Devised by Dr Virginia Apgar in the 1950s, this provides a means of assessing the condition of the baby at birth in relation to five variables: respiratory effort, heart rate, colour, muscle tone and reflex irritability. The score is initially assigned at 1 minute, to allow time for the changes to begin. Further scores are undertaken at 5 and 10 minutes. The score can be assessed more frequently if any of the scores are low and resuscitation is required, to provide an indication of the effectiveness of resuscitation measures undertaken (e.g. at 3 and 5 minutes). Low 1-minute scores have no correlation with future outcome. The 5-minute score provides an indication of neonatal mortality but poor long-term prediction of future outcome (AAP (American Academy of Pediatrics), ACOG (American College of Obstetricians and Gynecologists), 2006, O’Donnell et al., 2006 and Pinheiro, 2009).

Each variable is assigned a score of 0, 1 or 2, thus the baby is given a total score out of 10. A mnemonic, APGAR, can be used to remember the five variables (Table 37.1). A score of 7–10 at 1 minute suggests the baby is in a good condition. A score of 4–6 indicates moderate depression, requiring some degree of resuscitation but may also be due to other factors such as prematurity, effects of maternal drugs, congenital malformation, etc. (AAP & ACOG 2006). A baby who scores 0–3 is severely depressed (Mead 1996) and is usually already undergoing resuscitation, possibly ventilation. An Apgar score assigned during resuscitation is not equivalent to that obtained from a baby who is breathing spontaneously and there is no accepted standard for reporting Apgar scores for babies who are being resuscitated (AAP (American Academy of Pediatrics), ACOG (American College of Obstetricians and Gynecologists), 2006 and Pinheiro, 2009).

It is difficult to anticipate which babies will have a low Apgar score at birth. Dijxhoorn et al (1986) suggest changes in the fetal heart rate do not compare well with Apgar scores at delivery. This may explain why some emergency caesarean sections undertaken because of serious concerns regarding the fetal heart rate deliver a baby with a total Apgar score of 9 or 10. A persistently low Apgar score on its own should not be considered a specific indicator of intrapartum asphyxia.

The Apgar score is a subjective scoring system and is therefore vulnerable to bias. Ideally, it should not be assigned by the person undertaking the delivery, however this is not always feasible when only one midwife is in attendance at the birth. At the time of birth, the midwife delivering has to consider the condition of both the mother and the baby. This can result in retrospective scoring, influenced by subsequent events. Additionally, Letko (1996) suggests midwives could be less objective due to their involvement with the outcome. Although the Apgar score could be jointly assigned by all present at delivery, O’Donnell et al (2006) suggest there is poor interobserver reliability.

Other factors can influence the score; for example, assessment of colour can be affected by lighting, skin pigmentation, haemoglobin levels, degree of peripheral perfusion, maternal drugs, trauma, congenital abnormality, infection, hypoxia and hypovolaemia (AAP (American Academy of Pediatrics), ACOG (American College of Obstetricians and Gynecologists), 2006 and Letko, 1996). Skin pigmentation generally develops from the fifth day of life in non-Caucasian babies (Silverton 1993); however, if the skin is darkly pigmented, the appearance can be assessed by observing the mucous membranes, the palms and the soles – these should be pink. The preterm baby is likely to have lower Apgar scores than the term baby due to neurological immaturity resulting in poor muscle tone, slower reflexes and a bluish-red colouring of the skin. Low scores are inversely related to body weight and are limited in predicting morbidity and mortality (AAP & ACOG 2006).