The Apgar score is a quick health check performed on every newborn, typically at one minute and five minutes after birth, rating five observable signs on a scale of 0 to 2 for a maximum total of 10. Developed in the 1950s by anesthesiologist Virginia Apgar, the system was designed to give delivery room staff a fast, standardized way to decide which babies needed immediate help breathing or warming up. A score of 7 or above generally signals that a baby is doing well, while lower scores prompt closer monitoring or intervention. The test is deceptively simple, though, and decades of research have revealed both its predictive power and its blind spots.
What the Five Components Actually Measure
Each letter in “APGAR” maps to a physical sign that can be observed without any lab equipment or imaging: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort).1PubMed Central. Virginia Apgar (1909-1974): The Mother of Neonatal Resuscitation A score of 0 means the sign is absent, 1 means it’s present but weak or incomplete, and 2 means it looks healthy. A baby with a strong cry, a heart rate above 100 beats per minute, active movement, a good grimace when stimulated, and pink skin from head to toe earns a perfect 10.2PubMed Central. The Apgar Score and Infant Mortality
In practice, few babies score a 10 at one minute. Most healthy newborns have bluish hands and feet for the first few minutes of life as their circulation adjusts, which costs a point on the appearance component. A score of 8 or 9 at one minute is entirely normal and not a cause for concern. By five minutes, as the baby settles into breathing room air, scores typically climb.
Why the Score Is Taken More Than Once
The one-minute score is mainly a snapshot of how the baby handled the transition from womb to open air. It helps the medical team decide whether to start basic interventions like suctioning the airway or providing supplemental oxygen. The five-minute score carries more clinical weight because it reflects how well the baby responded to those first minutes of life, or to any resuscitation that was needed. If the five-minute score is still low, many hospitals assign a ten-minute score as well.
A large Canadian study following children to age five found that both the one-minute and five-minute scores tracked with developmental outcomes, but the pattern of change between them also mattered. Children whose scores stayed at 9 at both one and five minutes had slightly higher rates of developmental vulnerability than those whose scores rose to 10 by five minutes.3PubMed Central. One-minute and five-minute Apgar scores and child developmental health at 5 years of age: a population-based cohort study in British Columbia, Canada In other words, trajectory can matter as much as any single number. At the extreme end, babies who score 0 at both one and five minutes have a grim outlook, but survival is still possible; birth weight, gestational age, and whether the ten-minute score climbs above zero are all strong predictors of who survives.4PubMed. Outcome after successful resuscitation of babies born with apgar scores of 0 at both 1 and 5 minutes
What Low Scores Mean for Survival
The link between very low Apgar scores and neonatal death is among the strongest associations in obstetrics. A population-based study in Sweden found that a five-minute score of 0 to 3 in term infants carried a roughly 360-fold increase in the risk of early neonatal death compared to a score of 7 to 10.5The Lancet. Accuracy of Apgar score at 5 min for predicting subsequent risk of neonatal and infant death: population-based cohort study An Australian study of term infants found similarly dramatic risk increases for those scoring 0 or 1, with the strength of the association growing at later gestational ages.6PubMed Central. Five-minute Apgar score and risk of neonatal mortality, severe neurological morbidity and severe non-neurological morbidity in term infants
The score is also useful in premature babies, though the relationship is messier. A study in the New England Journal of Medicine confirmed that lower Apgar scores predicted higher neonatal death rates across all gestational-age groups in preterm infants, but the baseline risk is already elevated for preemies, which compresses the score’s ability to distinguish between degrees of illness.7PubMed. Apgar Score and Risk of Neonatal Death among Preterm Infants Older research noted the same pattern: in normal-birthweight babies the score strongly predicts mortality, while in low-birthweight babies the predictive value is more limited.8PubMed. The Apgar score: evolution, limitations, and scoring guidelines
Cerebral Palsy and Neurological Risk
Beyond immediate survival, low Apgar scores are strongly linked to cerebral palsy. A Norwegian population study found that about 11 percent of children with a five-minute score below 3 were eventually diagnosed with cerebral palsy, compared to just 0.1 percent of those who scored 10. After accounting for birth weight, children with the lowest scores still had roughly 53 times the odds of a cerebral palsy diagnosis.9PubMed Central. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study
A Swedish cohort study added an important nuance: the risk climbs steeply and continuously as the score drops. Compared to a perfect 10 at five minutes, a score of 9 roughly doubled the risk of cerebral palsy, and a score of 0 was associated with a nearly 278-fold increase. When researchers looked at ten-minute scores, the associations were even stronger; a ten-minute score of 3 carried a hazard ratio above 400 for cerebral palsy.10BMJ. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden A 2025 study took the analysis further by combining Apgar scores with umbilical cord blood pH. Among babies with both the lowest Apgar range (0 to 3) and the lowest pH (below 7.00), about 15 percent developed cerebral palsy, representing the highest-risk group identified.11JAMA Network Open. Cerebral Palsy Risk by Combined Apgar Score and Umbilical Cord Blood pH Levels
