Newborn Assessment Part 4: APGAR Scoring

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APGAR scoring is probably one of the biggest topics concerning OBGYN and newborn. But what does APGAR stand for and how does it work?

Let’s get into it.

What is APGAR?

APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns.

For example, you get this test question:

The nurse is assessing a newborn that has a heart rate 198, a strong cry, which resists when touched and has blue hands and feet. What is the APGAR score and condition of the client?

Think about this scenario, and we’ll get back to it later.

As a nurse, you have to efficiently and accurately classify those characteristics. Therefore, APGAR is like a scoring chart to identify the health status of a newborn baby. Just like everything else, there’s good, bad, and worst.

APGAR Category and Scoring

APGAR stands for:

  • Appearance or how the baby looks
  • Pulse
  • Grimace
  • Activity
  • Respiratory rate

In each category, a nurse can only score a maximum of two and a minimum of 0. Here, the higher the score, the better. The overall score is 10 points.

Let’s review each category and what their scoring stands for.

Appearance

If you have a blue core, you always have to equate that with low oxygen or cyanosis; therefore, it’s not a good appearance, so it gets a zero on the score sheet. Blue arms and legs or extremities are a bit better than a blue core, so it gets a score of one. A pink baby is the most desired appearance so it will get a score of two.

Summary:

0 – Blue core (cyanotic)

1 – Blue arms and legs

2 – Pink

Pulse

Without a pulse, that’s a zero and is not a good sign. If the pulse is less than a hundred, the score is one. If the pulse is greater than a hundred, it doesn’t matter if it reaches 200, the score would be two.

Summary:

0 – No pulse

1 – Less than 100

2 – More than 100

Grimace

Is the client moving? Does the newborn automatically cry and pull away when touched? When a newborn is stimulated, the normal reaction would be extending, retracting, or pulling away. If the newborn you’re assessing is not doing any of these reactions naturally, there is a need for stimulation.

If the baby does not react at all, that’s a zero. If the baby cries with stimuli, the score is one. For a baby to get a two, they should cry and pull away automatically even without stimuli. Six out of 10 babies usually require stimuli to get them to cry. Stimuli can be in the form of feet or back rubbing.

Summary:

0 – No normal reactions

1 – Cry with stimuli

2 – Cry and pull away automatically

Activity

No activity is a zero on the scoreboard. If you have a baby that shows no sign of activity, a code blue will take place because the baby is deteriorating. Minor flexion will get a score of one. Minor flexion means that the baby is not going to have full-on flexion-extension and he or she will not move around that much; there is also some sluggishness. Flexion and extension, when the baby is normal moving up and about, get two on the scoreboard.

Summary:

0 – No activity

1 – Minor flexion, slightly sluggish

2 – Flexion and extension

Respiratory rate

Does the baby have a strong cry or a weak one, like irregular gasps? With weak, irregular gasps, the nurse has to suction the baby because they might have aspirated some amniotic fluid while inside the uterus. As a nurse, you would want to suck out all the amniotic fluid and meconium to prevent brain damage.

If the baby’s breathing is absent, that’s a zero. If the baby has weak, irregular gasps, that’s a one. But the baby’s cry is strong, he or she has a good respiratory rate, which calls for a score of two.

Summary:

0 – No cry

1 – Weak irregular gasps

2 – Strong cry

APGAR Summarization

So, how do you assess if the baby is bad or good, or is doing well? Here’s how to summarize APGAR scoring.

Score 10 – 7 = Normal

However, do note that there is no such thing as an APGAR score of 10. Usually, eight is the average.

Score 6 – 4 = Okay but with five-minute monitoring

If the APGAR score is within six to four, the baby is doing okay; but constant monitoring is necessary, like every five minutes right after birth until the baby gets better.

Score 3 – 0 = Not good; needs immediate intervention

If the APGAR score is three below, assessment and monitoring must be done every minute. The nurse has to immediately call a code and inform the doctor since the baby’s health is quickly deteriorating.

APGAR Setting

If the score is an eight, the first thing to do is to warm the baby up because everything’s fine, there is no need for reassessment.

If the score is a five, reassess every five minutes until the baby gets a higher score. Pediatric clients need constant reassessment, especially newborns because their condition can either get better or worse in a matter of minutes. Newborns tend to spiral really quick.

But, if the newborn’s APGAR score is three, what is the FIRST nursing intervention?

Answer:

Call for help – doctor, and code blue team.

Answering the Question

So, going back to the question above:

The nurse is assessing a newborn that has a heart rate 198, a strong cry, which resists staff with flexion and extension when touched and has blue hands and feet.

Answering with your APGAR:

  • A – blue hands and feet (1 point)
  • P – more than 100 (2 points)
  • G – resists staff when touched (2 points)
  • A – flexion and extension (2 points)
  • R – Strong cry (2 points)

APGAR total score: 9 points

Points to Remember

APGAR scoring is done a minute after giving birth. If the score is below seven, you have to do it again in five minutes until the client gets a good score or is normal. It is a good thing to write this APGAR scoring down like a chart so you can carry it around with you.

On our next lecture, we will be discussing RH factors.