Generality
The Apgar index is the result of a series of checks performed on the newborn, in the first minutes of life. This assessment quickly establishes the state of health of the newborn child, providing a first judgment about the efficiency of the most important functions of his organism.
In more practical terms, the Apgar index takes into consideration five vital parameters :
- Heart rate ;
- Respiratory rhythm ;
- Reaction to stimuli ;
- Skin color ;
- Muscle tone .
For each of these elements, a score ranging from zero to two is assigned: if the sum is greater than seven, the conditions of the newborn are considered satisfactory. The test is performed within 1 minute of birth and repeated after 5 minutes .
A low Apgar index is not, in itself, a sign of serious problems in place, but it induces doctors to intensify post-natal examinations.
What's this
The Apgar index (also known as Apgar score or score ) is an evaluation system to which the newborn is subjected immediately after birth. The assessments to assign the score are carried out in the first minutes of life: the aim is to establish whether the newborn child is able to overcome the effort associated with childbirth without problems or presents some suffering that requires immediate medical intervention.
The examination to establish the Apgar index is repeated twice :
- Within the first minute of life : it determines the reaction of the newborn child to delivery;
- After the fifth minute from birth : it provides indications on adaptation to extra-uterine life.
The Apgar index takes into account five parameters, indicative of the ability of the newborn to survive independently, outside the maternal uterus:
- Colorful;
- Reflex excitability (verified by introducing a catheter into a nostril);
- Muscle tone;
- Respiratory activity;
- Heart rate.
Each of these clinical signs is given a score from zero to two and their sum represents the Apgar index . The latter can vary, therefore, from a maximum of 10 (newborn in excellent condition) to a minimum of 0 (index of very serious difficulties at the time of birth). Usually, scores above 7 are considered good.
However, when five minutes after birth, the Apgar index is still less than 7, the evaluation is repeated a third time at 10 minutes and, if the result is still low, the child is transferred to the neonatology department for treatment of the case.
Did you know that…
The Apgar index is named after Virginia Apgar, an American physician who, in 1952, introduced him to clinical practice. Initially, the score was used by doctors and nurses in the delivery room to determine whether or not a baby needed resuscitation. At the time it happened, in fact, that apparently healthy children at birth, died after a few minutes, as they did not receive the right attentions, in terms of support to vital functions. Dr. Apgar established that five criteria had to be considered to assess the health of newborn babies: cardiac activity, respiratory activity, muscle tone, reactivity to stimulation and color. At each clinical sign, a score of 0, 1 or 2 was assigned, depending on the presence or absence of the same.
Later, to facilitate memorization of the checks to be carried out on the newborn, an acronym was created, curiously using the letters of the surname of the doctor:
- A → Appearence (colorful)
- P → Pulse (heart rate)
- G → Grimace (reflections)
- A → Activity (muscle tone)
- R → Respiratory effort (respiratory activity)
Why do you run it?
The purpose of the Apgar index is to establish the degree of health of the newborn and decide very quickly in which cases it is necessary to intervene with specific care.
The exam to assign the score allows to evaluate the efficiency of primary vital functions, monitor the adaptation of the newborn to extra-uterine life and measure the sequelae of intra-partum stress.
On the other hand, the Apgar test provides a sort of shortcut to practice timely perinatal and neonatal care if necessary.
When do you run?
The newborn undergoes the Apgar test within the first minute of birth. Then, the visit is repeated after 5 minutes. In this period of time, in fact, the Apgar index can change, even by a lot. For example, children who are born by caesarean section are often assigned a low initial score; this depends on the effect of the anesthetic administered to the mother, who passes in small quantities through the placenta, making the infant weak or asleep. However, if the evaluation is repeated after 5 minutes, the Apgar index tends to fall within the norm.
When the child's condition is particularly critical or if the score remains low, the Apgar index can be repeated at regular intervals (every 5 minutes), at any time of life, until stabilization.
How to do it
Immediately after birth, the midwife or doctor in the delivery room, based on observation, evaluates the newborn and monitors the following 5 parameters:
- Heart rate : it is a very important element to determine if the child needs medical assistance. When the heart rate is regular and between 100 and 140 beats per minute (bpm), it is considered good and corresponds to a score of 2. If the parameter is below 100 bpm, it receives 1 point. A value of 0 is attributed, instead, in the cases in which no heartbeat can be heard or heard.
- Spontaneous respiratory activity : a newborn who breathes normally and cries vigorously receives 2 points. In the case of apnea 60 seconds after birth, 0 points are awarded (meaning that breathing is absent). All other types of respiratory activity (difficult, slow and irregular) are given 1 point.
- Muscle tone : a little tonic or completely flaccid baby receives a score of 0. If the baby is actively moving and has a spontaneous flexion of arms and legs, he receives 2 points.
- Reactivity to stimuli: measured by observing the reactions of the child to particular stimulations, such as a slight blow on the soles of the feet. The most widely used method for testing reflexes is the introduction of a soft catheter in the oropharynx and nostrils: if the newborn responds with a contraction of mimic muscles, a sneeze or a cough, the score assigned is 2.
- Color : it is a difficult parameter to evaluate, since it can be interpreted differently from observer to observer. Normally, the color is rosy. It must be considered, however, that all children at birth are transiently more or less cyanotic (ie have a pale or bluish skin color); this depends on the breathing difficulty that results during the passage from the birth canal and the relative low saturation of oxygen in their organism. The resolution of cyanosis is closely related to respiratory activity and heart rate.
A score of 2 is therefore assigned only to those newborns who are completely rosy; a value equal to 1 is attributed to a child whose extremities tend to be bluish-purple, while a score of 0 coincides with a pale or diffusely cyanotic complexion.