Cognitive Outcomes Later in Life
Parents often worry about whether a slightly rocky start means lasting trouble with learning or thinking. The research here is more reassuring than the cerebral palsy data. A cohort study following children into adolescence found that those with prolonged low Apgar scores had modestly increased odds of scoring low on IQ tests, but the effect on school grades by age 15 to 16 was not significant. The researchers estimated that the proportion of low IQ scores in the population that could be attributed to transiently low Apgars was less than one percent.12PubMed Central. A cohort study of low Apgar scores and cognitive outcomes
A larger Swedish study found a somewhat more noticeable effect: children with five-minute scores of 0 to 3 had lower odds of completing upper secondary education and scored slightly lower on military conscription intelligence tests compared to those scoring 7 to 10.13PubMed Central. Association of Apgar score at 5 minutes with academic performance and intelligence in youth: A cohort study The gap existed but was small in absolute terms. Even in children with Down syndrome, higher one-minute Apgar scores were associated with better performance on verbal and memory tasks later in life, suggesting that the score captures something about early brain oxygenation that carries forward regardless of underlying genetic conditions.14Scientific Reports. Relationship between Apgar scores and long-term cognitive outcomes in individuals with Down syndrome
The Difference Between a 9 and a 10
Most delivery teams treat any score of 7 or above as “normal,” but population-level studies tell a more granular story. A large Swedish study of term infants found that even within the 7 to 10 range, lower scores carried higher risks of respiratory distress, infections, and neonatal hypoglycemia. A five-minute score of 9 versus 10 doubled the odds of respiratory distress; at ten minutes, a score of 9 was associated with a nearly tenfold increase in the absolute rate of breathing problems compared to a score of 10.15BMJ. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden An Australian study found that children who scored 7 or 8 at five minutes were at increased risk of gross motor delays compared to those who scored 10, though communication delays were not significantly different.16International Journal of Environmental Research and Public Health. The Association between the Five-Minute Apgar Score and Neurodevelopmental Outcomes Among Children Aged 8–66 Months in Australia
None of this means parents should panic over a 9 instead of a 10. The absolute risk differences are tiny, and most babies who score 8 or 9 do perfectly well. The research matters more for epidemiologists and hospital systems than for individual families. But it does challenge the old binary view that 7-and-above is “fine” and 6-and-below is “worrying,” revealing the score as more of a gradient.
Why Two Providers Might Give Different Scores
A major limitation of the Apgar is that it relies on human judgment. One study presented the same video recordings of preterm infants to neonatologists, obstetricians, and midwives and found statistically significant differences in the scores each profession assigned. Neonatologists tended to score higher than midwives, and obstetricians scored the lowest on average.17Journal of Neonatology & Clinical Pediatrics. Inter-Observer Variability of the Apgar Score of Preterm Infants between Neonatologists, Obstetricians and Midwives Another study found that scores assigned in the delivery room were, on average, about 2.4 points higher than scores assigned by observers watching video playback of the same births, and variability was large regardless of how sick the baby appeared.18PubMed. Interobserver variability of the 5-minute Apgar score
This subjectivity is worth knowing about because it means a one-point or even two-point difference between one baby’s chart and another’s may reflect who was scoring, not a real difference in the babies’ conditions. It also means that comparing Apgar scores across hospitals, or even across shifts at the same hospital, introduces noise that researchers have to account for.
The Skin Color Problem
The appearance component of the Apgar score is based on skin color: pink all over earns a 2, bluish extremities earn a 1, and a pale or blue body earns a 0. This was designed in an era when the developers were thinking about light-skinned newborns, and it works poorly for babies with darker skin. A systematic review found that Black neonates received significantly lower appearance scores than white neonates even after controlling for gestational age, cord blood gases, and maternal health.19Pediatric Research. Systematic review of Apgar scores & cyanosis in Black, Asian, and ethnic minority infants
This is not just an academic concern. A U.S. cohort study of nearly 7 million infants found that the association between low Apgar scores and mortality was weaker in Black infants than in white infants, which researchers suggested may partly reflect systematic differences in how the score is assigned rather than real biological differences.20PLoS Medicine. Associations between low Apgar scores and mortality by race in the United States: A cohort study of 6,809,653 infants The underlying issue is straightforward: the words “pink,” “pale,” and “blue” do not translate reliably across a range of skin tones, yet a review of clinical policies found that none provided guidance on how these color descriptions should be adapted for different pigmentation.21PubMed Central. A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates Some clinicians have proposed assessing color at the mucous membranes (inside the mouth, for example) rather than overall skin, but this has not been formally standardized in most guidelines.
Does an Epidural Affect the Score?
