Apgar Score
Score the five newborn signs at 1 and 5 minutes, with what each level means.
Recorded at 1 and 5 minutes, then every 5 minutes to 20 minutes while the score stays below 7.
The Apgar score rates five newborn signs — appearance, pulse, grimace, activity and respiration — from 0 to 2 each, giving a total out of 10 at 1 and 5 minutes. A baby with acrocyanosis, a pulse of 120, a grimace, some flexion and a strong cry scores 7, which is reassuring.
A shared description, not a verdict
Virginia Apgar introduced the score in 1952 to give delivery rooms a consistent way of describing a newborn’s condition in the minutes after birth. Before it, assessments were narrative and hard to compare. The five signs were chosen because they can be observed quickly, need no equipment, and between them cover the circulation, the breathing and the neurological response.
The initials of the five signs spell the inventor’s surname, which is how most people remember them — Appearance, Pulse, Grimace, Activity, Respiration — though the backronym was coined later by someone else, not by Apgar herself.
What the score does not do
This is the point the joint statement from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists is most concerned with. The score is not used to decide whether resuscitation is needed, which steps to take, or when to take them — those decisions follow the newborn resuscitation algorithm and begin well before the first minute is up. Nor does it predict an individual baby’s neurological outcome. A low 5-minute score correlates with mortality across large populations, but it cannot be read backwards onto one child.
- 1 Score each of the five signs from 0 to 2. Appearance, pulse, grimace, activity and respiration are rated independently, so the maximum is 10.
- 2 Use 100 beats per minute as the pulse cut-off. Absent is 0, below 100 is 1, and 100 or above is 2.
- 3 Do not penalise blue hands and feet alone. A pink body with blue extremities is acrocyanosis and scores 1; blue or pale all over scores 0. Most healthy newborns are not completely pink at one minute.
- 4 Add the five and record the time. Acrocyanosis 1, pulse 120 gives 2, grimace 1, some flexion 1, strong cry 2 — a total of 7.
- 5 Repeat at 5 minutes, and keep going if it stays low. Scores are recorded at 1 and 5 minutes, then every 5 minutes up to 20 minutes while the score remains below 7.
The five signs
Each sign scores 0, 1 or 2. The initials spell APGAR, which is how the list is usually remembered.
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (colour) | Blue or pale all over | Body pink, extremities blue | Completely pink |
| Pulse (heart rate) | Absent | Below 100/min | 100/min or above |
| Grimace (reflex) | No response | Grimace only | Cry, cough or sneeze |
| Activity (tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow, irregular, weak cry | Good, strong cry |
How the total is described
Bands describe the newborn’s condition at that moment; they do not forecast an individual outcome.
| Total | Description |
|---|---|
| 7–10 | Reassuring |
| 4–6 | Moderately abnormal |
| 0–3 | Low |
Why a perfect 10 is uncommon
Most healthy newborns still have bluish hands and feet at one minute, so the colour component scores 1 rather than 2 and the total comes to 9. That is entirely normal and not a sign of anything wrong — a 10 simply means the peripheries had already pinked up, which takes a few more minutes in most babies.
Several factors shift the score without reflecting the condition the scale was designed to describe. Prematurity lowers tone and respiratory effort, maternal sedation depresses responses, and congenital abnormalities or an ongoing resuscitation all affect what is observed. The score records what the baby is doing at that moment and how it has responded to any resuscitation already under way; assessment and all clinical decisions belong to a qualified professional working to local protocol.