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Apgar Score

Getting Ready

  1. Perform hand hygiene and apply clean gloves.
  2. Verify the patient's identity using two patient identifiers in accordance with institutional policy. Before delivery, use maternal information.
  3. Start timer or have another team member document the time immediately after delivery of the newborn. Warm, dry, and stimulate the infant if indicated and perform resuscitation measures as needed.

Assess respiratory effort and other parts of the score as quickly as possible at 1 minute after time of birth.

    *  Absent respiratory effort - 0

    * Weak effort requiring assistance - 1
    * Adequate with good cry - 2

Assess apical heart rate by using a clean stethoscope.

    * Absent heart rate - 0
    * Rate is less than 100 - 1
    * Rate is greater than 100 - 2

Assess color.

    * Pallid or cyanotic - 0
    * Pink with blue extremities - 1
    * Pink all over - 2

Assess reflex irritability or response to stimulation such as back or foot rubbing.

    * No response - 0
    * Grimace - 1
    * Good cry - 2

Assess tone of extremities.

    * Flaccid - 0
    * Some flexion of extremities - 1
    * Well-flexed extremities - 2

Repeat scoring

   1. Repeat the Apgar score at 5-minute intervals for up to 20 minutes until the score is 7 or greater.
   2. Continue resuscitation measures as needed until the score is 7 or greater.
   3. Remove gloves and discard in proper trash receptacle. Perform hand hygiene.
   4. Document the procedure in the patient's record.
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