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APGAR Scoring Maternity NCLEX Quiz

Learn how to calculate a newborn’s APGAR score  for the NCLEX exam with this practice quiz . APGAR scoring is a tool used to quickly assess a newborn’s health status after birth. It is important you know how to calculate the APGAR score when given a scenario and what nursing interventions to provide based on that score.

The NCLEX exam, along with other nursing exams such as lecture, HESI, or ATI, love to ask questions about calculating the APGAR score. I remember these questions from my nursing lecture exams. So, be very familiar with how to do it.

Don’t forget to check out our other NCLEX review quizzes  for maternity nursing.

APGAR Questions Quiz NCLEX

This quiz will test your knowledge on APGAR scoring for the NCLEX exam (maternity nursing).

• B. APGAR 10
• C. APGAR 12

A. Routine post-delivery care

B. Continue to monitor and reassess the APGAR score in 10 minutes.

C. Some resuscitation assistance such as oxygen and rubbing baby’s back and reassess APGAR score.

D. Full resuscitation assistance is needed and reassess APGAR score.

A. 2 minutes after the previous APGAR assessment

B. 15 minutes after the previous APGAR assessment

C. 5 minutes after the previous APGAR assessment

• D. No reassessment of the APGAR score is needed.

B. Full resuscitation assistance is needed and reassess APGAR score

C. Continue to monitor and reassess the APGAR score in 10 minutes

D. Some resuscitation assistance such as oxygen

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Lecture on APGAR Scoring

APGAR NCLEX Practice Questions

1.  You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient’s APGAR score?

A.      APGAR 9

B.      APGAR 10

C.      APGAR 8

D.      APGAR 5

2.       You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient’s APGAR score?

A.      APGAR 4

B.      APGAR 6

C.      APGAR 3

D.      APGAR 2

3.       You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: weak cry, some flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is your patient’s APGAR score?

A.      APGAR  5

B.      APGAR 9

C.      APGAR 12

D.      APGAR 6

4. A newborn’s five minute APGAR score is 5. Which of the following nursing interventions will you provide to this newborn?

5. Regarding the scenario in the question above, when would you reassess the APGAR score?

D. No reassessment of the APGAR score is needed

6. You’re assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: pink body and hand with cyanotic feet, heart rate 109, grimace to stimulation, flaccid, and irregular cry. What is your patient’s APGAR score?

7. You’re assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 97, no response to stimulation, flaccid, absent respirations, cyanotic throughout. What is your patient’s APGAR score?

8. A newborn’s one minute APGAR score is 8. Which of the following nursing interventions will you provide to this newborn?

Answer Key:

1. C 2. A 3. D 4. C 5. C 6. B 7. D 8. A

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Introduction

Limitations of the apgar score, apgar score and resuscitation, prediction of outcome, other applications, conclusions, recommendations, aap committee on fetus and newborn, 2014–2015, acog committee on obstetric practice, 2014–2015, the apgar score.

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AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON FETUS AND NEWBORN , AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE , Kristi L. Watterberg , Susan Aucott , William E. Benitz , James J. Cummings , Eric C. Eichenwald , Jay Goldsmith , Brenda B. Poindexter , Karen Puopolo , Dan L. Stewart , Kasper S. Wang , Jeffrey L. Ecker , Joseph R. Wax , Ann Elizabeth Bryant Borders , Yasser Yehia El-Sayed , R. Phillips Heine , Denise J. Jamieson , Maria Anne Mascola , Howard L. Minkoff , Alison M. Stuebe , James E. Sumners , Methodius G. Tuuli , Kurt R. Wharton; The Apgar Score. Pediatrics October 2015; 136 (4): 819–822. 10.1542/peds.2015-2651

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The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions.

