When Virginia Apgar introduced her scoring system in the early 1950s, she transformed newborn care. Before her innovation, attention during delivery was almost exclusively on the mother; the infant often received little systematic evaluation in those critical first minutes of life. Apgar’s simple tool brought immediate, structured attention to the newborn and remains one of the most widely used assessments in medicine today (Calmes, 2015).
The Birth of the Apgar Score
Virginia Apgar (1909–1974) was a trailblazing anesthesiologist whose curiosity, energy, and determination reshaped newborn care. Born in Westfield, New Jersey, she grew up in a family that valued science and music. Her father built telescopes and radios in the basement, while she played violin in orchestras throughout her youth—traits that reflected both her scientific curiosity and her boundless energy (Calmes, 2015; Tan & Yong, 2018).
Breaking Barriers in Medicine
When Apgar graduated from Mount Holyoke College in 1929 and entered Columbia University’s College of Physicians and Surgeons, she was one of only nine women in her class of ninety. She originally trained as a surgeon, but at the urging of Dr. Allen Whipple—famous for the “Whipple procedure”—she pursued anesthesiology, a field with few physicians at the time and even fewer women. In 1939, she became only the second woman in the United States to be board-certified in anesthesiology (Calmes, 2015).
Apgar’s career flourished at Columbia, where she became the first woman to achieve the rank of full professor at the medical school. But her greatest legacy grew out of her work in obstetric anesthesia. She noticed that despite advances in care for mothers, infants were often overlooked in the delivery room, with no consistent system to describe their condition.
“Nine Months for the Mother, One Minute for the Baby”
In 1952, Apgar presented her idea at a medical meeting: a simple, repeatable scoring system to assess a newborn’s health at one and five minutes after birth. She later wrote that “nine months observation of the mother surely warrants one-minute observation of the baby” (Rüdiger, 2020).
Her system evaluated five easily observable signs—heart rate, respiratory effort, reflex irritability, muscle tone, and color. Each was given a score of 0, 1, or 2, for a total score of up to 10. This method gave clinicians a quick, standardized language to describe newborns and determine who needed resuscitation.
From Idea to Global Standard
Apgar published her first study of the score in 1953 in Anesthesia & Analgesia. The tool quickly spread across hospitals in the United States and, by the 1960s, around the world (Tan & Yong, 2018). What began as a way to encourage attention to newborns became one of the most widely used scoring systems in medicine. Her work also opened doors for broader evaluations of obstetric anesthesia and neonatal resuscitation practices. By showing that babies with low Apgar scores were often acidotic and hypoxic, Apgar and colleagues helped drive advances in both anesthesia safety and newborn care (Calmes, 2015).
A Legacy That Lasts
Beyond her famous score, Virginia Apgar was a passionate advocate for maternal and child health. Later in life, she worked for the March of Dimes, focusing on congenital anomalies and prematurity. She was also known for her vibrant personality, love of music, and advocacy for women in medicine. Today, the Apgar Score stands as both a clinical tool and a testament to her vision: that every baby deserves immediate, systematic attention at birth.
How the Apgar Score is Calculated
The genius of Virginia Apgar’s system lies in its simplicity. Within the first minute of life, a clinician observes five key signs of a newborn’s condition: skin color, heart rate, reflexes, muscle tone, and breathing. Each of these is scored on a scale of 0, 1, or 2. A completely blue or pale baby receives a 0 for appearance, while one who is entirely pink earns a 2. The heart rate is another critical measure—no detectable pulse is a 0, fewer than 100 beats per minute is a 1, and a healthy 100 or more earns a 2. Reflexes are tested by gently stimulating the infant; a lack of response scores a 0, a weak grimace or cry a 1, and a vigorous cry or withdrawal a 2. Similarly, muscle tone ranges from limp (0) to active, spontaneous movement (2). Finally, the baby’s breathing effort is judged—absent respirations are scored 0, weak or irregular effort earns a 1, and a strong, lusty cry secures the full 2 points.
When the five scores are added together, the result is a total between 0 and 10. That number paints a quick picture of how well the baby is transitioning to life outside the womb. A score between 7 and 10 is generally considered reassuring—the newborn is adapting well. Scores in the 4 to 6 range suggest the baby may be struggling and could need closer observation or mild interventions. A total of 0 to 3 is an urgent red flag, signaling serious compromise and the likely need for immediate resuscitation (AAP & ACOG, 2015).
Timing also matters. The score is traditionally reported at 1 minute and 5 minutes after birth. The first score reflects how well the infant tolerated labor and delivery, while the second reflects how well they are adapting to extrauterine life. If the 5-minute score is less than 7, the assessment is repeated every 5 minutes until 20 minutes of life, giving clinicians a running record of the baby’s progress or continued difficulties (AAP & ACOG, 2006).
Why Lactation Professionals Should Pay Attention
For lactation professionals, the Apgar score is much more than a number in the medical chart—it offers valuable context for understanding how an infant may feed in those first critical hours and days.
