The Apgar test is a quick, standardized check performed on every newborn in the first minutes after birth, rating five physical signs on a scale of 0 to 2 each for a total score between 0 and 10. Developed by anesthesiologist Virginia Apgar in 1952, it was designed to give delivery room staff an immediate, at-a-glance sense of whether a baby needs urgent medical help. The test has barely changed in over seventy years, and while its simplicity is a strength, it also creates misunderstandings about what a score can and cannot tell you about a child’s future.
The Five Components and How Each Is Scored
The Apgar score evaluates five signs: heart rate, respiratory effort, reflex irritability (how the baby responds to stimulation), muscle tone, and skin color. Each sign gets a 0, 1, or 2. A baby with a strong cry, active limbs, a heart rate above 100 beats per minute, good reflexes, and pink skin earns the maximum of 10. A baby showing weak or absent signs in any category receives lower marks. Virginia Apgar originally reviewed records of over a thousand infants at Columbia Presbyterian Medical Center using this method, categorizing babies scoring 0 to 2 as being in poor condition, 3 to 7 as fair, and 8 to 10 as good.
1Anesthesiology. The Apgar Score Has Survived the Test of TimeOf the five components, skin color is consistently the hardest to score and produces the most disagreement among clinicians. A perfect 10 is less common than most parents expect, largely because mild blueness in the hands and feet is extremely common in the first minute. Muscle tone and reflex irritability also leave room for interpretation, which becomes relevant in discussions about how reliable the score really is.
When the Test Is Done
The standard timing is at one minute and five minutes after birth. The one-minute score gives a snapshot of how the baby tolerated the birth process. The five-minute score reflects how the baby is responding to the outside world and, if resuscitation was needed, how well it is working. The change between those two scores matters as much as either number alone. The American Academy of Pediatrics notes that this change is a useful index of the baby’s response to resuscitation.
2Pediatrics. The Apgar Score – Section: Apgar Score and ResuscitationIf the five-minute score is below 7, guidelines call for the assessment to be repeated every five minutes, up to 20 minutes after birth. That extended scoring is especially important for babies who needed significant intervention at delivery.
3Pediatrics. The Apgar Score – Section: APGAR SCORE AND RESUSCITATIONWhat Counts as a “Good” Score
Most healthy newborns score between 7 and 10 at five minutes. A score of 7 or above generally means the baby is doing well and does not need immediate intervention beyond routine care. Scores in the 4 to 6 range suggest the baby may need some help, such as supplemental oxygen or gentle stimulation. Scores of 0 to 3 signal serious distress, and the medical team will typically begin active resuscitation.
Parents sometimes worry if the one-minute score is lower than expected, but a lower initial score is common and does not by itself indicate a problem. Babies delivered by cesarean section, premature babies, and those who experienced a long labor often have depressed one-minute scores that climb quickly by the five-minute mark. The trajectory matters more than the starting point. A large Canadian cohort study found that even among babies scoring in the normal 7-to-10 range at one minute, small differences in the change between one-minute and five-minute scores were associated with measurable differences in developmental outcomes at age five.
4BMJ Open. One-minute and five-minute Apgar scores and child developmental health at 5 years of age: a population-based cohort study in British Columbia, CanadaWhat Happens When the Score Stays Low at Ten Minutes
A persistently low Apgar score at ten minutes is a much stronger signal than the one- or five-minute values. In a study of term infants who had experienced oxygen deprivation during birth, each one-point decrease in the ten-minute score was linked to roughly a 45 percent increase in the odds of death or disability. Among infants who scored 0, 1, or 2 at ten minutes, between 76 and 82 percent had a poor outcome.
5PubMed Central. Prediction of Early Childhood Outcome of Term Infants using Apgar Scores at 10 Minutes following Hypoxic-Ischemic EncephalopathyIn low-resource settings, the picture is even starker. A study from a hospital in a resource-limited environment found that among newborns with Apgar scores of 0 to 1 at ten minutes, 98 percent died within two days despite continued resuscitation efforts. The authors emphasized that decisions about how long to continue resuscitation should account for the medical resources available.
