As a nurse, one of the most important things you should know is assessing and interpreting APGAR scores. This score – developed by Dr. Virginia Apgar back in 1952 – is designed to measure the overall health and well-being of newborn babies immediately following birth.
Knowing what an APGAR score means and what interventions may be necessary based on it can help ensure that all infants get off to a healthy start in life.
In this blog post, we’ll take a closer look at the components of an APGAR score, how they’re calculated, and some possible nursing interventions for each component level. So read on to make sure you understand everything there is to know about APGAR scores.
Table of Contents
APGAR Scores System
APGAR scores are composed of five components: appearance, pulse, grimace, activity, and respiration. Each component is given a score from 0 to 2 based on the baby’s condition at one minute and again five minutes after birth.
|Apgar Scoring System
|Score of 0
|Score of 1
|Score of 2
|Skin Color / Complexion (Appearance)
|Blue all over
|Blue at extremities and body pink (acrocyanosis)
|No cyanosis body and extremities pink
|Pulse Rate (Pulse)
|Less than 100 beats per minute
|Greater than 100 beats per minute
|Reflex Irritability (Grimace)
|No response to stimulation
|Grimace – feeble cry when stimulated
|Sneezes/loud cry when stimulated
|Muscle Tone (Activity)
|Some flexion is present
|Active movement is present
|Weak or irregular respiratory movement
|Strong respiratory movement
Appearance: Refers to how pink or blue the infant’s skin appears; 0 means the skin is blue all over, 1 means it’s pale or pink on the extremities and blue elsewhere, and 2 means it’s uniformly pink.
Pulse: Pulse measures the infant’s heart rate; 0 indicates no pulse, 1 indicates fewer than 100 beats per minute (BPM), and 2 indicates greater than 100 BPM. Grimace refers to the baby’s reaction when touched or given a mild stimulus; 0 means no response, 1 indicates weak flexion of the arms and legs, and 2 indicates strong flexion.
Activity: Activity measures muscle tone; 0 means no action is present, 1 means some movement is present but not vigorous, and 2 indicates good, vigorous movement. Finally, respiration refers to the infant’s breathing; 0 means none is present, 1 indicates weak or irregular respiration, and 2 shows reasonable respiratory effort.
Grimace: If the grimace score is 0 or 1, gently stimulating the baby’s feet and hands may help improve its response. Positioning and swaddling could improve muscle tone for a weak activity score (0 or 1). And if the respiration is 0 or 1, then suctioning of the airway may be necessary.
Respiration Rate: If the baby’s cry is weak and consists of irregular gasps, the nurse must suction them to ensure that any amniotic fluid or meconium they aspirated while in the womb is removed. This helps prevent brain damage. If the baby’s breathing is absent, it gets a score of zero. But if it has a robust and steady cry and an excellent respiratory rate, its score is 2.
What’s Considered a Normal Apgar score?
At the end of the assessment, the nurse adds up all five scores and then interprets them as follows:
- A score of 7-10 is considered normal,
- 4-6 is a moderate score which requires some intervention, and
- Three or lower is an abnormal score indicating urgent medical attention.
What occurs if the Apgar score is low?
Any score below 7 on the Apgar scale will warrant an intervention from the nurse. Most low Apgar scores are caused by the following:
- High-risk pregnancy.
- Premature births.
- Complicated labor and delivery.
- Cesarean section (C-section) births.
- Fluid in your baby’s airway.
Common interventions for low APGAR scores include providing supplemental oxygen, suctioning the airway, and stimulating muscle tone through positioning and swaddling.
It’s also important to note that although an APGAR score may be low immediately after birth, it doesn’t necessarily mean the baby is in poor health. Many babies score well below 7 at birth, but with some nursing interventions and timely medical care, their scores can improve significantly within a few minutes.
Nurse Interventions: How To improve the APGAR Score
- Stimulating the baby to breathe or delivering positive pressure ventilation (PPV) via the bag valve mask.
- Manually clearing airways.
- Providing oxygen therapy as needed.
- Administering medications such as epinephrine or naloxone to stimulate breathing and heart rate.
- Performing chest compressions if necessary.
- Positioning the baby in a head-down position to facilitate drainage of fluids.
- Position the baby on its side or prone to enable breathing and strengthen muscle tone.
- Provide skin-to-skin contact to help regulate temperature and heart rate.
- Administering glucose if necessary to prevent hypoglycemia.
- Swaddling to increase muscle tone.
Nursing Implication On Each Level of the APGAR
Appearance: If the infant’s skin is blue, the nurse should check for any signs of birth asphyxia or other congenital disabilities. If these are present, they may require medical attention. The nurse can also provide oxygen therapy to help improve the baby’s skin color.
Pulse: For low pulse rates, the nurse should closely monitor and assess the infant’s heart rate. If it is below 100 BPM, oxygen therapy or medications may be necessary.
Grimace: If the grimace score is 0 or 1, gently stimulating the baby’s feet and hands may help improve its response. This can include stroking, rubbing, or patting the feet or hands.
Activity: Positioning and swaddling could improve muscle tone for a weak activity score (0 or 1). This can be done by holding the baby upright, with its arms pressed against its chest and legs slightly flexed, and then wrapping a blanket around them to keep them secure.
Respiration: If the respiration is 0 or 1, then suctioning of the airway may be necessary. This can help clear any blockage that might prevent the baby from breathing correctly.
What other interventions can be taken in the postpartum period?
Upon the baby’s birth, obtaining their APGAR score and taking any necessary measures is essential. However, depending on your facility’s policies, other assessments, and interventions must be carried out in the first 24 hours post-delivery. Generally speaking, these may include:
- Readjusting or removing the umbilical cord and monitoring for bleeding.
- Checking the baby’s temperature and providing warmed blankets if needed.
- Monitoring for jaundice, including performing an initial bilirubin test.
- Assessment of the baby’s muscle tone, reflexes, movement, and responses to stimuli.
- Evaluation of the baby’s head circumference, weight, and length.
- Assessment of breastfeeding technique and latch-on.
- Evaluating feeding patterns and urine output.
- Checking for any signs of infection or congenital defects.
- Providing routine immunizations as needed.
- These assessments and interventions are essential to help ensure that your baby is in the best health possible. It’s important to follow your healthcare provider’s instructions for any assessments or interventions they recommend.
Taking these measures can help ensure that your baby has a healthy start to life and goes on to reach their full potential.
What Indicate It If a Heart Rate Of 60 Bpm Or Less Is Detected?
If the Apgar Heart Rate is 60 bpm or less, it warrants urgent medical attention. The nurse should immediately provide oxygen and other interventions such as chest compressions or medication administration.
Many hospitals have an ALS team that provides NRP (neonatal resuscitation), however, the nurse at the bedside will be responsible for initiating it
What Considers When Interventions for Apgar Score of 8?
No interventions are typically needed for an Apgar score of 8-10, considered normal. However, monitoring the infant closely for any changes in their condition is essential.
The Apgar score is an assessment of a newborn’s health and well-being that is performed shortly after birth. It assesses five criteria–appearance, pulse rate, grimace response, activity level, and respiration–to determine the overall state of the baby at birth.
In addition to obtaining the APGAR score, other assessments and interventions should be carried out in the first 24 hours post-delivery depending on the facility’s policies. These interventions and assessments are essential to ensure that your baby has a healthy start to life and goes on to reach their full potential.
I hope this article has helped you understand the importance of assessing a newborn’s Apgar Score shortly after birth and the measures that can be taken to improve a low score.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.