The Apgar score is a test to evaluate newborns shortly after birth. This test assesses the baby’s heart rate, muscle tone, and other signs to determine if they need additional emergency medical help.
The Apgar test (also known as the “Apgar test”) is usually given to the baby twice: the first time, one minute after birth, and again, five minutes after birth. Sometimes, if the baby’s physical condition is of concern, the baby can be evaluated a third time.
What does “Apgar” mean?
The word Apgar refers to “Appearance, Pulse, Irritability (from English Grimace), Activity and Breathing.”
In the test, these five factors are used to assess the health of the baby. And each factor or aspect is evaluated on a scale that goes from 0 to 2, with 2 being the highest possible score:
Appearance (skin color) Pulse (heart rate) Irritability (reflex response) (from Grimace) Activity (muscle tone) Respiration (respiratory rate and respiratory effort)
The physicians, midwives, and nurses add the scores for these five factors to calculate the Apgar score. A baby can score between 0 and 10. 10 is the highest possible score, but very few babies reach it. This is because many babies’ hands and feet remain blue until they warm up.
Apgar factor 2 1 0
(skin color) Standard color all over the body (pink hands and feet) Normal color (but bluish hands and feet) Blue-gray or pale color all over the body
(heart rate) Regular (greater than 100 beats per minute) Less than 100 beats per minute Absent
(“Reflex response”) Withdraws, sneezes, coughs, or cries at stimulation Slight facial gesture or discrete grimaces at stimulation Absent (no response to stimulation)
(muscle tone) Active, spontaneous movements Bent arms and legs with little movement No movement, lax tone
(respiratory rate and respiratory effort) Average respiratory rate and effort, adequate cry Slow or irregular breathing, weak cry Absent (no breathing)
What does my baby’s Apgar score mean?
A baby who scores seven or higher on the Apgar Test is generally considered in good health. Getting a lower score does not mean that the baby is sick. All it means is that the baby needs some immediate medical treatment, such as suctioning his airways or giving him oxygen, to help him breathe. Some perfectly healthy babies have lower scores than average, especially in the first minutes of life.
A somewhat lower score (especially at minute 1) is standard, especially in babies born:
high-risk pregnancies by cesarean section after a complicated delivery prematurely
Five minutes after birth, the Apgar test is applied again. Suppose the baby’s score was low at the first evaluation and did not improve, or the medical staff is concerned about the baby’s condition for other reasons. In that case, the medical and nursing staff will continue to give the baby the necessary medical treatment. And they will closely monitor the baby.
In 1979, the perinatal governmental collaborative project carried out by the American National Institute of Neurological Disorders and Stroke indicated that a very low Apgar at first and at 5 min was associated with an increased risk of death and cerebral palsy survivors8. So doctors and scientists attributed most cases of cerebral palsy to suffocation and other complications during childbirth. However, in 1981 Nelson9 carried out an extensive and careful study in 49,000 NBs in which he reviewed the Apgar score at 1, 5, 10, 15, and 20 min and described that among the term NBs with a score between 0 and 3 at 5 min, there was less than 1% of cerebral palsy, if the Apgar remains low 3 for 15 min the incidence of cerebral palsy among the NBs that survive is 9% but, if the Apgar continues to be less than three at 20 min the incidence of significant motor sequelae increases to 57%. A term NB with an Apgar between 0 and 3 at 5 min and which improves at 10 min and has an Apgar of 4 or more, has a 99% chance of not having cerebral palsy at seven years of age9-10. These findings have profoundly altered medical theories about cerebral palsy and motivating today’s researchers to explore different causes.
In 1986, the American Academy of Pediatrics (APP), through the Committee on the fetus and the newborn11, refers to the Apgar test and indicates that determining lThe presence of asphyxia only due to a low Apgar represents an inappropriate use of the test. A low score at the minute indicates that this child requires special attention and is not correlated with a poor prognosis. The Apgar at 5 min and particularly the changes in the score are a valuable index of the effectiveness of resuscitation maneuvers. It is emphasized that a poor neurological prognosis could be presumed if three factors concur: Apgar between 0 to 3 for more than 10 min, if the NB remains hypotonic for several hours and if it presents seizures. Hypoxia should be confirmed by metabolic acidemia of the umbilical cord vessels. Following this recommendation, to define the newborn’s condition more objectively, several biochemical indices derived from the metabolic disaster produced by the phytic state have been studied. In recent years, interest has focused on determining the acid-base status of the umbilical vessels, particularly the values in the umbilical artery12-18.
Umbilical artery pH has been widely adopted in conjunction with the Apgar test as an essential criterion for defining asphyxia. The placenta is the organ of fetal respiration and typically provides sufficient oxygen for fetal growth under conditions of aerobic metabolism. When O2 transfer is restricted, completing the metabolism of carbohydrates to CO2 and water is impossible. Fetal metabolism occurs through anaerobic pathways, and excess lactic acid accumulates. H + ions react with bicarbonate in fetal blood, lowering the bicarbonate concentration and causing metabolic acidosis. The accumulation of non-volatile acids also lowers the concentration of bicarbonate. Sykes in 198213 defined umbilical cord acidemia as a pH of 7.11, but later different values have been suggested, varying between 7.11 and 7.27.
Some figures are arbitrary, and others are based on two standard deviations from what was found in the respective study populations. During the 1980-89 decade, most publications defined acidemia as umbilical artery pH <7.20. In 1993 Goldaber15 published a study carried out in women without pathology, normal pregnancies, and healthy newborns and found pH values with a range between 7.15 and 7.43. The predictive value of umbilical artery pH has also been evaluated. Goodwin et al. 19 studied 129 NBs with low pH 7.0 and demonstrated that there is a correlation between pH and hypoxic-ischemic encephalopathy in this range of profound umbilical artery acidemia. This correlation only exists in ranges of severe acid-base abnormality. Goldaber20, when analyzing a series of 3,506 children with umbilical artery pH less than 7.20 and stratifying the neonates according to different degrees of acidemia, found that only with a pH low 7.0 did the number of children who presented seizures and those who died. In conclusion, like the Apgar score, only extreme acidemia values predicted neurological outcomes.
Umbilical artery gases should always be obtained in all risky deliveries and in cases where the newborn is born with cardiorespiratory depression. The reference value used as usual is still arbitrary; some authors suggest a pH as low as 7.10. Clinicians agree that mixed acidemia deserves more attention than respiratory acidemia alone. There are no national norms regarding the value considered normal; in the Clinical Hospital of the University of Chile, an umbilical artery pH less than 7.15 is abnormal.