Apgar Score Explained: The Five Criteria, Scoring and an Example

The Apgar score is a quick check of a newborn on five signs: breathing effort, heart rate, muscle tone, reflex response and skin color. Each sign earns 0, 1 or 2 points, so the total runs from 0 to 10. It is usually assigned at 1 and 5 minutes after birth (MedlinePlus).

The scale

MedlinePlus, from the National Library of Medicine, lists what earns each point (MedlinePlus).

MedlinePlus describes 7 to 9 as normal and notes a 10 is unusual, because most newborns lose a point for blue hands and feet right after birth. A score below 7 means the baby may need medical help, and the page adds that a low 1-minute score is often near normal by 5 minutes.

Timing: the score is assigned at 1 and 5 minutes, and occasionally at 10 minutes. If the 5-minute score is below 7, providers may check again a few minutes later to see whether interventions helped (MedlinePlus).

Using it in NurseTools

The Apgar tool is in clinical review and is not available yet. NurseTools is an iPhone app for nurses that is coming soon to the App Store, and nothing is downloadable yet. Only the BMI and MAP tools will be interactive at launch.

In the app, the Apgar tool will appear locked. A release-gates timeline will show the steps a tool goes through before it opens:

1. Source and rights audit.
2. Clinical editorial review.
3. Independent testing.
4. Regulatory and App Store review.

A “Notify me when available” switch will let you ask to be told when the tool is released. Nothing unlocks a tool that has not passed review. NurseTools has no account, never asks for patient data and works offline.

Worked example

This example uses a made-up scenario. It is not a patient.

At 1 minute:

• Breathing effort: slow or irregular = 1.
• Heart rate: above 100 beats per minute = 2.
• Muscle tone: some muscle tone = 1.
• Reflex response: grimace = 1.
• Skin color: pink body, blue hands and feet = 1.

Total: 1 + 2 + 1 + 1 + 1 = 6.

At 5 minutes in the same made-up scenario:

• Breathing effort: cries well = 2.
• Heart rate: above 100 beats per minute = 2.
• Muscle tone: active motion = 2.
• Reflex response: grimace plus cough = 2.
• Skin color: pink body, blue hands and feet = 1.

Total: 2 + 2 + 2 + 2 + 1 = 9.

Each score is the plain sum of five numbers, with no rounding or weighting. The difference between the two totals shows why the score is reported at more than one time point.

Limits and common pitfalls

• It does not predict outcomes for an individual. The AAP and ACOG state that the score alone is not evidence of asphyxia and does not predict an individual newborn’s mortality or neurologic outcome (ACOG Committee Opinion). MedlinePlus likewise says a low score does not predict long-term health problems.
• It is not used to start resuscitation. A journal article citing the AAP and ACOG statement reports that the AAP does not recommend using the Apgar score to start resuscitation (PMC). The score describes status and response to resuscitation.
• Scores given during resuscitation are not equal to scores in a spontaneously breathing infant. The AAP and ACOG encourage an expanded reporting form that records resuscitation steps alongside the number (ACOG Committee Opinion).
• Observers can differ. The same journal article cites interobserver variability and advises caution when the score is used as a basis for treatment decisions (PMC).
• Preterm infants. That article says the score may not have good prognostic value for long-term outcomes in infants born extremely preterm.
• Blue hands and feet are common. This is why a score of 10 is unusual and why a 9 is normal.
• Missing or skipped scores. A recent study of U.S. birth data describes how often the 5-minute score goes unreported in some births (PMC).

The Apgar score is a standard way to report how a newborn is doing in the first minutes. Care decisions come from the clinical team at the bedside.