nurse has a crucial role in evaluating neonates using the APGAR score, and she should inform the clinician of any untoward changes in the APGAR score of the newborn. The nurse should document the findings of the APGAR score at 1 minute and 5 minutes, respectively. The nurse assists the clinician in the initial resuscitative measures of the neonates, particularly if they have low APGAR scores. The interprofessional team should communicate the findings of the resuscitation efforts to the woman and her family and should formulate a care plan to neonates with low APGAR scores. The nurse should collaborate with the clinician to address any concerns, the woman and her family might have. The nurse should provide the woman with the necessary information leaflets about neonatal care. Patient education is key to the successful management of neonates with low APGAR scores. The best possible standard of care could only be achieved through coordinated collaboration and clear communication among the members of the interprofessional team.  [level V]

Nurses looking after newborns should be familiar with the Apgar score. Also, they should know what the score signifies. Nurses should understand that a score between 7-10 is normal; a score between 4-6 needs proper reevaluation as the infant does require monitoring for 5 minutes. A score of less than 3 is never good, and immediate attention is mandatory. The nurse should call a code and inform the clinician immediately.

• APGAR scoring at 1 and 5 minutes
• General condition of the neonate
• Vital signs of the newborn
• Umbilical cord pH
• Arterial blood gases of the newborn