_id

683a15ecc782e11e38d1b08a

id

23

title

APGAR Score

full_title

APGAR Score

short_title

APGAR Score

med_description

Assesses neonates 1 and 5 minutes after birth.

short_description

Assesses neonates 1 and 5 mins postpartum.

slug

apgar-score

description

The APGAR Score assesses neonates vitality at 1 and 5 minutes after birth.

keywords

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complaint

[ "Abdominal Pain" ]

formula

Addition of assigned points. 5 independent items, each scored 0 (Absent), 1 (Intermediate), or 2 (Present) Minimum score = 0; maximum = 10 Initial testing for “Reflex Irritability” was nasal and oropharyngeal suctioning with rubber catheter meant to elicit grimace, sneeze, or cough.Later, a rapid, tangential slap of the sole of the foot was found to be an easier and more effective stimulus. Later, a rapid, tangential slap of the sole of the foot was found to be an easier and more effective stimulus.

evidence

• The original 1953 series included 1,021 newborns from a single hospital center.
• The sample included all live singleton/twin neonates with birth weights >500 grams as a result of any spontaneous, instrument/surgically-assisted delivery using multiple anesthesia methods.
• Two raters were used for each assessment point.
  • Despite no published measure of inter-rater reliability, variability between observers was only ±1 point.
  • Variation was most common in the mildly depressed range (i.e., 5-7).
• To assess for score “accuracy”, the sample was subcategorized into 3 groups. Percent death by category was 14% with score 0-2, 1.1% death in those 3-7, and 0.13% with score 8-10.
  • Though intended to convey clinical status during a moment in time, the original article did make mention of prognosis.
• Apgar’s Second Report in 1958 internally validated the scoring system and compared it to UA blood gas samples in >15,000 newborns.
  • Death rates were similar by score category to the initial paper.
  • Lower scores associated with “chemical findings characteristic of asphyxia…”
  • Concluded score was particularly beneficial in determining need for resuscitation.
• The 2001 study validated the original measure on >150,000 mothers of singleton newborns born at >26 weeks GA.
  • In premature newborns, those with 5 minute APGAR scores of 0-3 had a relative risk of neonatal death of 59 (95% CI 40-87) compared to a score of 7-10. In term newborns, the RR was 1460 (95% CI 835-2555).
  • After accounting for GA, the lower 5 minute APGAR score was still significantly correlated with increased risk of neonatal mortality.
  • APGAR score was a better predictor of neonatal mortality than degree of acidemia on UA blood gas. Scores of 0-3 plus pH <7.0 almost doubled the risk of neonatal mortality.
  • Scores of 0-3 was significantly correlated with early death (i.e., >24 hours of life) in all GAs.
  • In term infants with 5 minute scores of 0-3, RR of death by Hypoxic-Ischemic Encephalopathy was 13 (95% CI 3-58).

measurements

[]

information

Score interpretation:

• Scores ≥7; generally normal
• Score of 4 to 6; fairly low
• Scores ≤3; critically low, needs intervention

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/13083014", "text": " Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 1953;32(4): 260–267. doi:10.1213/00000539-195301000-00041. PMID 13083014." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/13598635", "text": "Apgar V, Holaday D, Stanley James L, et al. Evaluation of the Newborn Infant – Second Report. JAMA. 1958; 168(15): 1985-8." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/11172187", "text": "Casey BM, McIntire DD Leveno KJ The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med. 2001; 344 (7): 467–471.doi:10.1056/NEJM200102153440701. PMID 11172187" }, { "href": "https://pediatrics.aappublications.org/content/136/4/819", "text": "The American Academy of Pediatrics Committee on Fetus and Newborn, The American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2015; 136: 819-22." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/15791116", "text": " Finster M, Wood M. The Apgar score has survived the test of time. Anesthesiology. 2005;102 (4): 855–857. doi:10.1097/00000542-200504000-00022. PMID 15791116." } ], "Validations": [] }

pearls

• The APGAR Score was developed to provide a simple and reliable grading scheme of newborns to communicate effects of obstetrical practices, maternal analgesia, and resuscitative efforts.
• 5 objective signs were chosen for easy determination without interfering in patient care.
• It should NOT be used to predict individual risk of mortality and adverse neurologic outcome.
• Gestational age (GA), maternal sedation, congenital malformations, trauma, inter-observer variability may affect APGAR scoring.

usecase

Perform on every live newborn, regardless of GA, at 1 and 5 minutes of life.

• 60 seconds after complete delivery of the newborn was deemed the point of most marked depression.
• Per Neonatal Resuscitation Program (NRP), scoring continues at 5 minute intervals until reaching a score of 7 or until 20 minutes of life is encountered.
• Scored by any provider with direct patient contact at the specified time.

reasons

Convenient and validated method to report status of a newborn and response to resuscitation. Simple to teach in the delivery room. 1958 Second Report used ratings of house officers, nurses, and medical/nursing students. Reliable to use, as variability between independent raters was minimal. Useful in preterm and term newborns. Corroborated by biochemical lab data.

next_advice

• The 5 criteria are not of equal significance. The original article noted that HR and respiratory effort were most important, while color was least important.
  • To improve ease and utility, the criteria were not weighted for item importance.
• The 5 minute score is regarded as the better predictor of survival.
• Multiple publications from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) since 1996 including “Use and Abuse of APGAR” have emphasized limitations of APGAR to identify birth asphyxia and neurologic prognosis.
  • Score of 0-3 at ≥5 minutes is nonspecific marker of illness, “which may be one of the first indications of encephalopathy” but is not specific for asphyxia (Pediatrics 2015).
  • Asphyxia is only considered with evidence of impaired intrapartum or immediate postpartum gas exchange based on clinical condition and lab data.
    • Non-reassuring fetal HR tracings, imaging studies, EEG tracings, placental pathology may aid diagnosis.
  • Scores of ≤5 at 5 minutes and 10 minutes are associated with increased population risk of cerebral palsy (20-100 fold) and poor neurologic outcome, respectively.
    • Such population risks should not be extrapolated for any individual.

