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Clinical Practice Procedures: Assessment/APGAR score

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Date February, 2015

Purpose To ensure a consistent procedural approach to determining the APGAR score.

Scope Applies to all QAS clinical staff.Author Clinical Quality & Patient Safety Unit, QAS

Review date February, 2017

URL https://ambulance.qld.gov.au/clinical.html

387QUEENSLAND AMBULANCE SERVICE

APGAR score

The APGAR score is a valuable method to determine the health

of newborns immediately after birth. It is determined by

allocating scores to five (5) simple criteria:

• colour ( A ppearance )• heart rate ( P ulse )• reflex irritability ( G rimace ) • muscle tone ( A ctivity ) • breathing ( R espiration )

Indications

Contraindications

• Nil in this setting

Complications

• All newly borns at one minute and five minutes following delivery.

• Nil in this setting

The purpose of the APGAR score is to

determine whether a newly born needs

immediate medical care. It is NOT designed to make long-term predictions of a child’s health.

[1,2]

February, 2015

Figure 3.18

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Procedure – APGAR score

• Using the table provided, assign the newborn a score (0 – 2) for each of the five criteria at 1 minute and agin at 5 minutes following delivery. Add all individual scores to calculate the total APGAR score (0   –  10). Additional information

An APGAR score of:

• 0   –    3 represents severe distress, (refer to CPG: Resuscitation – Newly born).

• 4    –    7 indicates moderate distress, (refer to CPG: Resuscitation – Newly born).

• 7    –    10 indicates an absence of difficulty

in adjusting to extrauterine life.

APGAR SCOREAPGAR SCOREAPGAR SCOREAPGAR SCOREAPGAR SCORE

Action 0 1 2

Appearance Look at skin colour

Blue/pale Pink

(extremities blue)All pink

Pulse Count heart rate

Absent < 100 > 100

Grimace Monitor response

No response

Grimace Vigorous

cough

Activity Look at muscle tone

Limp Some

flexion/extension Active

motion

Respiration Count and assess

Absent Slow/irregular Good cry

e

388QUEENSLAND AMBULANCE SERVICE

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