In 1952, Dr Virginia Apgar devised a scoring system that was a rapid method of assessing the clinical status of the newborn infant at 1 minute of age and the need for prompt intervention to establish breathing. 1 Dr Apgar subsequently published a second report that included a larger number of patients. 2 This scoring system provided a standardized assessment for infants after delivery. The Apgar score comprises 5 components: (1) color; (2) heart rate; (3) reflexes; (4) muscle tone; and (5) respiration. Each of these components is given a score of 0, 1, or 2. Thus, the Apgar score quantitates clinical signs of neonatal depression, such as cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or gasping respirations. The score is reported at 1 minute and 5 minutes after birth for all infants, and at 5-minute intervals thereafter until 20 minutes for infants with a score less than 7. 3 The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if it is needed; however, it has been inappropriately used to predict individual adverse neurologic outcome.

The purpose of the present statement was to place the Apgar score in its proper perspective. This statement revises the 2006 College Committee Opinion/American Academy of Pediatrics policy statement to include updated guidance from the 2014 report Neonatal Encephalopathy and Neurologic Outcome (second edition) 4 published by the American College of Obstetricians and Gynecologists in collaboration with the American Academy of Pediatrics, along with new guidance on neonatal resuscitation. The guidelines of the Neonatal Resuscitation Program state that the Apgar score is useful for conveying information about the newborn infant’s overall status and response to resuscitation. However, resuscitation must be initiated before the 1-minute score is assigned. Therefore, the Apgar score is not used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to use them. 3  

An Apgar score that remains 0 beyond 10 minutes of age may, however, be useful in determining whether continued resuscitative efforts are indicated because very few infants with an Apgar score of 0 at 10 minutes have been reported to survive with a normal neurologic outcome. 3 , 5 , 6 In line with this outcome, the 2011 Neonatal Resuscitation Program guidelines state that “if you can confirm that no heart rate has been detectable for at least 10 minutes, discontinuation of resuscitative efforts may be appropriate.” 3  

The Neonatal Encephalopathy and Neurologic Outcome report defines a 5-minute Apgar score of 7 to 10 as reassuring, a score of 4 to 6 as moderately abnormal, and a score of 0 to 3 as low in the term infant and late-preterm infant. 4 In that report, an Apgar score of 0 to 3 at 5 minutes or more was considered a nonspecific sign of illness, which “may be one of the first indications of encephalopathy.” However, a persistently low Apgar score alone is not a specific indicator for intrapartum compromise. Furthermore, although the score is widely used in outcome studies, its inappropriate use has led to an erroneous definition of asphyxia. Asphyxia is defined as the marked impairment of gas exchange, which, if prolonged, leads to progressive hypoxemia, hypercapnia, and significant metabolic acidosis. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should not be applied to birth events unless specific evidence of markedly impaired intrapartum or immediate postnatal gas exchange can be documented on the basis of laboratory test results.

It is important to recognize the limitations of the Apgar score. It is an expression of the infant’s physiologic condition at 1 point in time, which includes subjective components. There are numerous factors that can influence the Apgar score, including maternal sedation or anesthesia, congenital malformations, gestational age, trauma, and interobserver variability. 4 In addition, the biochemical disturbance must be significant before the score is affected. Elements of the score, such as tone, color, and reflex irritability, can be subjective and partially depend on the physiologic maturity of the infant. The score may also be affected by variations in normal transition. For example, lower initial oxygen saturations in the first few minutes need not prompt immediate supplemental oxygen administration; the Neonatal Resuscitation Program targets for oxygen saturation are 60% to 65% at 1 minute and 80% to 85% at 5 minutes. 3 The healthy preterm infant with no evidence of asphyxia may receive a low score only because of immaturity. 7 , 8 The incidence of low Apgar scores is inversely related to birth weight, and a low score cannot predict morbidity or mortality for any individual infant. 8 , 9 As previously stated, it is also inappropriate to use an Apgar score alone to diagnose asphyxia.

