Clinicians should not use the Apgar score to predict neonatal outcomes or to diagnose asphyxia, and should use the expanded Apgar score form whenever possible, according to a joint recommendation statement issued by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG).

The AAP’s Committee on Fetus and Newborn and ACOG’s Committee on Obstetric Practice continued to recommend that Apgar scores not be used to predict neonatal mortality or neurologic outcome, and should not be the sole determinant in a diagnosis of asphyxia. These updated recommendations were published in both Pediatrics andObstetrics & Gynecology.

This was an update to the 2006 recommendation statement. The revision also recommends that clinicians obtain umbilical arterial blood samples from a clamped section of the cord for an infant with an Apgar score of less than 5 after 5 minutes. The expanded Apgar score form is particularly helpful in this case, as it allows clinicians to record time of birth, cord clamping, and initiation of resuscitation. The update also recommends submitting the placenta for future examination.

These recommendations incorporated findings from the 2014 Neonatal Encephalopathy and Neurologic Outcome report, and the 2011 Neonatal Resuscitation Program guidelines.The guidelines state that the Apgar score should not be used to determine the need for resuscitation or which steps are necessary, as any resuscitation must be initiated prior to the 1-minute Apgar score.

The committee also clarified asphyxia as a process, not an endpoint, and emphasized that Apgar score alone is not the sole determinant of asphyxia. They cite many other factors involved in diagnosing an intrapartum hypoxic-ischemic event, including abnormalities in:

• Umbilical arterial blood gas results
• Clinical cerebral function
• Neuroimaging studies
• Neonatal electroencephalography
• Placental pathology
• Hematologic studies
• Multisystem organ dysfunction
• Non-reassuring fetal heart rate monitoring patterns

The authors noted that an acute hypoxic-ischemic event is not consistent with an Apgar score of 7 or higher at 5 minutes, a category I (normal) or category II (indeterminate) fetal heart rate tracing and normal umbilical cord arterial blood pH (+/-1 SD).

Examining other neurologic outcomes, the committee cites several population-based studies where an Apgar score of 5 or less at 5 and 10 minutes is associated with an increased risk of cerebral palsy. This risk was as high as 20 to 100 fold compared to infants with an Apgar score of seven to 10 at 5 minutes.

Unchanged from the 2006 edition are recommendations that any Apgar score of 0 beyond 10 minutes of age is “useful” in determining whether continued resuscitation efforts are needed. In addition, an Apgar score of 0-3 at 5 minutes is still considered “a nonspecific sign of illness” and one of the first signs of encephalopathy, but is not a specific indicator for “intrapartum compromise.”

The authors reiterated the need for clinicians to monitor Apgar scores on both an individual and trend level. They cite individual case reports for identifying needs for educational programs and improvement in perinatal care symptoms, and trends in Apgar scores for assessing the impact of quality improvement interventions.