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Attorney Explains APGAR Scores for Birth Injury Evaluation

Husband holding wife's hand during labor, with two doctors in the background at the hospital.
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Dov Apfel

Content Reviewed by: Dov Apfel

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Since 1979, Dov Apfel has been passionate about advocating for birth injury and medical malpractice victims. Mr. Apfel’s career-long record of achievements in birth injury litigation, education, and advocacy has been recognized by the Executive Board of the Birth Trauma Litigation Group of the American Association for Justice. His expertise is demonstrated by his numerous awards, presentations on birth injury topics at legal conferences for organizations like the AAJ and ATLA, and articles published by Trial Magazine and many others.

The Apgar score is a rapid assessment of your baby’s health following birth to determine if intervention is needed. Although not used to diagnose birth injuries or predict long-term health outcomes, the scores could correlate to a birth injury. Our award-winning birth injury lawyers can help you investigate whether a birth injury occurred and whether medical negligence is to blame. Partner Seth Cardeli, a long-time advocate for disabled children, explains what the APGAR score measures.

Intervention during the first few minutes after birth is critical for preventing brain damage and other long-term consequences when the infant experiences depressed bodily functioning outside the womb. The APGAR score provides a means to rapidly assess a newborn infant’s well-being without losing valuable time.

If your baby was harmed during pregnancy or birth, our experienced birth injury lawyers can determine whether medical malpractice was involved. In some cases, a low Apgar score can serve as important evidence in proving a birth injury claim.

What Is an Apgar Score?

An Apgar score is a numerical value used to quickly determine a newborn infant’s health status one minute and five minutes after birth. It was first used in 1952 by Dr. Virginia Apgar. A doctor, midwife, or nurse may provide an Apgar assessment.

The Apgar test specifically measures five functions, each with a score ranging from zero to two.

These scores are then totaled to arrive at an overall score known as the Apgar score. Generally speaking, the higher the Apgar score, the better the state of infant health. The official scoring ranges are as follows:

Apgar Score Ranges
Score Interpretation
7-10 Reassuring - Healthy/normal
4-6 Moderately abnormal
0-3 Low

An Apgar score in the normal range does not mean an infant has not experienced a birth injury, just as a low Apgar score does not always indicate a birth injury.

What Does a Low Apgar Score Mean?

By itself, a low Apgar score one minute after birth is not regarded as medically significant because most infants improve before the five-minute Apgar assessment. However, a low score during the five-minute evaluation has been associated with a higher risk of cerebral palsy and infant death. The longer the score remains low, the higher the risk of future neurologic complications.

A low score may indicate one or more of the following:

  • Cardio-respiratory arrest
  • Metabolic acidosis
  • Hypoventilation
  • Central nervous system depression
  • Difficulty gaining a clear airway
  • Sepsis
  • Hypoxic-ischemic encephalopathy, or HIE

If your baby’s Apgar score is low at the one-minute assessment but improves by the five-minute assessment, HIE is less likely. If it remains below seven at the five-minute assessment, the standard of care is generally to perform another Apgar assessment at 10 minutes. The doctor may need to continue testing for as long as 20 minutes and throughout resuscitation.

If your baby’s Apgar score remains at three or lower at the five-minute assessment, the baby will likely require admission to the neonatal intensive care unit. If the Apgar score remains at zero beyond the ten-minute assessment, the baby is unlikely to survive, and resuscitation efforts may cease.

What Is the Appropriate Medical Response to a Low Apgar Score?

Any infant with an Apgar score lower than seven at the five-minute assessment requires prompt treatment. The treatment will vary depending on the cause. The treatment team should quickly diagnose the cause and begin neonatal resuscitation immediately. If the brain is deprived of oxygen for too long, brain damage could result.

If the baby is unable to start taking regular breaths, positive pressure ventilation using a special mask may be used to stimulate breathing. This may also be used if the heart rate is below 100 beats per minute. However, chest compressions are usually necessary if the heart rate is below 60 beats per minute.

Bulb suctioning of the airway is no longer the standard of care except in specific circumstances because it poses a risk of slowing the heart rate and causing fluid to back up into the lungs.

Other interventions may include warming the infant to reduce hypothermia and assessing cord blood gases.