6Archives of Disease in Childhood – Fetal and Neonatal Edition. Outcome of infants with 10 min Apgar scores of 0–1 in a low-resource settingLow Scores and the Risk of Serious Conditions
Large population studies consistently show that very low five-minute Apgar scores are associated with higher risks of neonatal death, cerebral palsy, and epilepsy. A Swedish population study found that compared to children who scored a perfect 10 at five minutes, those with a score of 0 had a roughly 278-fold higher rate of cerebral palsy. Even modest reductions mattered: a five-minute score of 9 was associated with about twice the rate of cerebral palsy compared to a score of 10. At ten minutes, the associations were stronger still, with a score of 3 linked to a more than 400-fold increase.
7BMJ. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in SwedenAnother large study looking at cerebral palsy across different birth weights found that among children scoring below 3, about 11 percent were eventually diagnosed with cerebral palsy, compared with about 0.1 percent of those who scored 10. The link was strongest for the most severe form, spastic quadriplegia.
8PubMed Central. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort studyFor preterm infants, lower scores also track with higher neonatal mortality across every gestational age group. Among babies born at 28 to 31 weeks, for instance, those with a five-minute score of 0 or 1 had a dramatically higher absolute death rate than those scoring 9 or 10 in the same gestational window.
9PubMed. Apgar Score and Risk of Neonatal Death among Preterm InfantsThese are population-level statistics, though, and they describe averages. They do not predict the outcome for any individual baby. A five-minute score of 5 does not sentence a child to a particular diagnosis. The vast majority of children with moderately low Apgar scores go on to develop normally.
Combining the Apgar Score with Cord Blood pH
One thing the Apgar score does not tell you is the baby’s blood chemistry. Umbilical cord blood gas analysis, a blood draw from the cord right after birth, measures acidity (pH) and gives objective information about whether the baby experienced oxygen deprivation. A common misconception is that a low Apgar score reliably indicates metabolic acidosis in the baby. In reality, only a minority of newborns with low five-minute scores show cord blood evidence of acidosis.
10PubMed Central. Correlation between Umbilical Cord pH and Apgar Score in High-Risk PregnancyStudies examining the statistical relationship between Apgar scores and cord blood pH consistently find that the correlation, while real, is weak. Two separate analyses reported correlation values below 0.2 for the relationship between the two measures.
11PubMed Central. The Correlation of Cord Arterial Blood Gas Analysis Results and Apgar Scores in Term Infants Without Fetal Distress12PubMed Central. An Assessment of the Relationships Between Umbilical Cord Blood Gas Analysis, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) Scores, and Neonatal Outcomes
This matters because combining both pieces of information gives a more accurate picture than either one alone. A 2025 study found that when the lowest Apgar scores (0 to 3) were paired with the lowest cord blood pH (below 7.00), about 15 percent of those infants developed cerebral palsy. But when the Apgar score was equally low and the cord pH was normal, only about 2 percent did. And when the Apgar score was in the normal range but cord pH was critically low, roughly 0.6 percent developed cerebral palsy. In other words, both measures together are far more informative than either alone, and a low Apgar score without abnormal blood chemistry should be interpreted cautiously.
13JAMA Network Open. Cerebral Palsy Risk by Combined Apgar Score and Umbilical Cord Blood pH LevelsWhy Two Doctors Might Give Different Scores
The Apgar score is subjective. Two clinicians watching the same baby can arrive at different numbers, and research confirms this happens regularly. A study using standardized video recordings of preterm births found that the average agreement among observers was moderate at best, with neonatologists tending to give higher scores than obstetricians, and a meaningful gap between neonatologists and midwives.
14Journal of Neonatology & Clinical Pediatrics. Inter-Observer Variability of the Apgar Score of Preterm Infants between Neonatologists, Obstetricians and MidwivesAnother study surveyed over a hundred clinicians and found that correct scoring varied widely by component. Before any refresher, only about 63 percent of respondents scored the reflex component correctly, and only 67 percent scored muscle tone correctly. A brief clarification handout improved both accuracy and consistency, suggesting that some of the disagreement is simply a training issue that could be addressed.