next_actions

next_management

• Per NRP protocol, resuscitation should commence prior to 1 minute, so APGAR score should not dictate need for initial resuscitation or specific interventions.
• A 2014 Neonatal Encephalopathy & Neurologic Outcome report defines 5 minute score of 7-10 as reassuring, 4-6 as moderately abnormal, and 0-3 as low.
• If score is ≤5 at 5 minutes, obtain an umbilical artery (UA) blood gas.
• 2015 ACOG/AAP publications and 2011 NRP reiterate that a score of 0 at 10 minutes may help decide whether continued resuscitative efforts are indicated due to poor prognosis.
• Score during resuscitation is different than for a spontaneously breathing newborn.
  • Expanded score reporting during resuscitation is encouraged (Pediatrics 2015).

diseases

[ "Pregnancy" ]

input_schema

[ { "conditionality": null, "default": null, "label_en": "Activity/muscle tone", "mdcalc_info_concept": null, "name": "activity", "option_fhir_rules": null, "optional": false, "options": [ { "label": "Active", "value": 2 }, { "label": "Some extremity flexion", "value": 1 }, { "label": "Limp", "value": 0 } ], "show_points": true, "tips_en": "", "type": "radio" }, { "conditionality": null, "default": null, "label_en": "Pulse", "mdcalc_info_concept": null, "name": "pulse", "option_fhir_rules": null, "optional": false, "options": [ { "label": "≥100 BPM", "value": 2 }, { "label": "<100 BPM", "value": 1 }, { "label": "Absent", "value": 0 } ], "show_points": true, "tips_en": "", "type": "radio" }, { "conditionality": null, "default": null, "label_en": "Grimace", "mdcalc_info_concept": null, "name": "grimace", "option_fhir_rules": null, "optional": false, "options": [ { "label": "Sneeze/cough", "value": 2 }, { "label": "Grimace", "value": 1 }, { "label": "None", "value": 0 } ], "show_points": true, "tips_en": "", "type": "radio" }, { "conditionality": null, "default": null, "label_en": "Appearance/color", "mdcalc_info_concept": null, "name": "appearance", "option_fhir_rules": null, "optional": false, "options": [ { "label": "All pink", "value": 2 }, { "label": "Blue extremities, pink body", "value": 1 }, { "label": "Blue/pale", "value": 0 } ], "show_points": true, "tips_en": "", "type": "radio" }, { "conditionality": null, "default": null, "label_en": "Respirations", "mdcalc_info_concept": null, "name": "respirations", "option_fhir_rules": null, "optional": false, "options": [ { "label": "Good/crying", "value": 2 }, { "label": "Irregular/slow", "value": 1 }, { "label": "Absent", "value": 0 } ], "show_points": true, "tips_en": "", "type": "radio" } ]

instructions

published

2022-04-21T20:29:10.174Z

purpose

[ "Prognosis", "Formula" ]

search_terms

[ "peds", "newborn", "neonate" ]

seo

{ "keywords_en": "apgar score, apgar calc, apgar neonates, apgar newborns, newborn assessment, newborn assessment calc, neonate assessment, birth assessment, birth calc, birth assessment calc, apgar score calc, apgar mdcalc, newborn mdcalc, newborn assessment mdcalc, newborn apgar score, activity neonate, activity neonate, activity assessment neonate, activity assessment newborn, mucsle tone neonate, activity neonate, mucsle tone assessment neonate, mucsle tone assessment newborn, pulse neonate, pulse neonate, pulse assessment neonate, pulse assessment newborn, grimace neonate, grimace neonate, grimace assessment neonate, grimace assessment newborn, appearance neonate, appearance neonate, appearance assessment neonate, appearance assessment newborn, respirations neonate, respirations neonate, respirations assessment neonate, respirations assessment newborn, apgar prognosis, neonate prognosis, newborn prognosis, newborn prognosis calc, newborn prognosis score", "meta_description_en": "The APGAR Score assesses neonates vitality at 1 and 5 minutes after birth." }

specialty

[ "Critical Care", "Critical Care (Neonatal)", "Emergency Medicine", "OB-Gyn", "Pediatrics" ]

departments

[ "Cardiac", "Neurologic", "Respiratory" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": "3320", "short_title_en": "Bishop Score", "slug": "bishop-score-vaginal-delivery-induction-labor" }, { "calcId": "3937", "short_title_en": "BWH Egg Freezing Counseling Tool", "slug": "bwh-egg-freezing-counseling-tool-efct" }, { "calcId": "4024", "short_title_en": "BPP Score", "slug": "fetal-biophysical-profile-bpp-score" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "cardiology", "neurology", "pulmonology" ]

cleaned_use

[ "Perform on every live newborn, regardless of GA, at 1 and 5 minutes of life.", "60 seconds after complete delivery of the newborn was deemed the point of most marked depression.", "Per Neonatal Resuscitation Program (NRP), scoring continues at 5 minute intervals until reaching a score of 7 or until 20 minutes of life is encountered.", "Scored by any provider with direct patient contact at the specified time." ]

pub

true