Why Your Baby Will Never Ace The Apgar, Their First Test

Your kid will take their first test exactly one minute after coming into this world, then repeat this evaluation four minutes later. The Apgar test assesses babies on their color, heart rate, reflexes, muscle tone, and respiration and assigns them a score from zero to 10. The point of this practice is to tell doctors how well the newborn is transitioning to life outside the womb and the level of immediate care needed — that’s it. A high Apgar score is not, as some proud parents want to believe, the first indicator that their child is destined for greatness. Nor is a low score a sign the baby will have health problems down the road.

Yet many new parents obsess over their newborn’s Apgar score. They get overly excited about a 9 or the incredibly rare 10, or they worry what a low or middle-of-the-road score may mean long term, even though their little one is now perfectly healthy. To these parents, pediatricians and obstetricians say, calm down. A child’s Apgar score is important to doctors and nurses in the moment, no question, but it tells very little about how the kid will turn out.

Doctors have been using the Apgar score in the delivery room since 1952. It was developed by Dr. Virginia Apgar, a pioneering obstetric anesthesiologist who was concerned about how scopolamine and other strong anesthetics given to women in labor impacted their newborns. These drugs transferred from the placenta to the baby and could hinder their breathing once they emerged from the womb, a condition called neonatal depression. The Apgar score provided a quick and effective way to assess how babies were faring based on exposure to those anesthetics.

“Back in those days, mothers were pretty knocked out and their babies came out very depressed,” says Jay P. Goldsmith, M.D., professor of pediatrics at Tulane University and member of the American Academy of Pediatrics’ Committee on Fetus and Newborn. “Dr. Apgar was trying to get people to pay attention to babies’ well-being in their first five minutes of life.”

Soon it became standard practice for doctors to administer this test at one minute and five minutes (and again at 10, 15, and 20 minutes if the score remained low) to inform whether newborns needed resuscitation or other interventions. For each of the five categories — color, heart rate, reflexes, muscle tone, and respiration — babies are given a score of zero, 1, or 2. For color, for example, a newborn who pops out looking blue or pale all over would get a zero, one who is mostly pinkish but has blue or pale hands or feet would get a 1, and a completely pink baby gets a 2. For heart rate, no heart rate scores a zero, below 100 beats per minute scores a 1, and above 100 beats per minute gets a 2. Then the sum of the scores from each category is the total Apgar score.

By now all those harsh anesthetics given to dull the pain of delivery have gone by the wayside, and epidurals and other safer analgesics have become the norm. Still, while anesthetic-induced depression isn’t nearly as common as it used to be, the Apgar score has endured. In fact, despite the countless medical advancements over the last 68 years, the test remains mostly unchanged. But that doesn’t mean it’s outdated or useless. The Apgar score turned out to be an effective method of gauging newborns’ overall health in their earliest moments.

“Now it is used to see how the baby transitions from in utero and to [help doctors] determine whether an infant needs more help because it is not making the transition well,” says Shivani Patel, M.D., assistant professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center. “Heart rate, respiration, color, and tone are all related to the cardiopulmonary system. If the heart rate is slow, the color probably is not good. If the baby is not breathing fast enough, both their color and heart rate are usually not good.”

Because the Apgar score is so comprehensive, Goldsmith says it’s an incredibly useful tool — but only for the medical professionals on duty. Parents, on the other hand, really don’t need to know their baby’s score, and it can be detrimental if they do. “Sometimes parents who’ve read about the Apgar score and are interested will ask, and we will tell them,” he says. “Or, more likely, I’ll say the baby had a hard time breathing or their heart rate was a little slow rather than just telling them the score. There can be problems with them knowing, so unless they ask, I don’t usually tell them.”

First of all, Goldsmith says, “every parent wants their child to be a 10 — but babies are not typically pink at birth and shouldn’t be. In the womb, they are not oxygenated through their lungs so they are supposed to be somewhat blue when they are born. We know from studies of normal, healthy, vigorous babies that they don’t get pink until about five to nine minutes. No baby should have a score of 10 at one minute.”

Parents, though, often don’t understand this and can become worried, completely unnecessarily, if their child scores anything less than 10 — which the vast majority of newborns do. “As an obstetrician, if I hear a score of 10, I’ll say really? Because it almost never happens,” says Patel. “We see 8’s and 9’s most often, which is like getting a 98 or 99 on a test instead of 100.”

Also, Goldsmith points out that while some of the Apgar measures are objective — heart rate, respiratory rate — others are somewhat subjective. Color, for instance, is left up to the medical professional’s discretion, and Goldsmith says it isn’t always assessed accurately. “It’s been shown that in darker-skinned babies are not analyzed as correctly as lighter-skinned,” he notes. “If you put an oxygen saturation monitor on a baby and asked the caretaker to assess color without looking at the monitor, they may have a harder time. Tone and reflexes are somewhat subjective too.”

Because of this, there can be some variation in the Apgar score depending on who’s assigning it — and that’s okay, stresses Goldsmith. As long as the baby receives the care they need and their score improves over time, with or without intervention, the exact score of the one-minute test doesn’t matter. “If they initially have a low score but then after five minutes are kicking and screaming and have good tone, then the first score is meaningless,” he explains.

If the score remains very low for 10 minutes, however, there may be health problems. “Long-term studies show that if scores are 3 or less at 10, 15, or 20 or minutes, that portends significant short- and long-term issues,” Goldsmith says.

But even in these cases, there is nothing parents can do about the score. The most important thing is that the baby gets proper help, and any doctor who assigns a concerning score multiple times will certainly give it to them. And when scores increase over subsequent tests, as they usually do, babies are just as likely to be healthy, happy bouncing babies who grow up to be healthy kids and adults as are newborns whose first scores are high.

“We’re not keeping the score from parents per se,” Patel says. “But because it doesn’t mean anything in terms of long-term outcomes, it is not important for parents to know.”