Timeline Entry
In July–August 1953, the American obstetric anaesthesiologist Virginia Apgar published a ten-point method for describing a newborn infant's condition exactly sixty seconds after birth. Developed at Columbia-Presbyterian's Sloane Hospital for Women in New York, it converted five observations—heart rate, respiratory effort, reflex irritability, muscle tone, and colour—into a common record (Apgar 1953).
The historical change was not a number that diagnosed a newborn. It was a disciplined minute of observation that made the effects of anaesthesia, delivery, and resuscitation easier to compare. The familiar one- and five-minute “Apgar score,” its mnemonic, and its much wider clinical and statistical uses emerged only after the 1953 paper (Jackson 2025).
Historical Significance
Apgar objected to “breathing time,” “crying time,” and broad labels such as mild, moderate, or severe depression. Maternal drugs could produce a first gasp followed by apnoea, while “crying time” was impossible to define in some ill infants. Five specified signs offered a more reproducible description (Apgar 1953).
The original purpose was to compare obstetric procedures, maternal pain relief, anaesthetic techniques, and methods of resuscitation. In this sense, newborn responses became evidence with which hospital teams could evaluate their own interventions, rather than the score being simply a verdict on an individual baby (Jackson 2025).
The method could be taught without special equipment and completed quickly. Its institutional effect was to assign value to observing the newborn during the first minute, when obstetricians and anaesthesia staff also had responsibilities to the mother (Apgar 1966).
Before the Score
Apgar entered anaesthesiology after Columbia surgeon Alan Whipple discouraged her from pursuing surgery, explicitly invoking the poor career prospects of women he had trained. Anaesthesia was then a low-status field, much of its work performed by nurses; it became a recognised medical specialty in the United States during the 1940s. In 1949 Columbia made Apgar its first woman full professor, and she increasingly studied how drugs given during labour and delivery affected newborns (National Library of Medicine).
In Apgar's 1966 retrospective account, heavy medication during labour and general anaesthesia at delivery made a gasp followed by apnoea a familiar clinical sequence. Between 1949 and 1952 she considered several signs, choosing five that delivery-room personnel could observe without special equipment. This account, written after the score had become established, is valuable testimony from its creator but is not a neutral record of how every hospital or birth attendant assessed infants (Apgar 1966).
The score therefore belongs first to a particular mid-century American hospital setting. It did not create attention to newborns everywhere, nor did it replace the varied knowledge of nurses, midwives, paediatricians, or birth attendants in other settings. It supplied one large hospital service with a standardised record that could circulate through papers, teaching, and multi-institution research.
The 1953 Method
Heart rate received zero if absent, one below 100 beats per minute, and two at 100–140; the three faster rates Apgar observed also received two. Respiratory effort ranged from absent, through irregular or shallow breathing, to a vigorous cry. These two signs carried immediate physiological and resuscitative meaning.
“Reflex irritability” meant response to stimulation, usually then tested by suctioning the mouth and nostrils with a soft catheter. Muscle tone ranged from complete flaccidity to active flexion and resistance to extension. The historical test procedure should not be mistaken for a current resuscitation instruction.
Apgar called colour “by far the most unsatisfactory sign.” Full marks required the infant to appear entirely pink; covering material, congenital conditions, and inherited pigmentation complicated the judgement. The original article used the now-obsolete term “colored children” while acknowledging this problem (Apgar 1953).
A total of ten represented the best condition within this scale. The apparent precision should not be overstated: the five components describe different functions, and two infants can reach the same total by different routes. Apgar's own analysis usually grouped scores as 0–2, 3–7, and 8–10 rather than treating each adjacent number as a distinct physiological state (Apgar 1953; Jackson 2025).
Evidence and Limits
Apgar reported 2,096 births over seven and a half months at Sloane Hospital. Of 1,760 available anaesthesia charts, 1,021 liveborn infants had received the new rating and 712 had not. Sixteen per cent of anaesthesia records were missing, chiefly births with pudendal block or “natural childbirth”—the cases Apgar herself said would have provided the best control group. She also stated that most subgroups were too small for statistical analysis (Apgar 1953).
Within that selected series, infants born by spontaneous or low-forceps delivery averaged 8.4, compared with 6.8 after caesarean section. Among 141 rated caesarean births, the average was 8.0 after spinal anaesthesia and 5.0 after general anaesthesia with cyclopropane and oxygen. These figures made differences visible, but the observational groups also differed in labour, indication, maternal risk, and other circumstances. They could generate questions about practice; they did not by themselves prove that the anaesthetic method caused every difference.
The paper's labour was collective even though it had one author. Apgar described obstetric house staff using the ratings and acknowledged nurse Rita Ruane for technical assistance with data collection, as well as H. C. Taylor Jr. for encouragement. Later studies formally brought together anaesthesia, obstetric, paediatric, laboratory, and nursing expertise.