Risk Factors of a Low Apgar Score

While a low Apgar score can occur without an obvious explanation, it is more common in the following scenarios:

  • C-sections that take longer than three minutes from incision or are performed using general anesthesia instead of spinal epidural anesthesia
  • Premature birth
  • Late-term birth after 42 weeks gestation
  • Birth weight lower than five-and-a-half pounds or higher than 8.8 pounds
  • Meconium in the amniotic fluid
  • Use of narcotic pain medications during labor
  • Breech presentation
  • Use of oxytocin for the induction of labor
  • Complications during childbirth

It is important to note that these risk factors are similar to the risk factors for many birth injuries. Premature birth, low birth weight, C-section complications, and breech presentations are just a few examples of complications that doctors may prevent by following the appropriate standard of care during prenatal care and throughout labor and delivery.

What Are the Long-Term Consequences of a Low Apgar Score?

A low Apgar score does not itself cause long-term complications. However, medical malpractice can have severe permanent effects, including death. Thus, it is the cause of the low score, not the score itself, that can have long-term effects.

These effects vary based on which measurements are low. If the categories related to breathing and heart rate scored low, this could indicate that your baby suffered birth asphyxia or HIE, which could result in brain damage, leading to the following:

  • Cerebral palsy
  • Cognitive disabilities
  • Problems with learning and memory
  • Behavioral problems
  • Mood disorders such as anxiety and depression
  • Shortened life expectancy

How Apgar Scores and Birth Injuries Are Related

A low Apgar score is often the first sign of a birth injury, but this is not always the case. An infant suffering from birth asphyxia will need resuscitation immediately after birth. The medical team should not wait until the one-minute Apgar test to determine resuscitation is needed. Waiting to initiate resuscitation could itself cause a birth injury.

A birth injury is a harm that occurs before, during, or shortly after birth. A birth injury could occur during or after the period of Apgar scoring. An injury can happen if medical professionals do not properly assess the infant or inadequately or improperly address any symptoms.

While a low Apgar score does not always indicate a birth injury, infants who experience birth injuries before or during birth are more likely to score lower on Apgar tests because birth injuries can cause trouble breathing, heart problems, and depression of the central nervous system. All of these contribute to low Apgar scores.

Primarily, the Apgar score promotes fast action by allowing medical personnel to quickly evaluate the child’s status and respond. The score cannot be used alone as a diagnostic test. However, it can point to a need for diagnostic testing.

How Does an Apgar Score Affect My Birth Injury Claim?

A low Apgar score is part of your child’s medical record and can support your birth injury claim, especially if your child’s score remains low at five minutes and beyond. While a low Apgar score alone is not proof of a birth injury, it is evidence that the infant suffered some type of stress during birth, and it can point to the following:

A low Apgar score can provide especially helpful evidence when the birth injury fails to become apparent until years later, which is common in cerebral palsy cases. Cerebral palsy is often not diagnosed until after the child’s second birthday. A low Apgar score can support that cerebral palsy stemmed from a birth complication rather than an injury that happened later.

How a Low Apgar Score Could Be a Sign of Medical Negligence

When combined with other facts, a low Apgar score can point to medical negligence. For example, if you experienced preventable complications during pregnancy, labor, or childbirth followed by a low Apgar score in your baby, medical malpractice may be to blame, including the following:

Does a High Apgar Score Hurt My Case?

The Apgar score is not a diagnostic instrument that cannot rule out a birth injury or negate your claim. The effects of birth injuries are not always immediate, and some birth injuries occur shortly after birth, even after the Apgar scores are tabulated.

Birth injury cases are complex medical malpractice cases that require consideration of the medical record as a whole. To prevail in a birth injury lawsuit, you must prove that all of the following elements of negligence were present, regardless of the Apgar score:

  1. Duty of care – Your baby was a patient of the hospital, birthing center, doctor, midwife, or other health care providers.
  2. Breach of duty – One or more health care providers failed to provide a reasonable standard of care according to medical guidelines.
  3. An injury – Your baby experienced an injury resulting in financial and other losses, which would not have occurred were it not for the breach of duty.
  4. Proximate cause – The breach of duty is the actual cause of your baby’s injuries.

Although scores above seven are considered normal, a Swedish study published by the British Medical Journal found that even a normal score was associated with a marked increase in the risk of infections, brain injury, breathing problems, and death if the score was less than 10 at one, five, or 10 minutes.

The study’s authors consequently recommended that all infants should be scored at 10 minutes, even with a normal score at one and five minutes.

The Reliability of Your Baby’s Apgar Score May Be Questionable

Apgar scoring is largely subjective, and this can allow bias to impact your child’s score. For example, one Apgar measurement is muscle tone. Determining whether the baby has normal or abnormal muscle tone can be a matter of opinion. The same is true of skin tone and reflexes. The only measurement that uses hard numbers is the heart rate.

