Review of the Reliability and Validity of the Apgar Score

Abstract

Background: The Apgar score is the most common score used to quantify neonatal status after birth. It is routinely used in clinical practice and research. However, since its introduction there have been significant changes in peripartum and neonatal management, our understanding of neonatal physiology, and changes in data analysis capabilities. Purpose: To assess the Apgar score's reliability and validity in the context of today's clinical and research environments. Method: PubMed was searched using the term “Apgar.” Just over 22,000 titles were identified. Full-text articles were obtained if they addressed the Apgar score's use, reliability, and validity, or if the score was a primary outcome measure. This was followed by a hand search using the same criteria. The 505 identified articles build the basis for this discussion of the Apgar score's reliability and validity. Findings: Multiple positive and negative aspects of the Apgar score's reliability and validity were identified. Some facets needed to evaluate reliability and validity do not seem to have been addressed in the literature. Overall, the identified concerns can introduce bias into outcomes obtained via the use of the Apgar score in both clinical practice and research. Implications for Practice: The Apgar score is no longer used to determine neonatal management in the delivery room. Implications for Research: The use of the Apgar score in research may introduce bias into outcomes. As discussed in the Video Abstract, researchers need to address and improve the score's weaknesses or consider developing a new tool better suited to today's research needs. Video Abstract available at: https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=45

Validity of Apgar Score as an Indicator of Neonatal SARS-CoV-2 Infection: A Scoping Review

“…Although the Apgar test was designed to be administered by a medical professional at 1 and 5 mins of life after delivery and extended at 5 min intervals for neonates with Apgar scores below 7 to a maximum of 20 mins, there is disagreement in the literature regarding reporting times ( 4 , 5 ). In particular, there has been criticism of the continued use of Apgar tests at 1 min.…”

“…For a given neonate, each of the five indices is assigned a value from 0 to 2, and the values of each of the five indices are tallied to calculate the total Apgar score (5,6). Apgar scores above 7 are considered "reassuring, " while scores between 4 and 6 are "below normal, " and scores of 1-3 are "critically low" and typically require urgent clinical intervention (4)(5)(6). Due to their ease of application, Apgar scores were ubiquitously implemented to assess neonatal asphyxia without the need for blood gas analyses (4).…”

“…Apgar scores above 7 are considered "reassuring, " while scores between 4 and 6 are "below normal, " and scores of 1-3 are "critically low" and typically require urgent clinical intervention (4)(5)(6). Due to their ease of application, Apgar scores were ubiquitously implemented to assess neonatal asphyxia without the need for blood gas analyses (4).…”

“…One measure of neonatal condition is the Apgar test, a discrete numerical test developed in 1953 by an anesthesiologist at Columbia University, which uses a mnemonic to assess neonatal status, measure response to resuscitation, and compare the outcomes of obstetrical practices, including intrapartum management and effects of maternal pain medication ( 4 ). The mnemonic relies on five objective observations: appearance, pulse, grimace, activity, and respiration ( 5 , 6 ).…”

“…However, the increasing scrutiny of Apgar scores as a commonly assessed and clinically reported metric in the literature has driven researchers to question the validity of Apgar scores ( 4 , 15 , 16 ). Therefore, this scoping review investigated whether Apgar scores are an accurate indicator of neonatal COVID-19 status and synthesized relevant articles on Apgar scores.…”