The 5-minute Apgar score, and particularly a change in the score between 1 minute and 5 minutes, is a useful index of the response to resuscitation. If the Apgar score is less than 7 at 5 minutes, the Neonatal Resuscitation Program guidelines state that the assessment should be repeated every 5 minutes for up to 20 minutes. 3 However, an Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. 10 There is no accepted standard for reporting an Apgar score in infants undergoing resuscitation after birth because many of the elements contributing to the score are altered by resuscitation. The concept of an assisted score that accounts for resuscitative interventions has been suggested, but the predictive reliability has not been studied. To correctly describe such infants and provide accurate documentation and data collection, an expanded Apgar score reporting form is encouraged ( Fig 1 ). This expanded Apgar score may also prove useful in the setting of delayed cord clamping, in which the time of birth (ie, complete delivery of the infant), the time of cord clamping, and the time of initiation of resuscitation can all be recorded in the comments box.

Expanded Apgar score reporting form. Scores should be recorded in the appropriate place at specific time intervals. The additional resuscitative measures (if appropriate) are recorded at the same time that the score is reported by using a checkmark in the appropriate box. The comment box is used to list other factors, including maternal medications and/or the response to resuscitation between the recorded times of scoring. ETT, endotracheal tube; PPV/NCPAP, positive pressure ventilation/nasal continuous positive airway pressure.

The Apgar score alone cannot be considered to be evidence of or a consequence of asphyxia. Many other factors, including nonreassuring fetal heart rate–monitoring patterns and abnormalities in umbilical arterial blood gas results, clinical cerebral function, neuroimaging studies, neonatal electroencephalography, placental pathology, hematologic studies, and multisystem organ dysfunction, need to be considered in diagnosing an intrapartum hypoxic–ischemic event. 6 When a category I (normal) or category II (indeterminate) fetal heart rate tracing is associated with Apgar scores of 7 or higher at 5 minutes, a normal umbilical cord arterial blood pH (±1 SD), or both, it is not consistent with an acute hypoxic–ischemic event. 4  

A 1-minute Apgar score of 0 to 3 does not predict any individual infant’s outcome. A 5-minute Apgar score of 0 to 3 correlates with neonatal mortality in large populations 11 , 12 but does not predict individual future neurologic dysfunction. Population studies have uniformly reassured us that most infants with low Apgar scores will not develop cerebral palsy. However, a low 5-minute Apgar score clearly confers an increased relative risk of cerebral palsy, reported to be as high as 20- to 100-fold over that of infants with a 5-minute Apgar score of 7 to 10. 9 , 13 , – 15 Although individual risk varies, the population risk of poor neurologic outcomes also increases when the Apgar score is 3 or less at 10 minutes, 15 minutes, and 20 minutes. 16 When a newborn infant has an Apgar score of 5 or less at 5 minutes, umbilical arterial blood gas samples from a clamped section of the umbilical cord should be obtained, if possible. 17 Submitting the placenta for pathologic examination may be valuable.

Monitoring of low Apgar scores from a delivery service may be useful. Individual case reviews can identify needs for focused educational programs and improvement in systems of perinatal care. Analyzing trends allows for the assessment of the effect of quality improvement interventions.

The Apgar score describes the condition of the newborn infant immediately after birth and, when properly applied, is a tool for standardized assessment. 18 It also provides a mechanism to record fetal-to-neonatal transition. Apgar scores do not predict individual mortality or adverse neurologic outcome. However, based on population studies, Apgar scores of less than 5 at 5 and 10 minutes clearly confer an increased relative risk of cerebral palsy, and the degree of abnormality correlates with the risk of cerebral palsy. Most infants with low Apgar scores, however, will not develop cerebral palsy. The Apgar score is affected by many factors, including gestational age, maternal medications, resuscitation, and cardiorespiratory and neurologic conditions. If the Apgar score at 5 minutes is 7 or greater, it is unlikely that peripartum hypoxia–ischemia caused neonatal encephalopathy.

The Apgar score does not predict individual neonatal mortality or neurologic outcome and should not be used for that purpose.

It is inappropriate to use the Apgar score alone to establish the diagnosis of asphyxia. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should not be applied to birth events unless specific evidence of markedly impaired intrapartum or immediate postnatal gas exchange can be documented.

