Understanding Newborn APGAR Score Meanings
As a newborn nurse, I attend to deliveries for babies born during my shift. At each standard delivery, a newborn nurse, a labor nurse, and an OB-GYN are in attendance.
For higher-risk deliveries, such as those involving preterm babies, additional medical staff will be present in the room, including a respiratory therapist and a newborn nurse practitioner or pediatrician.
A tool that newborn nurses use at delivery to assess the overall health of the newborn is the APGAR test. It helps quickly identify babies who may need extra support. Low scores are sometimes an early sign of birth injuries.
Infants are assessed at one minute and five minutes of life and given a score based on five factors. Each of the five factors is scored from 0 to 2, with a maximum score of 10, indicating that the newborn is in perfect health. If an infant receives a score of 8 or less, further assessment and interventions are necessary.
APGAR stands for: Appearance, Pulse, Grimace, Activity, and Respiration. Learn more about each of these measures below.
1. Appearance
Newborns should appear pink by 5 minutes of life. It is common for babies to have a blue or dusky appearance in the first minute of life. It’s also normal to have decreased color in their hands and feet within the first 5 minutes of life.
However, it is important for the face and most of the body to have a pink tone within 5 minutes of life. If the body remains blue, it means the baby is not getting enough oxygen, and respiratory interventions are needed.
Severe oxygen deprivation can increase the risk of conditions like hypoxic-ischemic encephalopathy (HIE), a type of brain injury caused by lack of oxygen and blood flow.
Here is how appearance is scored:
- Score of 0: Blue or dusky skin color all over the baby
- Score of 1: Blue or dusky hands and feet, with the rest of the body being pink
- Score of 2: Pink skin color all over the baby
A healthy appearance reassures the medical team that oxygen is circulating well. The next important step is checking the baby's pulse.
2. Pulse
One of the first things to assess, especially in a high-risk delivery, is the infant’s heart rate. A normal newborn heart rate ranges between 110 and 160 beats per minute.
A nurse can listen to the baby’s heart rate with a stethoscope or by feeling a pulse. One way to assess the pulse is by pressing on the umbilical cord stump that is still attached to the baby.
In emergencies, we count the number of beats we feel in six seconds and multiply that by 10 to estimate how many times the heart beats in 60 seconds.
If the pulse is less than 100, resuscitative standards require nurses to give assisted breaths to the baby via a mask, a method called PPV (positive pressure ventilation).
When a baby's pulse is less than 60, the newborn medical staff starts compressions. Medications to increase the heart rate may also be given.
Pulse scoring includes:
- Score of 0: Absent heart rate (no pulse)
- Score of 1: Heart rate less than 100 beats per minute
- Score of 2: Heart rate greater than 100 beats per minute
A strong, steady pulse indicates that a newborn's heart is pumping well. Next, nurses assess the baby's reflexes with the grimace test.
3. Grimace
A grimace is a response given by the infant when being dried off and stimulated to test reflexes. As an infant is being dried, they should be crying and upset.
Crying is a great response by an infant at delivery because it also helps their lungs. A baby who is irritated and upset shows optimal newborn health.
If a baby gives mild facial movement but not a full-body response, this is a decreased grimace response. If the baby shows no response and doesn't cry or show irritation, it may be a sign of poor infant health.
With a decreased response or no grimace reaction, interventions such as respiratory support are needed.
This is how grimace is scored:
- Score of 0: No grimace reflex
- Score of 1: Minimal grimace reflex (facial reaction only)
- Score of 2: Infant is irritable and crying after stimulation
A good grimace response is a positive sign of healthy reflexes. In some cases, a poor reflex response can be an early sign of brain damage.
4. Activity
Newborn activity at delivery refers to a baby's muscle tone. A healthy newborn will move spontaneously and exhibit muscle contractions while crying.
An infant in distress at delivery will have decreased muscle tone, floppy arms and legs, and minimal to no muscle movement. If an infant is adequately oxygenated, they display more muscle movement and activity.
Here is how activity is scored:
- Score of 0: No muscle tone or movement
- Score of 1: Minimal muscle tone or movement
- Score of 2: Spontaneous movement and muscle contraction or increased muscle tone
Active movement shows that the baby’s muscles and nervous system are working properly. Low muscle tone at birth can sometimes be an early sign of cerebral palsy (CP), a condition caused by brain injury or abnormal brain development.
5. Respiration
A healthy newborn should cry independently and show good respiratory effort after birth. An infant should not have long pauses in breathing (apnea), breathe too quickly (tachypnea), have shallow breathing, or show decreased breathing effort.
Additionally, if an infant is working too hard to breathe, it is also a sign of distress, such as when a baby has retractions (the chest pulls in too deeply with each breath).
A healthy newborn will take 30 to 60 breaths per minute. Decreased or increased breathing can be a sign of respiratory problems.
Conditions like meconium aspiration syndrome (MAS), when a newborn inhales amniotic fluid stained with their first feces (meconium), can also cause serious breathing difficulties. If signs of respiratory distress are observed, immediate interventions are needed.
Some treatments that may be necessary include administering oxygen and pressure to the lungs, giving breaths to the baby, and suctioning to remove amniotic fluid.
Here is how respiration is scored:
- Score of 0: No breathing effort (no respiration)
- Score of 1: Reduced breathing effort (weak cry or irregular breathing patterns)
- Score of 2: Good, strong cry and a regular breathing pattern
Breathing patterns help doctors know if a baby is adjusting to life outside the womb.
After all five areas are assessed, the results are added together to form the APGAR score.
Apgar Score Chart
The chart below shows how newborns are scored based on their health at birth.
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Color | Blue or Pale | Acrocyanotic | Completely Pink |
| Heart Rate | Absent | <100 minute | >100 minute |
| Reflex Irritability | No Response | Grimace | Cry or Active Withdrawal |
| Muscle tone | Limp | Some Flexion | Active Motion |
| Respiration | Absent | Weak Cry; Hypoventilation | Good, Crying |
If an infant has a low score at 5 minutes of life, the scores will be taken every 5 minutes until the score reaches 8 or above, or once the infant reaches 20 minutes of life.
A baby's APGAR score is shared among health care professionals, from the nurses who continue caring for the baby to the newborn nurse practitioner or neonatologist at the hospital and the pediatrician caring for the infant after discharge.
Low Apgar Scores and Birth Injuries
As a newborn nurse, I have spent my career working alongside labor and delivery teams, caring for newborns and responding to emergencies in the delivery room.
I understand how critical those first few minutes are — and how scary it can feel when an APGAR score is lower than expected. When a baby needs extra help at birth, parents are often left with questions they never imagined having to ask.
If your child had a low APGAR score or needed emergency care after delivery and you’re left with unanswered questions, the team at Cerebral Palsy Guide is here to support you.
We can listen to your story, help you understand what may have happened, and explain what options you may have for financial support for your child.
Call a member of our team today at (855) 220-1101. You can also download our free Birth Injury Guide for practical tips and trusted information from registered nurses.
Written by:Katie Lavender, RNKatie Lavender has over 8 years of experience as a Registered Nurse in postpartum mother/baby care. With hands-on experience in Labor and Delivery and a role as a Community Educator for newborn care, Katie is a staunch advocate for patient rights and education. As a Medical Reviewer, she is committed to ensuring accurate and trustworthy patient information.