Consequently, an objective health care provider who did not assist in the birthing process should perform the Apgar test. Someone who participated in the birthing process may tend to assign a higher score, resulting in the baby being deprived of the necessary treatment to avoid long-term complications.

Racial Inconsistencies

A study published by PLOS Medicine found racial disparities in Apgar scoring. Black infants are more likely than lighter-skinned infants to receive low Apgar scores, which has resulted in a lesser association between Apgar scores and infant mortality in black infants.

This could lead to a failure to diagnose other serious conditions if low Apgar scores in black infants are considered the norm and thus disregarded. It could also lead to overtreatment, which has the potential to cause harm.

The Journal of Perinatal Medicine published a study that has called on the medical field to remove skin color from testing criteria to prevent racial bias from affecting Apgar scores.

What to Do If You Suspect a Birth Injury After a Low Apgar Score

Many infants with low Apgar scores are healthy and uninjured. They just need extra help coping with the stress of childbirth and adapting to life outside the womb. However, low Apgar scores do point to birth injuries in some cases, and these injuries may have resulted from medical malpractice.

If you suspect your baby suffered an injury during birth, you deserve answers. You can take steps now to ensure your baby has the best possible outcome while you start building your legal case. These steps include the following:

  • Obtain a second opinion from a doctor who works for a different practice.
  • Document your baby’s developmental milestones as they happen, including when your baby first smiles, walks, rolls over, and any other “firsts.”
  • Write down any observations of your baby’s development or behavior that you find questionable.
  • Notify your pediatrician of any health challenges.
  • Contact an experienced birth injury lawyer as soon as possible.

Need Legal Advice? Contact Our Birth Injury Attorneys for a Free Case Review

Our nationally recognized birth injury attorneys have more than 400 years of combined experience standing up to insurance companies and health care organizations, and we are pioneers in birth injury litigation.

Since our founding in 1992, we have developed the most effective and aggressive approach to handling birth injury litigation. We have the best experts in the field working for us to investigate your case and strengthen your claim. Our knowledge of federal and state birth injury laws is unmatched.

We never settle for less than our clients deserve. Our commitment to each client has helped us win more than $2 billion in case results, including the following:

  • \$40 million verdict for a disabled 19-year-old who suffered a brain injury due to a delayed C-section
  • $20 million verdict for a child who developed cognitive and developmental impairments after suffering preventable HIE injuries at birth
  • $14 million for the family of a child who was brain injured as a result of oxygen deprivation during birth due to inadequate fetal monitoring and an untimely C-section.
  • $11.5 million FTCA settlement for the active duty parents of a baby who suffered a catastrophic brain injury at the U.S. Naval Hospital in Guam
  • $9 million settlement for the family of a baby who suffered permanent brain damage when a doctor failed to test the mother for meningitis during prenatal care
  • $6.71 million verdict against a hospital after an inexperienced resident performed a vaginal delivery of a breech presentation, resulting in crippling brachial plexus
  • $6.5 million settlement for a young girl who developed cerebral palsy after doctors failed to perform a timely C-section

We are actively involved in birth injury advocacy outside of the courtroom. We have testified in front of state and federal legislators in support of laws to protect children and families, and our attorneys are national leaders in child advocacy.

Partners Seth Cardeli and Dov Apfel are highly sought-after lecturers and advocates for children with cerebral palsy and other disabilities. Dov Apfel has mentored thousands of attorneys throughout his remarkable forty-plus-year career, and he is the author of a law review article that set the standard for handling birth injury litigation.

We are passionate about helping birth-injured children and their parents get justice for medical negligence. We regularly receive unsolicited, glowing testimonials from our satisfied clients, such as the following:


If you suspect your baby was injured at birth, our compassionate and skilled birth injury lawyers can help you hold the negligent providers accountable and pursue significant financial compensation. Contact us today for a free consultation.

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Steven M Levin

Steven M. Levin

Founder and Senior Partner
Since 1976, Steve Levin has been dedicated to helping people injured by others’ negligence. He is one of the first attorneys in the U.S. to prosecute nursing homes for abuse and negligence. He's also helped write new legislation that governs the operation of nursing homes, including the Illinois Nursing Home Care Act. Moreover, Levin & Perconti has obtained the top three jury verdicts in nursing home negligence cases in Illinois.