15PubMed. Variability in Apgar Score Assignment among Clinicians: Role of a Simple ClarificationThe subjectivity problem is compounded in premature infants, who are expected to have lower muscle tone and weaker reflexes simply because of their gestational age. A healthy 28-week preterm baby will almost always score lower than a healthy full-term baby, even if both are doing well for their developmental stage. This has led to ongoing debate about whether the same scoring thresholds should apply to preterm and term infants.
16The Journal of Pediatrics. What Is the Apgar Test and What Do Scores Mean?Skin Color, Race, and Scoring Bias
The color component of the Apgar score asks clinicians to assess whether a baby is pink, blue at the extremities, or entirely blue. Evaluating skin pinkness is inherently harder on darker skin. A systematic review examining Apgar scores across racial and ethnic groups found that Black neonates are more likely to receive low Apgar scores than white neonates. At the same time, studies consistently found that at any given low Apgar score, Black neonates had lower rates of neonatal death than white neonates. The biggest mortality gap appeared at the very lowest scores (0 to 3).
17Pediatric Research. Systematic review of Apgar scores & cyanosis in Black, Asian, and ethnic minority infantsThis pattern suggests that the color component may be systematically underscored in babies with darker skin, making their overall Apgar scores appear worse than their actual physiological condition warrants. Since the score is used to guide resuscitation decisions and is documented in the medical record, inaccurate scoring can have downstream consequences: unnecessary interventions, parental anxiety, and misleading risk labels that follow the child. Researchers have called for alternatives to the color assessment, such as pulse oximetry, which objectively measures oxygen saturation regardless of skin tone.
Do Epidurals Affect Apgar Scores?
The question of whether epidural analgesia during labor affects the baby’s Apgar score has been studied extensively, and the answer is not straightforward. Some older studies linked epidurals to slightly lower scores and higher rates of neonatal distress. A prospective study found no statistically significant difference in birth asphyxia (defined as a five-minute Apgar below 6) between the epidural and non-epidural groups, though the numbers were small.
18PubMed Central. Effects of maternal epidural analgesia on the neonate – a prospective cohort studyA population-based cohort study found that epidural use was associated with roughly 76 percent higher odds of a low Apgar score, but a mediation analysis suggested this was driven not by the epidural itself but by complications it was associated with, such as maternal fever and assisted delivery.
19PubMed. Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort studyA large Scottish study with more than 400,000 births found the opposite direction of effect: epidural use was actually associated with a decreased risk of a five-minute Apgar score below 7 after adjusting for confounders and accounting for the way epidurals change the mode of delivery.
20JAMA Network Open. Association of Epidural Analgesia in Women in Labor With Neonatal and Childhood Outcomes in a Population CohortThe takeaway for expecting parents: epidurals are not reliably associated with worse Apgar scores once you account for the complications that tend to accompany difficult labors. Women who receive epidurals are more likely to be in complicated labor to begin with, which confounds any simple comparison.
Apgar Scores in Out-of-Hospital Births
Parents who deliver at home or in birth centers sometimes hear that babies born in those settings receive higher Apgar scores than hospital-born babies. This is technically true in many datasets but misleading. An analysis of U.S. birth data found that newborns delivered by midwives at home or in birth centers were dramatically more likely to receive a perfect five-minute score of 10 compared to hospital births.
21PubMed. Justified skepticism about Apgar scoring in out-of-hospital birth settingsThe problem is that out-of-hospital births also have higher rates of missing scores. A study comparing planned home births with hospital births found that five-minute scores were missing in about 3 percent of home births compared to 0.13 percent of hospital births. When the researchers modeled what would happen if even half of those missing scores were in the severely compromised range, the adjusted odds of severe compromise jumped substantially for home births. The higher rate of perfect scores in out-of-hospital settings may partly reflect less rigorous scoring practices, different patient populations (lower-risk pregnancies are selected for home birth), or both.