When a newborn infant has an Apgar score of 5 or less at 5 minutes, umbilical arterial blood gas samples from a clamped section of the umbilical cord should be obtained. Submitting the placenta for pathologic examination may be valuable.

Perinatal health care professionals should be consistent in assigning an Apgar score during resuscitation; therefore, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions.

Kristi L. Watterberg, MD, FAAP, Chairperson

Susan Aucott, MD, FAAP

William E. Benitz, MD, FAAP

James J. Cummings, MD, FAAP

Eric C. Eichenwald, MD, FAAP

Jay Goldsmith, MD, FAAP

Brenda B. Poindexter, MD, FAAP

Karen Puopolo, MD, FAAP

Dan L. Stewart, MD, FAAP

Kasper S. Wang, MD, FAAP

Captain Wanda D. Barfield, MD, MPH, FAAP – Centers for Disease Control and Prevention

James Goldberg, MD – American College of Obstetricians and Gynecologists

Thierry Lacaze, MD – Canadian Pediatric Society

Erin L. Keels, APRN, MS, NNP-BC – National Association of Neonatal Nurses

Tonse N.K. Raju, MD, DCH, FAAP – National Institutes of Health

Jim Couto, MA

Jeffrey L. Ecker, MD, Chairperson

Joseph R. Wax, MD, Vice Chairperson

Ann Elizabeth Bryant Borders, MD

Yasser Yehia El-Sayed, MD

R. Phillips Heine, MD

Denise J. Jamieson, MD

Maria Anne Mascola, MD

Howard L. Minkoff, MD

Alison M. Stuebe, MD

James E. Sumners, MD

Methodius G. Tuuli, MD

Kurt R. Wharton, MD

Debra Bingham, DrPh, RN – Association of Women’s Health Obstetric Neonatal Nurses

Sean C. Blackwell, MD – Society for Maternal–Fetal Medicine

William M. Callaghan, MD – Centers for Disease Control and Prevention

Julia Carey-Corrado, MD – US Food and Drug Administration

Beth Choby, MD – American Academy of Family Physicians

Joshua A. Copel, MD – American Institute of Ultrasound in Medicine

Nathaniel DeNicola, MD, MS – American Academy of Pediatrics Council on Environmental   Health (ACOG liaison)

Tina Clark-Samazan Foster, MD – Committee on Patient Safety and Quality Improvement – Ex-Officio

William Adam Grobman, MD – Committee on Practice Bulletins-Obstetrics – Ex-Officio

Rhonda Hearns-Stokes, MD – US Food and Drug Administration

Tekoa King, CNM, FACNM – American College of Nurse-Midwives

Uma Reddy, MD, MPH – National Institute of Child Health and Human Development

Kristi L. Watterberg, MD – American Academy of Pediatrics

Cathy H. Whittlesey – Executive Board – Ex-Officio

Edward A. Yaghmour, MD – American Society of Anesthesiologists

Gerald F. Joseph, Jr, MD

Mindy Saraco, MHA

Debra Hawks, MPH

Margaret Villalonga

Amanda Guiliano

This document is copyrighted and is the property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Also published in Obstetrics & Gynecology . Copyright October 2015 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 and the American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927. All rights reserved. ISSN 1074-861×

The American College of Obstetricians and Gynecologists Committee Opinion no. 644: The Apgar score. Obstet Gynecol . 2015;126:e52–e55. Accepted for publication Jul 22, 2015

Re:Time for the Combined Apgar

We thank the authors for their recently published study of the ability of alternative versions of the Apgar score to predict perinatal mortality. Your study is consistent with the main points of our statement regarding the limitations of the Apgar score: (1) the Apgar score does not predict individual outcomes and should not be used for that purpose; (2) the Apgar score alone does not establish a diagnosis of asphyxia; and (3) the use of an expanded Apgar score can provide additional information detailing resuscitative efforts. The suggestion that adding a second number to the existing Apgar score to summarize the interventions described in the expanded Apgar score table is certainly intriguing, and could potentially improve communication. We look forward to confirmation of your findings in subsequent cohorts.

