The Apgar Score: A Predictor of Survival of Newborn Infants, 5/2001

In 1952, Dr. Virginia Apgar developed a rating system for evaluation of the status of the newborn infant as a measure of probable survival. It has become known as the Apgar Score. The score has four components: heart rate (e.g. slow, normal, fast, irregular) respiratory effort (e.g. normal; distressed) reflex irritability (e.g. over-reactive; under-reactive) color (e.g. pale, normal, blue, flushed) The total score is rated from 0-10; the higher the score the better the prediction. A total score of 7 or higher (up to 10) indicates the infant's condition is good to excellent. The score is determined at one minute and at five minutes after delivery. Of the two scores, the five minute score is generally accepted as the better predictor of the survival of the newborn infant.

50 years has passed since the Apgar score was introduced. With 50 years of experience, is it still a good predictor of infant survival?

A study has been done of 13,399 premature infants born between 21-36 weeks of gestation. The mortality rate at birth was 315 per 1000 for infants with Apgar scores 0-3; it was 5 per 1000 infants with five minute Apgar scores of 7-10. Thus, it was an accurate predictor of mortality for prematures. For 132,228 infants born at 37 weeks or later (term infants), the mortality rate was 244 per 1000 for infants with Apgar five minute scores of 0-3 as compared to 0.2 per 1000 for infants with Apgar five minute scores of 7 to 10. Thus, it was also an accurate predictor of mortality for term infants.

Comment:Assessing the status of a newborn infant as a basis for decision making about needed interventions and for predicting outcome is a very important responsibility of the obstetrician, anesthesiologist and neonatologist. The Apgar score at one minute focuses attention on the overall condition of the infant one minute after birth; at five minutes, it predicts mortality.

Unfortunately, the Apgar score has sometimes been used to also try to identify lack of sufficient oxygen at birth (birth asphyxia) or to predict later developmental disability. It does not do either with any degree of reliability. In 2001, it does what it was designed to do in 1952 by Dr. Apgar and her colleagues; it draws attention to infant distress and predicts mortality. Other evaluations are available to better determine the cause of the infant's distress. However, except for rare situations, such as a gross anatomical defect, there are very few reliable indicators at birth of the probability of developmental disability.