The Origin Of The Apgar Test And Newborn Health

Here’s how doctors and nurses score newborn babies’ health within the first five minutes after birth and what that means for your child.

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As an expecting mother, there is nothing you want more than a healthy baby. When the time finally comes for you to greet your baby for the first time, there is nothing you hope for more than hearing those first few cries and then hearing the doctor confirm that all is well. And when the time comes to take your child home from the hospital, you want to leave with the confidence that your baby will thrive. That’s where the Apgar test comes in. Using a one to 10 scale, the standardized test is meant to measure how well the baby is doing after birth. Most moms who have given birth in a modern hospital are familiar with Apgar scores. Some mothers have smiled in joy hearing that their newborn was scored at an eight or a nine, while other mothers have furrowed their brows in concern when the doctor says the baby has scored a lower number. Here’s what you need to know about the test, its origins, and what your baby’s score means for their health.

What are the origins of the Apgar test?

The Apgar test was named after its creator, Virginia Apgar, MD. After spending many years working as a surgeon, Apgar experienced a career shift. In 1949, she was named a professor of anesthesiology at Columbia University’s College of Physicians and Surgeons, according to Profiles in Science published by the U.S. National Library of Medicine. Her new work provided the opportunity for research, and it piqued her interest in maternal anesthesiology. More specifically, she was interested in spending more time researching mortality rates in newborn babies. By 1952, she had developed a scoring system used on newborn babies during the first minute after their birth. The main goal of her system was to see what effects labor, delivery, and maternal anesthesia had on the well-being of brand new babies. Her attendance of over 17,000 births informed her development of the test. Today, the Apgar test is standard in modern hospitals. Apgar’s system for scoring newborn health within the first five minutes of life is used all over the world.

What does the Apgar test measure?

Although the test was originally named after its creator, it was later developed into an acronym describing what it specifically measures. Each letter of the test’s name indicates one aspect of newborn health that is given a score between zero and two: appearance, pulse, grimace response, activity, and respiration. During the first minute after birth, the evaluating nurse, doctor, or midwife scores the baby’s appearance first by looking at their skin tone. The baby will receive a score of zero, one, or two. A score of zero indicates a blueish pale color, while a score of two indicates pink skin all the way to fingers and toes, according to the U.S. National Library of Medicine. Next, the medical professional checks the newborn’s pulse. Babies with a heart rate over 100 beats per minute, a healthy heart rate for a newborn, receive a score of two, and babies born with no pulse receive a zero. The grimace response measures the baby’s reflexes, or how they respond to stimulation like a mild pinch, according to the U.S. National Library of Medicine. Babies who pull away have strong reflexes and are scored with a two, while a one is given to babies who simply grimace, and a zero is given to babies who don’t respond at all. Activity refers to a baby’s muscle tone. Babies who appear floppy or aren’t moving are scored a zero, while babies who are moving often are scored a two. Lastly, respiration is measured based on the baby’s breathing rate and the strength of their cry. A strong cry earns a score of two, while a baby who doesn’t cry at all will be scored at zero. An audible but weak cry is given a score of one. These individual scores are added up to create one score given to the baby. Babies who score seven or higher on the Apgar test are considered healthy, while a lower score may indicate a problem or the need for immediate medical care.

What are the limitations of the Apgar test?

“The Apgar test helps determine how well a baby is immediately after birth and if a baby requires resuscitation or support breathing,” Yvonne Bohn, MD, OB-GYN at Providence Saint John’s Health Center in Santa Monica, California, says. However, babies do undergo additional testing and monitoring before they leave the hospital with their parents, usually within the first day or two of life. Healthy babies without exceptional medical needs will all undergo the same three tests at some point during their hospital stay, according to Baby’s First Test—a blood test, a hearing test, and a pulse-oximetry test. Additional testing is only performed if the parents request it or the doctors have concerns about the baby’s health. The standard newborn hearing test is actually two different screenings that take between five and ten minutes to complete. One tests the hearing nerves and how they respond to sound. The other actually uses a probe placed in the baby’s inner ear to measure sound waves. The blood test, also known as the heel prick test, is meant to monitor for genetic conditions long before symptoms might be noticed, according to Erin O’Toole, a certified genetic counselor who works with expecting parents and parents of newborns. “Conditions on the newborn screen all have a much better prognosis if treatment is started before symptoms are present,” she says. “Each state runs their own newborn screen, so depending on where you live, the baby is tested for different conditions.” The pulse oximetry test is completely non-invasive. A nurse will place a monitor on the baby’s foot or hand that measures both their heart rate and the oxygen in their blood. This test is used to catch early symptoms of congenital heart defects. The Apgar test is generally seen as a reliable first look at the baby’s health. Labor and delivery can be a stressful experience for babies, especially in high-risk pregnancies, difficult labors, and cesarean sections. A lower Apgar score is more common in these cases.  Babies born prematurely are also more likely to have a lower Apgar score. Even though it has become the standard, it is not a perfect test. One of the major limitations is that not all measurements are exact. Sure, the respiration rate is a hard number, along with the pulse, but the rest of the factors measured are fairly subjective. “These measurements are subjective and the score may be different based on the observer,” says Bohn. So, one doctor may see a great reflex response while another sees a response they believe is not as strong. At this time, Bohn says there are no new newborn tests being developed, but O’Toole does say that the newborn blood tests are becoming less expensive and more accessible. She hopes this will result in better outcomes for children with genetic disorders over time.

What do I need to know about my baby’s Apgar score?

Regardless of your baby’s score, they will be tested again at five minutes. “The hope is that the score will be at least seven at the five-minute mark to help the medical team determine how the baby is transitioning to breathing outside the womb and decide when to intervene,” explains O’Toole. After the test at five minutes, babies with a score of seven or less will continue being tested. During this time, some babies might require additional support to aid breathing. A member of your baby’s care team may also take a gas sample from the umbilical cord, according to O’Toole. From this point, medical treatment will continue if the baby’s score doesn’t climb to seven or higher. For parents, it is important to remember that even a low Apgar score isn’t the final word on a baby’s health. Some babies score low immediately after birth because they are having a more difficult time transitioning into the world, according to O’Toole. It’s helpful to think of this test as an answer to the question, “What does this baby need right now?” Remember, those first few minutes are important, but they’re not always an indication of what a baby’s next day, year, or entire life will be like. If you have questions or concerns about your baby’s Apgar score, either while you are in the hospital or after you have been sent home, express your concerns to your care provider, who can offer further recommendations and information to ease your worries.