APGAR Scores

Labor and delivery is stressful on everyone involved, including the babies themselves. Medical professionals can and should use every test or method of observation available to ensure the baby arrives safe and sound.

Unfortunately, babies sometimes are injured by birth complications before, during, and after birth. Some injuries are preventable. Doctors, nurses, midwives, and other medical professionals must carefully observe the mother and baby and intervene when necessary to prevent or minimize birth injuries.

For example, a baby’s heart monitor may show irregular heartbeats during labor and delivery. Certain abnormalities on a fetal monitoring strip can indicate that the baby is in fetal distress that requires immediate intervention. Such intervention can range from changing the mother’s position to performing an emergency C-section.

Healthcare providers also need to determine a baby’s status immediately after birth. They should observe the newborn and conduct several standard tests, including the Apgar test. The baby’s Apgar score is particularly crucial for newborns who may have been in fetal distress. That’s because it indicates a need for additional observation and treatment, like hypothermia therapy.

The Apgar score is used in every medically-assisted birth, so it’s important to understand what it means.

The medical staff involved with labor and delivery quickly assesses a baby immediately after birth. A newborn’s team could include obstetricians, neonatologists, pediatricians, registered nurses, nurse practitioners, anesthesiologists, and even respiratory therapists.

Their assessment usually comes after a fairly routine birth. But some babies arrive after labor filled with complications, including fetal distress. These babies are particularly at risk for birth-related brain damage.

The Apgar score gives a standardized, quick way to determine a baby’s status. It also makes it easier to report the status to other team members in language they immediately understand. Apgar scores consist of five categories:

• Appearance
• Pulse
• Grimace
• Activity
• Respiration

The Apgar scoring system was initially intended to assist medical professionals in determining the need for resuscitation. But experts now recommend that resuscitation begin before the 1-minute Apgar score when necessary.

A doctor, nurse, or nurse practitioner assesses a baby at 1 minute after birth and 5 minutes after birth. Ideally, the person calculating the Apgar score was not involved in the baby’s delivery—but this is not always the case. When the person calculating the APGAR is not involved in the birth, they are typically more objective when assigning scores during the Apgar assessment, which is very subjective.

Zero to 2 points are assigned per each of the categories listed above (Appearance, Pulse, Grimace, Activity, Respiration) based on certain criteria:

Doctors and nurses use a stethoscope to assess the baby’s heart. The baby’s heartbeat (Pulse) is one of the most important categories of the Apgar score because of its impact on the decision to resuscitate or not.

The medical person assessing the baby adds the scores for each category (0 – 2) to arrive at a total ranging from 10 (the highest) to 0.

• Score of 7-10 = reassuring. The baby appears to be normal based on the Apgar score. However, the score should always be considered in context. Newborns that suffered birth injuries may have a normal Apgar score.
• Score of 4-6 = moderately abnormal. Immediate intervention is needed until the baby’s Apgar score increases above 7.
• Score of 0-3 = abnormal. The baby requires immediate attention and likely admission to the Neonatal Intensive Care Unit (NICU) for further observation and assessment.

A score of 10 is unlikely because most newborns have some blue tinge on their hands and feet. The lowest score is very serious and causes concern for possible intrauterine problems during labor.

The Apgar score combined with other factors could indicate long-term health issues. However, many infants with a low 1-minute Apgar have recovered by their 5-minute test.

In fact, the 1-minute Apgar might be slightly low (4-6) even in healthy infants. But medical professionals could begin or continue resuscitation at this point. Their course of action could depend on the context of the baby’s birth, especially whether there were indications of birth trauma or fetal distress.

The 5-minute Apgar score becomes even more important for babies with a low 1-minute Apgar. If low scores continue, the infant is at greater risk for brain damage and cerebral palsy. An Apgar of 0-3 at the 5-minute mark may be an indication that hypoxic-ischemic encephalopathy (HIE) has occurred.

Neonatal resuscitation often begins immediately after birth and before the 1-minute Apgar score. Where the baby is already being treated, an improvement between the 1-minute and 5-minute scores could show the newborn is responding well to treatment.

When a baby’s score is less than seven at the 5-minute mark, medical professionals should continue interventions and repeat their assessments every 5 minutes for up to 20 minutes.

Medical professionals develop a treatment plan, but it’s based on more than the Apgar score. They have to consider the score in context with other factors, including:

• whether the baby showed signs of fetal distress before birth,
• any signs of hypoxic-ischemic encephalopathy,
• pre-existing maternal or fetal medical conditions, and
• which part of the Apgar score is low.