Conflict of Interest:

None declared

Time for the Combined Apgar

on behalf of the TEST-APGAR study group

In regard to The AAP and the ACOG report on the usage of the Apgar-Score in the current issue of Pediatrics.

We agree with the authors that it is necessary "to place the Apgar score in its proper perspective", especially in the light of recent advances in delivery room management (1). Furthermore, we strongly support their conclusion that "perinatal health care professionals should be consistent in assigning an Apgar score during resuscitation." However, to our disappointment the authors missed the opportunity to give - based on current scientific evidence (2,3) - a suggestion on how to make the assignment more consistent. The authors encourage the use of the Expanded-Apgar as already suggested in 2006 without giving a practical approach on how to report its results in daily work and discharge letters (4). In addition to these practical issues, the Expanded-Apgar will be less predictive and uncertainties remain without a specification of the conventional Apgar score (2). The combination of both, a Specified-Apgar (which scores infant`s condition irrespective of treatment or gestational age) plus the Expanded- Apgar (scoring the interventions the infant has received), will solve both problems (2). In contrast to author's statement, this combination of two scores - named Combined-Apgar - was prospectively tested in about 2000 infants. A large international multicenter study in VLBW infants proved the Combined-Apgar at 5 and 10 minutes to have a high predictive value on perinatal mortality: A Combined-Apgar of 0 to 5 (many interventions with poor response) at 5 and/or 10 minutes was associated with a 30-fold increase in mortality in 1855 VLBW infants (2). A similar good predictive value of the Combined-Apgar was shown in term infants (2). Thus, as previously stated, "... changes to perinatal care necessitate a reformation of the conventional Apgar and the Combined-Apgar Score represents a chance to do so" (5).

1) Statement P. The Apgar Score. Pediatrics. 2015;136(4):819-822. doi:10.1542/peds.2015-2651. 2) Rudiger M, Braun N, Aranda J, et al. Neonatal assessment in the delivery room - Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatr. 2015;15:18. doi:10.1186/s12887-015-0334-7. 3) Dalili H, Nili F, Sheikh M, Hardani AK, Shariat M, Nayeri F. Comparison of the four proposed apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PLoS One. 2015;10(3):e0122116. doi:10.1371/journal.pone.0122116. 4) Statement P. The Apgar score. Pediatrics. 2006;117(4):1444-1447. doi:10.1542/peds.2006-0325. 5) Rudiger M, Konstantelos D. Apgar score and risk of cause-specific infant mortality. Lancet. 2015;385(9967):505-6. doi:10.1016/S0140- 6736(15)60196-9.

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APGAR Scores

• A 30-year-old G2P1 woman at 39 weeks of gestation is in active labor. She undergoes a vaginal delivery and gives birth to a baby boy. The baby is vigorously dried and he begins to cry. At 1 minute after delivery, the baby is crying, he has a pink body and but somewhat grey extremities, and his pulse is 130/min. He is moving all 4 limbs and grimaces in response to nasal suction. The nurse calculates an APGAR score of 8. At 5 minutes after delivery, the nurse notes that the baby continues to show good breathing with intermittent crying, is now pink all over, and his pulse is 134/min. The baby coughs and pulls away in response to nasal suction and continues to move all 4 extremities with good tone. The nurse calculates a new APGAR score of 10. Given the baby's strong APGAR scores, he does not undergo any intervention/resuscitation after the five-minute mark.
• a scoring system used to assess the newborn at 1 minute and 5 minutes after delivery
• 90% of neonates have an APGAR score of 7-10
• APGAR score
• One Minute designed to assess the neonates status and the uterine environment
• Five Minute designed to assess the neonates status and adaptation to the external world
• - APGAR Scores

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Apgar Scores: Examining the Long-term Significance

The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention. In the most recent past, individuals have unsuccessfully attempted to link Apgar scores with long-term developmental outcomes. This practice is not appropriate, as the Apgar score is currently defined. Expectant parents need to be aware of the limitations of the Apgar score and its appropriate uses.