22The Lancet Regional Health – Americas. Comparison of Apgar score patterns and reporting across planned home versus hospital birthsLong-Term Cognitive Outcomes
Beyond the immediate neonatal period, researchers have looked at whether Apgar scores predict cognitive development years later. A cohort study following children through school found that infants with prolonged low Apgar scores had about 35 percent higher odds of a low IQ at age seven. The longer it took for a baby to reach a normal score, the greater the risk. Interestingly, this association did not extend to school grades at age 15 to 16, suggesting that other factors eventually play a larger role in academic performance.
23Archives of Disease in Childhood – Fetal and Neonatal Edition. A cohort study of low Apgar scores and cognitive outcomesA separate study examining children with all three perinatal risk factors (low birth weight, small head circumference, and low Apgar score) found consistent associations with lower IQ at ages four and seven and lower academic performance at age eight, with the largest gaps appearing in arithmetic rather than reading or spelling.
24PubMed Central. Short and Long-Term Effects of Compromised Birth Weight, Head Circumference, and Apgar Scores on Neuropsychological DevelopmentThese findings describe statistical trends across large groups. A low Apgar score at birth is one data point among many, and for the vast majority of children who experienced brief dips in their score, the long-term outlook is no different from their peers.
The Combined Apgar and Newer Adaptations
Because the traditional Apgar score does not account for interventions the baby is receiving, some researchers have developed a “Combined Apgar” that factors in whether the baby needed oxygen, continuous positive airway pressure, or intubation at the time of scoring. The idea is that a baby with a heart rate of 120 while on a ventilator is in a fundamentally different situation than a baby with a heart rate of 120 breathing independently, and the score should reflect that.
Studies testing the Combined Apgar found that it outperformed the traditional score in predicting neonatal mortality, the need for mechanical ventilation, and brain hemorrhage. One analysis found that a low five-minute Combined Apgar score was associated with roughly a 20-fold increase in the odds of neonatal death after adjusting for other factors.
25PubMed Central. Comparison of the Combined versus Conventional Apgar Scores in Predicting Adverse Neonatal OutcomesA separate trial comparing multiple expanded scoring systems found that the Combined Apgar was significantly better at predicting poor outcomes at one minute than the other expanded versions tested. Among infants who had a very low score at ten minutes, 100 percent had a poor outcome.
26PubMed Central. Neonatal assessment in the delivery room–Trial to Evaluate a Specified Type of Apgar (TEST-Apgar)Despite these findings, the Combined Apgar has not replaced the traditional version in routine practice. Part of the appeal of the original is its sheer simplicity: it requires no equipment, takes seconds, and anyone in the delivery room can do it. Adding categories for respiratory support introduces complexity that may slow down assessment when speed matters most. For now, the traditional Apgar remains standard, with the Combined version used mainly in research and in neonatal units that already track detailed intervention data.
Scoring Accuracy in Low-Resource Settings
The Apgar score’s reliance on clinical judgment, rather than technology, makes it usable almost anywhere. But that same reliance means accuracy depends heavily on the training and tools available to the person doing the scoring. A study at a Kenyan tertiary hospital compared Apgar-based assessments of birth asphyxia against a gold-standard clinical diagnosis and found that the five-minute Apgar had a sensitivity of about 71 percent and a specificity of about 89 percent. The most striking finding was that healthcare workers who did not have a printed Apgar scoring chart on hand were 56 times more likely to classify asphyxia incorrectly.
27PLoS ONE. A comparative analysis of APGAR score and the gold standard in the diagnosis of birth asphyxia at a tertiary health facility in KenyaThat finding underscores an unglamorous but critical point about the Apgar test: its value depends on how carefully it is applied. In well-staffed hospitals with experienced teams, it is a useful rapid screen. In settings where staff are stretched thin, undertrained, or lack basic reference materials, the same test can produce misleading results that affect life-and-death resuscitation decisions. Virginia Apgar’s original tool was built for simplicity, but simplicity does not eliminate the need for training.