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In the first minute of life, someone in the delivery room looks at a newborn and gives it a number out of 10. That number helps the team decide, quickly and consistently, whether the baby needs help breathing. Before 1952 there was no standard way to make that call. This post covers who Virginia Apgar was, how her score works, a worked scoring example, what the score can and cannot tell you, and what you can learn from her approach.
Who was Virginia Apgar?
The US National Library of Medicine's Changing the Face of Medicine biography records that Apgar (1909 to 1974) studied zoology at Mount Holyoke College, graduating in 1929, and graduated fourth in her class from Columbia University's College of Physicians and Surgeons in 1933.
She trained as a surgeon, but the chair of surgery, Alan Whipple, steered her towards anaesthesia, then mostly done by nurses and not yet a recognised specialty. In 1938 she returned to Columbia to head its division of anaesthesia, and in 1949 she became the first woman to be made a full professor there.
What problem was she trying to solve?
Apgar studied how drugs given to a mother during labour affected the baby. To compare babies, she needed a way to describe their condition that any trained person could apply in seconds and that gave the same answer from different observers.
The NLM biography describes the result: "Five points—heart rate, respiratory effort, muscle tone, reflex response, and color—are observed and given 0, 1, or 2 points." She presented it in 1952 and published it in 1953 in Current Researches in Anesthesia and Analgesia.
How is the Apgar score worked out?
The MedlinePlus Medical Encyclopedia, also from the NLM, lists the criteria:
Heart rate: none scores 0; under 100 beats a minute scores 1; over 100 scores 2.
Breathing: not breathing scores 0; slow or irregular scores 1; a good cry scores 2.
Muscle tone: loose and floppy scores 0; some tone scores 1; active motion scores 2.
Reflex response to stimulation: no reaction scores 0; grimacing scores 1; grimacing with a cough, sneeze or vigorous cry scores 2.
Colour: pale blue scores 0; pink body with blue hands and feet scores 1; pink all over scores 2.
It is taken at one and five minutes after birth. Apgar first planned the one-minute score as a guide to whether resuscitation was needed; the five-minute score later became standard too.
Worked example: scoring a sample baby
These are sample observations for practice, not a real case. At one minute a baby has a heart rate of 120, is breathing but irregularly, has some flexion of the limbs, grimaces when the sole of the foot is flicked, and has a pink body with bluish hands and feet.
Heart rate 120: over 100, so 2.
Irregular breathing: 1.
Some tone: 1.
Grimace only: 1.
Pink body, blue extremities: 1.
Total: 2 + 1 + 1 + 1 + 1 = 6. MedlinePlus says any score below 7 is a sign the baby needs medical attention, so this baby would get help, for example with breathing, and be checked again.
Does a low score predict anything?
A large study in the New England Journal of Medicine in 2001 looked at 151,891 live-born single babies at an inner-city public hospital between 1988 and 1998. Among babies born at term, the death rate in the first 28 days was 244 per 1,000 for five-minute scores of 0 to 3, compared with 0.2 per 1,000 for scores of 7 to 10. The authors concluded the score remained as relevant for predicting newborn survival as it had been almost 50 years earlier.
MedlinePlus adds an important limit: a low score does not mean a child will have long-term problems, and the score is not designed to predict a child's future health.
What did Apgar do next?
In 1959 she earned a master's in public health at Johns Hopkins and left academic medicine to work on preventing birth defects, becoming director of the division of congenital defects at the National Foundation, now the March of Dimes, according to the NLM biography.
Each sign in the score is something you study in Class 11 biology, from heart rate to breathing. Our post on breathing and exchange of gases explains why colour and breathing go together. If a term in the score is unclear, the Fermi Concept Library covers every concept in physics, chemistry, biology, mathematics and computing.
What can a student learn from Apgar's way of working?
Turn a judgement into a checklist. "Looks fine" became five items anyone could score in seconds.
Keep it simple enough to use. Three levels per sign meant the score was used, not ignored.
State its limits. A good tool says what it measures and what it does not.
Next step: score a sample baby with heart rate 90, a strong cry, active movement, a sneeze on stimulation and blue hands, then check your total against the criteria.