Virginia Apgar, a physician and anesthesiologist, developed the Apgar scoring system in 1952 ( Apgar, 1953 ) to evaluate a newborn's condition at birth. The Apgar score is performed at 1 and 5 minutes of life. The purpose of this paper is to discuss the appropriate use of the Apgar score and to examine the appropriateness of using the Apgar score to predict long-term developmental outcomes.

The Apgar scoring system is a comprehensive screening tool to evaluate a newborn's condition at birth (see Table 1 ). Newborn infants are evaluated based on five variables: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A numerical score of 0–2 is assigned in each category for a maximum score of 10. Apgar scoring is best used in conjunction with additional evaluative techniques such as physical assessment and vital signs.

Apgar scoring is best used in conjuction with additional evaluative techniques such as physical assessment and vital signs.

The Apgar Scoring System (from Apgar, V., 1966 )

In recent years, many researchers have attempted to correlate Apgar scores with various outcomes including development ( Behnke et al., 1989 ; Blackman, 1988 ; Riehn, Petzold, Kuhlisch, & Distler, 1998 ), later delinquency ( Gibson & Tibbetts, 1998 ), intelligence ( Nelson & Ellenberg, 1981 ), and neurological development ( Sommerfelt, Pedersen, Ellertsen, & Markestad, 1996 ; Wolf, M., Beunen, Casaer, & Wolf, B., 1998 ; Wolf, M., Beunen, Casaer, & Wolf, B., 1997 ; Wolf, M., Wolf, B., Bijleveld, Beunen, & Casaer, 1997 ) for the purposes of research. However, individuals have misinterpreted this research and, in some instances, attempted to apply causality (i.e., that low Apgar scores caused later delinquency or poor neurological outcomes). Causality has been neither established nor a goal of the currently reported research in this area. Research in this area has focused on establishing a correlation between these outcomes and an individual's Apgar scores. The aim was not to demonstrate that low Apgar scores caused or predicted these conditions; however, some individuals have incorrectly interpreted the research as stating low Apgar scores could predict or actually caused certain behaviors or deficits. Not only is this inappropriate use of the Apgar score, there is also little scientific evidence to support its use in predicting long-term outcomes. Please see Table 2 for clarification of selected research terms.

… there is also little scientific evidence to support [the Apgar score's] use in predicting long-term outcomes.

Glossary of Selected Research Terms

After reading and studying “Perspectives on Learning for Childbirth Educators,” the learner will be able to accomplish the following:

• discuss two models for preparing childbirth curricula and describe the underlying assumptions of each;
• describe the nature of the learning environment for adult learners as a function of promoting true education, not just training;
• explore implications of “Ways of Knowing” for childbirth educators;
• explore implications of “Types of Learning” for childbirth educators; and
• discuss the value of active learning strategies in facilitating childbirth education goals.

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The cost of this continuing education program is $35 for Lamaze International members and $50 for nonmembers.

• After reading the following article, answer the test questions located at the end of the program. Each question has only one correct answer.
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Review of the Literature

According to the American Academy of Pediatrics' Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice (1996), the Apgar score should be used to assess the condition of an infant at birth. These committees also warn that the Apgar score should not be used as the only measure to evaluate the possibility that neurological damage occurred during the birthing process. In addition to low Apgar scores (3 or less for longer than 5 minutes), an infant who is asphyxiated prior to delivery would demonstrate severe metabolic or mixed acidemia (pH < 7.00) via umbilical artery blood sample and additional neurological manifestations such as seizure activity, coma, hypotonia, and finally, evidence of multiorgan dysfunction (Committee on Fetus and Newborn, American Academy of Pediatrics, & Committee on Obstetric Practice, American College of Obstetricians and Gynecologists, 1996). Furthermore, research conducted over 30 years ago ( Apgar, 1966 ; Apgar & James, 1962 ) provided initial evidence to disclaim the reliability of Apgar scores for predicting long-term outcomes of any type (e.g., developmental and neurological). Prediction of long-term outcomes was never a goal of the Apgar scoring system. Rather, the goal was to make certain that infants were systematically observed for their need for immediate care at birth.