Apgar scheme for evaluating the vitality of the newborn | |||
PARAMETERS | 0 points | 1 point | 2 point |
Heart rate | Pulse absent | Less than 100 beats per minute (bpm) | Greater than 100 bpm |
Respiratory activity | Absent (the baby is not breathing) | Slow or irregular and weak cry after the first breath | Normal, effortless, vigorous with crying |
Muscle tone | Absent (atony) | Slight mobility or some bending mentioned | Active and spontaneous movements |
| Reflexes | Absent (no response to stimulation) | Scarse (slight grimace or cry) | Sneezing, lively crying, vigorous cry or cough |
| Colorful | Cyanotic (gray-bluish) or pale in a diffuse way | Cyanotic on the extremities (hands and feet) and pink on the trunk | Uniformly rosy |
The Apgar index derives from the sum of the scores attributed to all these parameters and can vary from 0 to 10. An overall result from 7 to 10 identifies a vital and healthy newborn.
Score <4 | The newborn needs immediate medical intervention |
Score between 4 and 6 | The newborn is considered "at risk" and requires assistance, supervision and repetition of the test every 5 minutes |
Score between 7 and 10 | The newborn is considered normal |
Who does it run from?
The Apgar test is performed by the midwife or doctor in the delivery room (gynecologist or pediatrician), immediately after birth.
How long does it last?
Parents often do not even notice that the midwife is evaluating the child to assign the Apgar index, since everything is done in a very short time and without resorting to particular tools.
What does the report contain?
In the discharge report of the newborn, the Apgar index is reported with the initials IA, followed by a numerical value (eg 9/10). Usually, the score is reported twice : the first number corresponds to the evaluation of the child within one minute of birth, while the second coincides with the test performed after 5 minutes.
The Apgar index can reach up to 10 (IA: 10/10). This value depends on the score given for heart rate, muscle tone, breath, reflexes and color. For each of these parameters, you can assign from 0 to 2 points. Therefore, the Apgar index obtained from the sum of the scores obtained considering the five vital parameters, can vary from a maximum of 10 (newborn in excellent condition) to a minimum of 0 (index of very serious difficulties at the time of delivery).
Interpretation of results
The result of the Apgar index is included in the range of values from 0 to 10:
- Apgar index between 7 and 10 : the newborn is well and does not present significant problems;
- Apgar index between 4 and 6 : the newborn shows a medium grade suffering, it must be stimulated to breathe and an external cardiac massage must be practiced;
- Apgar index between 0 and 3 : the newborn is in severe pain and needs intensive care.
Usually, newborns with a score equal to or greater than 7 are considered normal. An Apgar index of 10 indicates that the newborn is in the best possible condition.
Index of high Apgar
When the birth takes place at the end of the pregnancy and both the mother and the baby are doing well, Apgar's index is high. It should be noted that a newborn child is rarely assigned a score of 10/10, due to the prevalence of transient cyanosis .
In fact, most newborns have a score of 9/10 . This means that on the first minute after birth, a full score (equal to 2) was assigned for each parameter, except for the color of the skin. Often, newborn babies are pale or cyanotic (bluish), especially in the face; the rest, instead, is normal: the heart rate exceeds 100 beats per minute, the crying is strong, the muscles are in tension and the baby reacts well to stimuli.
An Apgar index of 8 is good: in that case, it is possible, for example, that the baby cries a little, so it is given a score of 1 for the breath. All scores below 7 need, instead, the attention of doctors.
Low Apgar Index
When the Apgar index in the first minute starts to be equal to or less than 7, the newborn baby must undergo further checks, either in the delivery room or in the neonatal ward.
Infants with an index between 4 and 6 are moderately in need of assistance and supervision. In these cases the test is repeated every 5 minutes, until stabilization.
If a score of less than 4 is attributed (usually it happens if it is premature or when complications arise during paro), the child is immediately evaluated by the neonatologist and is often admitted to intensive care.
Infants who have a very low Apgar index ( equal to or less than 3 ) need immediate assistance: a poor score is a symptom of critical or even life-threatening conditions.
Usually, a low Apgar index is due to a diminished supply of oxygen to the fetus (as happens, for example, in the case of cord prolapse, uterine rupture, premature placental detachment, perinatal trauma, infections and pre-eclampsia) . This condition is extremely dangerous for the unborn child and can cause serious neurological problems (such as hypoxic-ischemic encephalopathy).
A low Apgar index is not, however, always correlated to pathologies, abnormalities or problems in progress: thanks to their extraordinary ability to recover, it can happen that newborns with a score reduced at birth, can result, over time, perfectly normal.
Limitations
Although it is useful for establishing the health condition of the newborn at birth, the Apgar index has some limits, since it is influenced by various factors, including:
- Asphyxiation;
- Diseases of the central nervous system;
- Congenital muscle diseases;
- Prematurity;
- Fetal sepsis;
- Drugs taken by the mother.
However, each situation will be evaluated individually by the medical staff present.
The Apgar index is inappropriate for predicting specific neurological outcomes in the term child. In the premature infant, instead, there are no conflicting opinions about the clinical significance of this evaluation.
An Apgar index that remains below 3 at later times (for example, after 10, 15 or 30 minutes from birth) may indicate neurological damage (including a small but significant increase in the risk of cerebral palsy). However, the purpose of the Apgar test is to quickly determine if a newborn needs immediate medical attention and is not designed to establish a long-term prognosis. In this regard, the doctor will indicate further checks, to assess the child's health in the first weeks of life more precisely.