Chronology of Adoption
Apgar presented the method at a joint anaesthetists' congress in Virginia Beach, Virginia, in September 1952. Current Researches in Anesthesia and Analgesia published the report in July–August 1953. The paper specified one score at sixty seconds, although several hundred infants had also been observed at three or five minutes.
Apgar, Duncan Holaday, L. Stanley James, Irvin Weisbrot, and Cornelia Berrien reported scores for 15,348 infants. Low scores were associated at group level with higher neonatal mortality and with blood chemistry characteristic of asphyxia. The larger study strengthened the score's research and reporting value; association still did not turn the score into a diagnosis for an individual infant (Apgar et al. 1958).
Clinicians added later observations to show change after resuscitation, and the one- and five-minute scores became standard. Reports from the twelve-institution Collaborative Perinatal Study helped extend use beyond obstetric anaesthesia into clinical records and epidemiology. In 1966, however, Apgar warned that inconsistent observers and timing weakened comparisons between hospitals (Apgar 1966; Jackson 2025).
Paediatricians Joseph Butterfield and Mervyn Covey published Appearance, Pulse, Grimace, Activity, and Respiration as an “epigram” for remembering the existing signs. APGAR is therefore a later teaching device based on Virginia Apgar's surname, not the design process that produced the score (Butterfield and Covey 1962).
Later Use and Misuse
Current American Academy of Pediatrics and American College of Obstetricians and Gynecologists guidance, reaffirmed in 2025, treats the score as a report of newborn status and response to resuscitation. The score alone neither proves birth asphyxia nor predicts an individual's mortality or neurological outcome (AAP–ACOG Committee Opinion).
Modern resuscitation begins when needed before the one-minute score is assigned; the total is not an algorithm for deciding the initial steps. Gestational age, maternal medication, congenital conditions, trauma, observer variation, and ongoing assistance can all affect the result. This page is historical context, not clinical guidance.
The scale's “completely pink” ideal centres light skin even though Apgar recognised pigmentation as a problem in 1953. A 2025 systematic review found that visual assessment of colour and cyanosis is especially inaccurate in darker-skinned newborns and that scoring practices vary by ethnicity. The review also found that very low totals remained associated with neonatal mortality across ethnic groups; criticism of one component does not make the entire historical measure worthless (Fair et al. 2025).
Historians distinguish the 1953 scoring method, designed largely to compare groups and interventions, from the later clinical and epidemiological score attached to individual records. That shift explains both the system's reach and its recurring misuse as a retrospective diagnosis or a forecast of a child's future (Jackson 2025).
Reading Path
Read the 1953 publication as a situated primary source, with its study population, period language, and acknowledged limits.
Follow Apgar's path through surgery, anaesthesiology, obstetrics, and later public-health work.
Set the score beside changing drugs, professional roles, monitoring practices, and ideas of safety.
Compare the hospital delivery room with other practitioners, birth settings, and traditions of maternal and newborn care.
Trace how a bedside observation became a recorded variable in population research and health systems.
References
Current Researches in Anesthesia & Analgesia 32, no. 4 (1953): 260–267. DOI: 10.1213/00000539-195301000-00041. Complete digitised article from the U.S. National Library of Medicine; the primary report of the five signs, 60-second timing, Sloane Hospital series, anaesthesia comparisons, resuscitation observations, acknowledged collaborators, and study limitations.
JAMA 168, no. 15 (1958): 1985–1988. The multi-department study of 15,348 infants that related score groups to neonatal mortality, obstetric and anaesthetic circumstances, and umbilical blood findings.
Pediatric Clinics of North America 13, no. 3 (1966): 645–650. DOI: 10.1016/S0031-3955(16)31874-0. Apgar's retrospective account of the 1949–1952 development period and her warnings about observers, timing, hospital comparison, and long-term follow-up.
JAMA 181, no. 4 (1962): 353. The brief primary publication of Appearance, Pulse, Grimace, Activity, and Respiration as a teaching aid for the pre-existing score.
History and Philosophy of the Life Sciences 47 (2025). A peer-reviewed history of the score's changing research, clinical, and prognostic uses, with analysis of measurement, race, institutional practice, and the Collaborative Perinatal Study.
Pediatric Research 97 (2025): 939–952. A systematic review of evidence on ethnic variation in scoring and the limits of visually assessing skin colour and cyanosis.
Committee Opinion No. 644, Obstetrics & Gynecology 126 (2015): e52–e55; reaffirmed 2025. Authoritative current guidance used only to distinguish the score from a resuscitation algorithm, a diagnosis of asphyxia, or an individual prognosis.
An institutional biographical account of Apgar's surgical training, gendered career constraints, work in the emerging specialty of anaesthesiology, Columbia appointments, and later collaborators.