Reliability of Apgar Scores

According to Jepson, Talashek, and Tichy (1991) , the Apgar score as a “tool” (to measure newborn adaptation to extrauterine life) lacks sensitivity and specificity. Sensitivity measures how well the tool captures the infant's condition at birth (stable vs. depressed) and specificity refers to how well the tool measures the differences between the values of the scores (0–2 for each of the five categories). Additionally, various authors have noted that great variability exists in how individual health care providers score the assessment ( Clark & Hakanson, 1988 ; Livingston, 1990 ). Clark and Hakanson (1988) compared the consistency (inner-rater reliability) of Apgar scoring among various health care disciplines. In their study, groups of health care providers were visually shown case presentations and then asked to assign Apgar scores to the infants who were presented. Pediatricians and pediatric house staff had a consistency rating of 68%, obstetricians and obstetric house staff had a consistency rating of 46%, intensive care nursery staff had a consistency score of 42%, obstetric nurses 36%, and community hospital nurses a consistency rating of 24%.

Livingston examined how consistent two health care providers were in assigning scores when compared to one another. In this study, the consistency of scores ranged from 55% to 82% with heart rate having the best rate of consistency at 82% for the 1-minute scores ( Livingston, 1990 ). For the 5-minute score, consistency ranged from 36% to 100%, again heart rate having the highest rate of consistency. Heart rate measures likely have greater consistency due to the ease of understanding and defining exactly what is being assessed. When consistency scoring was compared between full-term and premature newborns, health care providers were found to have better consistency when assessing full-term newborns ( Livingston, 1990 ). Additionally, full-term newborns may represent the “normal” in health care provider's minds; hence, full-term newborns may be more likely to receive a “normal” score, which accounts for the higher rate of consistency in term newborns than in preterm newborns.

Another concern is determining who has responsibility for assigning the Apgar score once the infant is born. According to both Apgar (1966) and the Regan Report (1987), the person assisting with the delivery of the infant should not assign the Apgar score. While in some respects the delivering individual seems the most logical choice, bias may be introduced into the score value, because the individual who attends the delivery may have a vested interest in the outcome.

Secondly, the newborn may be given to additional personnel immediately after delivery. This makes determining the Apgar score considerably more difficult for the health care provider who is assisting the delivery, necessitating leaving the mother's bedside briefly to assign the score. Additionally, if the infant remains with the mother for the first 5 minutes of life, the health care provider must later remember to document the score, often from memory. Both circumstances have the potential to introduce further bias to the already poor consistency of the Apgar score.

Often the nurse or someone from the department of neonatology assigns the Apgar score. Most frequently in a normal, full-term delivery, this would be the nurse. Nurses, at least in the Clark and Hakanson (1988) study, had a poor consistency rate. Questions regarding the accuracy of the Apgar score play a role in limiting the long-term predictive value.

Intended Uses of the Apgar Score

As the Apgar score was developed and refined over the years since its inception, the intended use has always been the same: to evaluate a newborn's condition at birth. Some clinicians like to use the Apgar score as a guide to their resuscitative efforts; however, this is not an intended use of the Apgar score. The novice practitioner may mistakenly believe that resuscitative efforts should not begin until the 5-minute Apgar score is determined. Experienced clinicians realize this would severely delay resuscitative efforts and compromise the potential for full recovery of neurological function. It is important to be both careful and consistent with language.