This is one of the most common questions parents ask, and the evidence is surprisingly mixed. A prospective study found that while slightly more babies in the epidural group experienced birth asphyxia, the difference was not statistically significant, suggesting the epidural itself was not directly responsible.22PubMed Central. Effects of maternal epidural analgesia on the neonate – a prospective cohort study A population-based study in Australia did find a higher rate of low Apgar scores in babies whose mothers received epidurals, but a mediation analysis indicated that the effect was driven by associated complications like maternal fever and labor augmentation rather than the epidural medication itself.23PubMed. Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study
Adding to the confusion, a large population cohort study published in JAMA Network Open found the opposite direction of effect: epidural use was associated with a slightly decreased risk of a five-minute Apgar score below 7 across several analytical approaches.24JAMA Network Open. Association of Epidural Analgesia in Women in Labor With Neonatal and Childhood Outcomes in a Population Cohort The takeaway is that epidurals do not appear to cause meaningfully lower Apgar scores on their own, though the cascade of events they sometimes accompany (longer labors, interventions, fever) can complicate the picture.
How Much the Score Overlaps with Blood Tests
Umbilical cord blood gas analysis gives an objective biochemical snapshot of how the baby was doing just before delivery. You might expect it to line up neatly with the Apgar, but the correlation is surprisingly weak. Two separate studies examining cord blood pH, lactate, and carbon dioxide levels against Apgar scores found statistically significant associations, but with correlation coefficients below 0.2, meaning the two assessments capture largely different information.25PubMed Central. The Correlation of Cord Arterial Blood Gas Analysis Results and Apgar Scores in Term Infants Without Fetal Distress 26PubMed Central. An Assessment of the Relationships Between Umbilical Cord Blood Gas Analysis, APGAR Scores, and Neonatal Outcomes
Older research found that arterial pH correlated best with Apgar scores compared to other blood gas measurements, though even that relationship was modest.27American Journal of Obstetrics and Gynecology. Routine umbilical cord blood gas determinations This is why many clinicians and researchers advocate using the Apgar and cord blood gases together rather than relying on either alone. As the cerebral palsy data above showed, combining a low Apgar with a low cord pH identifies the highest-risk babies more precisely than either measure by itself.
The Expanded Apgar Score
Because the traditional Apgar does not capture what interventions were needed to achieve a given score, some hospitals now record an “expanded” version. A baby who scores 7 at five minutes on their own is clearly in a different situation than a baby who scores 7 at five minutes while being intubated and receiving supplemental oxygen. The expanded score logs those interventions alongside the traditional five components. Research using the expanded score has found it useful for predicting complications the traditional score misses. For example, one study showed that newborns who required intubation within three minutes of life or who needed high concentrations of supplemental oxygen at ten minutes were significantly more likely to develop severe retinopathy of prematurity, a finding that did not emerge from the standard score alone.28Pediatria i Medycyna Rodzinna. Assessing the risk of retinopathy of prematurity in preterm neonates using the expanded Apgar score
Apgar Scores and Adult Health
Most conversations about the Apgar focus on the first days or months of life, but a growing body of research asks whether those initial minutes leave a trace decades later. A nationwide cohort study found that individuals who experienced asphyxia-related complications at birth (closely tied to very low Apgar scores) had roughly double the risk of cardiovascular disease and stroke in childhood and early adulthood. Those who had neonatal seizures, an even more severe marker, faced about a fivefold increase in the risk of stroke and heart failure.29The Lancet Regional Health – Europe. Association between Apgar score and asphyxia-related complications and subsequent risks of cardiovascular diseases in childhood and early adulthood: a nationwide cohort study The absolute numbers remain small because cardiovascular disease in young people is rare to begin with, but the findings suggest that a difficult birth can set in motion vascular changes that persist.
Scoring Newborns Outside the Hospital
The Apgar was built for well-staffed delivery rooms in high-income countries. In lower-resource settings, it serves a somewhat different role. A study in Ghana used Apgar scoring by midwives trained in a basic resuscitation program to evaluate how well resuscitation efforts were working at the district-hospital level. The researchers found the score was a practical tool for identifying where in the resuscitation process babies were still being lost and where additional training could reduce deaths from birth asphyxia.30PubMed Central. Use and implications of the Apgar score in evaluating resuscitation of newborns with birth asphyxia in a lower-middle-income country Its greatest strength in these settings is that it requires no equipment at all beyond a clock and a trained pair of eyes, making it deployable essentially anywhere births happen.
The Apgar in Veterinary Medicine
Virginia Apgar designed her score for human babies, but the concept has been exported to animals with surprisingly little modification. Researchers have developed modified Apgar systems for newborn puppies and lambs, swapping in species-appropriate vital signs. A puppy Apgar evaluates heart rate, breathing, reflex irritability, movement, and mucous membrane color at five minutes, with the score predicting short-term survival after vaginal or cesarean delivery.31PubMed. An Apgar scoring system for routine assessment of newborn puppy viability and short-term survival prognosis For lambs, a modified version uses a pulse oximeter on the ear and assesses response to nose and rump stimulation. Higher-scoring lambs stood faster, suckled sooner, and showed better passive immunity transfer, giving farmers an early signal of which lambs need intervention.32PubMed. Developing a modified Apgar scoring system for newborn lambs 33Applied Animal Behaviour Science. Prediction of vitality and survival of newborn lambs using a modified Apgar score The fact that the framework translates across species speaks to how fundamental the signs it captures really are: a beating heart, effective breathing, and responsiveness to the world are universal markers of a viable newborn, whether human or otherwise.