A baby who is born with a low initial score has likely experienced some degree of birth stress, resuscitation, or delayed transition to life outside the womb. These infants often come to the breast with weaker suck patterns, disorganized coordination, or less stamina to sustain a full feed. Knowing this background helps the IBCLC anticipate challenges and guide parents through strategies like skin-to-skin care, paced feeding, and early expression to protect milk supply.
When scores improve over time, the story is a little different. A baby who starts with a score of 4 at one minute but rises to an 8 at five minutes may look stable now, but they still carry a history of early stress. That history can translate into subtle feeding difficulties—shorter feeds, fatigue at the breast, or slower weight gain. The consultant who recognizes this pattern can watch feeding more closely and provide reassurance to parents who might otherwise feel something is “wrong” when their baby doesn’t nurse vigorously right away.
Preterm infants add another layer of complexity. They often score lower on the Apgar scale, not because they are in distress, but because their muscle tone and reflexes are immature. For the lactation consultant working in the NICU, these lower scores serve as a reminder that the baby’s developmental stage—not just medical stability—shapes how and when breastfeeding can begin (AAP & ACOG, 2006). Supporting milk expression, protecting supply, and gently guiding preterm babies toward oral feeding becomes part of the consultant’s specialized role.
Even a baby who earns a “perfect” 9 or 10 is not guaranteed to be free from challenges. Conditions such as hypoglycemia, acidemia, or metabolic instability may still be present, quietly influencing feeding behavior despite reassuring scores (Sabol & Caughey, 2016). A consultant who understands these nuances will avoid assuming that a high Apgar equals a smooth breastfeeding journey.
Ultimately, the Apgar score tells a story—but not the whole story. By understanding what the score captures, and just as importantly what it does not, lactation professionals can interpret infant behavior with greater accuracy, anticipate potential barriers to breastfeeding, and collaborate more effectively with the broader care team to support early feeding success.
Conclusion
The Apgar score has endured for more than seventy years because it does exactly what Virginia Apgar intended—it focuses immediate attention on the newborn and provides a common language for describing their early condition. For lactation professionals, understanding the meaning and limitations of the score offers an important window into the infant’s first experiences outside the womb. Whether a baby begins life needing significant support, makes a rapid recovery, or carries hidden challenges despite reassuring numbers, the Apgar score helps frame expectations for early feeding. By interpreting these scores in context, IBCLCs can anticipate potential hurdles, guide families with confidence, and strengthen collaboration with the medical team. In the end, the Apgar score is not just about survival—it’s also about setting the stage for thriving, and breastfeeding is a vital part of that journey.
References
American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2006). The Apgar Score. Pediatrics, 117(4), 1444–1447. https://doi.org/10.1542/peds.2006-03
American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2015). The Apgar Score. Pediatrics, 136(4), 819–822. https://doi.org/10.1542/peds.2015-2651
Calmes, S. H. (2015). Dr. Virginia Apgar and the Apgar Score: How the Apgar Score came to be. Anesthesia & Analgesia, 120(5), 1060–1064. https://doi.org/10.1213/ANE.0000000000000659
Li, F., Wu, T., Lei, X., Zhang, H., Mao, M., & Zhang, J. (2013). The Apgar score and infant mortality. PLoS ONE, 8(7), e69072. https://doi.org/10.1371/journal.pone.0069072
Rüdiger, M. (2020). It’s time to reevaluate the Apgar Score. JAMA Pediatrics, 174(7), 617–618. https://doi.org/10.1001/jamapediatrics.2020.041
Rüdiger, M., Braun, N., Aranda, J., Aguar, M., Bergert, R., Bystricka, A., Dimitriou, G., El-Atawi, K., Ifflaender, S., Jung, P., Matasova, K., Ojinaga, V., Petruskeviciene, Z., Roll, C., Schwindt, J., Simma, B., Staal, N., ValenciaG., Vasconcellos, M.G., Veinla, M., Vento, M. Weber, B., Wendt, A., Yigit, S. (2015). Neonatal assessment in the delivery room—Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatrics, 15, 18. https://doi.org/10.1186/s12887-015-0334-7
Sabol, B. A., & Caughey, A. B. (2016). Acidemia in neonates with a 5-minute Apgar score of ≥7—What are the outcomes? American Journal of Obstetrics & Gynecology, 215(4), 486.e1–486.e6. https://doi.org/10.1016/j.ajog.2016.05.035
Tan, S. Y., & YDavis, C.A. (2018). Virginia Apgar (1909–1974): Medicine in stamps. Singapore Medical Journal, 59(7), 395–396. https://doi.org/10.11622/smedj.2018091
Tiemeier, H., & McCormick, M. C. (2019). The Apgar paradox. European Journal of Epidemiology, 34, 103–104. https://doi.org/10.1007/s10654-018-04669
