APGAR Score — Complete Reference Table
The APGAR score was developed by Dr. Virginia Apgar in 1952 and published in 1953. It provides a rapid, standardised assessment of neonatal wellbeing at birth. Each of the five criteria is scored 0, 1, or 2, giving a total of 0–10.
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (Colour) | Blue/pale all over | Blue extremities, pink body | Completely pink |
| Pulse (Heart Rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (Reflex) | No response | Grimace/weak cry | Sneeze/cough/cry |
| Activity (Muscle Tone) | Limp/flaccid | Some flexion | Active motion |
| Respiration | Absent | Weak/irregular/gasping | Strong cry |
Score Interpretation
- 7–10: Normal. Routine post-delivery care. Continue monitoring.
- 4–6: Moderate depression. Stimulate, dry, warm, supplemental O₂. Consider PPV.
- 0–3: Severe depression. Immediate resuscitation — PPV, intubation, chest compressions.
1-Minute vs 5-Minute Score
The 1-minute APGAR reflects the newborn's condition at delivery and guides immediate resuscitation. It is influenced by intrapartum events — foetal distress, maternal analgesia, mode of delivery. It is not a predictor of long-term outcome.
The 5-minute APGAR better reflects the response to resuscitation and has greater prognostic significance. A 5-minute score consistently below 7 is associated with increased risk of neonatal morbidity. Studies show that neonates with 5-minute APGAR of 0–3 have a 53× higher risk of neonatal seizures compared to those scoring 7–10.
APGAR Score in the Context of NRP 2020
The Neonatal Resuscitation Program (NRP 2020, AAP/AHA) emphasises that resuscitation decisions should not wait for the 1-minute APGAR score. Assessment of three key signs — tone, breathing/crying, and heart rate — should guide immediate action. The APGAR score is documented as a record of condition and response to resuscitation, not as a trigger for intervention.
Limitations of the APGAR Score
The APGAR score has several important limitations. It is subjective — interobserver variability is significant, particularly for colour and reflex irritability. It does not reliably distinguish the cause of depression (hypoxia vs. prematurity vs. maternal opioids vs. infection). Preterm neonates score lower on muscle tone and colour regardless of their underlying condition. The score does not predict individual long-term neurological outcome.
For suspected hypoxic-ischaemic encephalopathy (HIE), the Thompson score, Sarnat staging, and amplitude-integrated EEG (aEEG) provide better prognostic information than APGAR alone.
Newborn Resuscitation — NRP Algorithm
Initial Steps (Birth to 30 Seconds)
All newborns: Warm (radiant warmer or kangaroo care for term, skin-to-skin), dry, stimulate, position airway. Assess: Is the baby term? Breathing/crying? Good muscle tone? If yes to all — routine care. If any no — begin resuscitation pathway.
Positive Pressure Ventilation (PPV)
Indicated if: Not breathing/gasping, HR <100 bpm despite stimulation. Rate: 40–60 breaths/min. Initial FiO₂: 21% (room air) for ≥35 weeks gestation; 21–30% for preterm. Titrate to target SpO₂ per NRP saturation table. Check for chest rise. If no improvement after 30 seconds of effective PPV — consider MR SOPA (Mask adjustment, Reposition, Suction mouth/nose, Open mouth, Pressure increase, Airway alternative).
Chest Compressions
Indicated if HR <60 bpm despite 30 seconds of effective PPV. Technique: 2-thumb encircling hands preferred (generates higher coronary perfusion pressure than 2-finger technique). Ratio: 3:1 compressions to ventilations (120 events/minute = 90 compressions + 30 ventilations). Increase FiO₂ to 100% when starting compressions. Reassess HR every 60 seconds.
Medications in Neonatal Resuscitation
- Adrenaline (Epinephrine): IV route preferred — 0.01–0.03 mg/kg IV. ETT route 0.05–0.1 mg/kg (less reliable). Repeat every 3–5 min if HR remains <60.
- Volume expander: NS or O-negative blood 10 mL/kg IV over 5–10 min if suspected hypovolaemia (pale, weak pulses, poor response to resuscitation).
- Sodium bicarbonate: Not routinely recommended in acute resuscitation.
- Naloxone: No longer recommended in NRP 2020 — maternal opioids are not an indication; focus on PPV.