Educating the Public

Letko (1996) notes that much of the public, especially expectant parents, has some level of familiarity with the Apgar score. However, as Letko also points out, many of these parents-to-be do not adequately understand the score or its capacities for predicting long-term outcomes. Parents need to receive the appropriate education through the popular media, childbirth classes, and health care providers. It is imperative that parents have appropriate information so they are not disappointed when their child receives a score of 9, believing that their child is somehow inadequate because he or she did not receive a score of 10. Parents need to understand that a score from 7–10 indicates a normal newborn at birth and that it is rather infrequent for a newborn to receive a score of 10. For example, most infants have some level of blueness to their extremities and will not initially be completely pink. This point can be covered when discussing the general appearance of a newborn. This anticipatory guidance can assist the parents in their understanding and promote a positive birthing experience, by avoiding potential disappointment.

It is imperative that parents have appropriate information so they are not disappointed when their child receives a score of 9, believing that their child is somehow inadequate because he or she did not receive a score of 10.

The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention. In the most recent past, individuals have unsuccessfully attempted to link Apgar scores with long-term developmental outcomes. This practice is not appropriate as the Apgar score is currently defined. Expectant parents need to be aware of the limitations of the Apgar score and its appropriate uses.

Directions for Future Research

Future research is needed to increase the consistency among health care providers assigning Apgar scores. This would take a training program and periodic practice sessions to establish and maintain inner-rater reliability of each professional whose role is to assign the scores. Enhanced consistency would be a first step to evaluating the effectiveness of Apgar scores. At present, Apgar scores serve as a somewhat useful screening tool for health care providers to communicate with each other about what a newborn's status was like at birth and as a mechanism to make certain that someone is systematically observing the condition of the new infant.

Acknowledgement

The author thanks Raquel Mayne, BSN, graduate of New York University Division of Nursing, for her assistance with article retrieval.

An Independent Study Continuing Education Program

Perspectives on Learning for Childbirth Educators

Norma N. Wilkerson, PhD, RN

* © by Lamaze International. No part of this program may be reproduced in any way without written permission from Lamaze International.

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Apgar Scoring System Self-Assessment Cases

• by Brieanne.Rogers
• Aug 02, 2015

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Your Child’s First Test: The APGAR

What is the apgar test.

The APGAR is a quick, overall assessment of newborn well-being. The test is used immediately following the delivery of a baby. APGAR scores are recorded at one minute and five minutes from the time of birth.

Why is it necessary?

The one minute APGAR assessment provides information about the baby’s physical health and helps the physician determine if an immediate or future medical treatment will be required. The five-minute assessment measures how the baby has responded to previous resuscitation attempts if such attempts were made.

What conditions does the APGAR test evaluate?

APGAR measures the baby’s color, heart rate, reflexes, muscle tone, and respiratory effort.

What do the APGAR scores mean?

APGAR scores range from zero to two for each condition with a maximum final total score of ten. At the one minute APGAR, scores between seven and ten indicate that the baby will need only routine post-delivery care.  Scores between four and six indicate that some assistance for breathing might be required. Scores under four can call for prompt, lifesaving measures. At the five minute APGAR, a score of seven to ten is normal. If the score falls below seven, the baby will continue to be monitored and retested every five minutes for up to twenty minutes. Lower than normal scores do not mean that there will be permanent health problems with the child. Heart rate: 0 – No heart rate 1 – Fewer than 100 beats per minute indicates that the baby is not very responsive. 2 – More than 100 beats per minute indicates that the baby is vigorous. Respiration: 0 – Not breathing 1 – Weak cry–may sound like whimpering or grunting 2 – Good, strong cry Muscle tone: 0 – Limp 1 – Some flexing (bending) of arms and legs 2 – Active motion Reflex response: 0 – No response to airways being stimulated 1 – Grimace during stimulation 2 – Grimace and cough or sneeze during stimulation Color: 0 – The baby’s entire body is blue or pale 1 – Good color in body but with blue hands or feet 2 – Completely pink or good color

Want to Know More?

• Labor & Birth Terms To Know
• Pregnancy Week 40

Compiled using information from the following sources:

Nemours Foundation, https://www.kidshealth.org

William’s Obstetrics Twenty-Second Ed . Cunningham, F. Gary, et al, Ch. 28.

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