For example, a newborn might have a 5-minute Apgar of seven. This doesn’t seem too bad, but the doctors and nurses need to determine why the Apgar is not higher (8 or 9). The baby could have maximum scores for Pulse, Respiration, and Appearance, but zeros or 1s in Grimace and Activity. Something is obviously wrong, and the infant’s treatment plan will need to focus on why the baby’s muscle tone and reflexes are abnormal.

On the other hand, low pulse and respiration scores should trigger immediate action regardless of how the baby fared in other categories. The doctors, nurses, midwives, and other professionals caring for the baby must observe carefully. They may do additional tests, including umbilical cord gases. Then, their treatment plan must be swift and appropriate to avoid further damage to the child.

Anything that affects Appearance, Pulse, Grimace, Activity, or Respiration will bring the score down. Factors that could depress Apgar scores include:

• C-sections. Babies born by cesarean section (C-section) often have lower 1-minute Apgar scores. Most recover quickly unless other conditions are present.
• Fluid. A newborn typically has some fluid in its airway. Doctors and nurses must clear the airway quickly to improve the baby’s respiration. Otherwise, oxygen starvation can affect the baby’s heart rate and cause hypoxia (low oxygen) or anoxia (no oxygen).
• Complications. Babies that suffer traumatic birth complications are more likely to have low Apgar scores. Complications include events that threaten both the mother (like high blood pressure or uterine rupture) and the baby (abnormal fetal heart rate).

The Apgar score is a snapshot of the baby’s condition shortly after being born. Medical professionals generally do not use a newborn’s Apgar score to predict the baby’s long-term outcome. In fact, an infant could have an acceptable Apgar score but still have suffered brain damage during birth.

That’s partially because several parts of the Apgar score assess activity controlled by the baby’s brainstem, which might have escaped injury. Damage to the cerebrum or cerebellum might not be diagnosed for months or even years after the baby’s birth.

Another reason that a high Apgar score might not correlate to the baby’s outcome is that most of the time the medical person calculating the Apgar was in fact involved in the birth. As such, there is a bias to providing a higher score even when there have been delivery complications such as fetal distress. We see time and time again high Apgar scores that are contradicted by clear cut evidence including the parents’ observations or even photographs and video evidence showing the opposite of the Apgar scoring. Therefore, while the Apgar is an important marker, parents should understand there is a high error rate in these scores when calculated by potentially biased medical personnel.

A newborn’s score indicates its current status and generally is not used to predict the baby’s outcome.

However, the child’s future can be negatively affected by medical negligence and malpractice that led to the complications causing a low Apgar score. Medical professionals might fail to properly analyze and treat a baby with one or more low scores. Without timely treatment, medical conditions could worsen. At some point, intervention may be too late to prevent injury and may even result in the baby’s death.

There’s also the potential that hypoxic-ischemic encephalopathy (HIE), neonatal hypoglycemia, and other conditions will lead to cerebral palsy, failure to progress, and cognitive disabilities.

The parents of children who suffered birth injuries often want answers. Many times parents see evidence at birth, including low Apgar scores, that their baby suffered a complication during labor. They want to know what happened to harm their child. Were there signs of fetal distress that the doctors and nurses failed to recognize and/or failed to respond to in a timely manner? Was a c-section not performed as early as it should have been or not performed at all?

Our dedicated birth injury lawyers want to help you find those answers.

We diligently investigate the facts, including a detailed examination of the fetal heart rate monitoring strips and labor and delivery records. We look closely at the Apgar scores and all of the surrounding evidence to determine the validity of these scores.

If this review shows the medical providers did not diagnose or respond to fetal distress, we hold responsible parties accountable by pursuing medical malpractice claims against them. The compensation our clients receive helps them pay for their child’s current and future medical treatment, assistive technology and equipment, attendant care, and the other expenses associated with caring for a child with brain injuries, seizure disorders, and cerebral palsy.

Sometimes families are afraid to talk to lawyers about their child’s case because they worry there is a fee. There is never a fee unless and until we make money recovery for our clients.

The only way to find out if you have a birth injury case is to talk to an attorney who understands birth injury. At Miller Weisbrod, a team of committed professionals uses our detailed case review process to assess your potential claim. They start by learning more about you and your child. Then we gather medical records to determine what happened before, during, and after your delivery. We call in skilled medical experts who review your records and let us know if they think medical errors could have caused your child’s injuries.

If we feel medical malpractice was present, we meet with you to discuss how you can receive compensation from the medical professionals who made the errors. At no point in our legal intake process will we ask you to pay anything. The medical review of your case and the consultation are free. We only receive payment when you do.