In dogs, perinatal mortality is relatively high, and deaths peak around birth and during the first week of age. Among the several causes, the long process of whelping plays an important role in canine perinatal mortality. Therefore, also in dogs the early neonatal assistance to puppies is mandatory. However, in comparison to humans, knowledge and technological ability in dog neonatology are tremendously scarce. The Apgar score for the newborn viability assessment at birth represent a feasible method for the prompt recognition of newborns that needs special assistance immediately after birth. The five parameters Apgar score, adapted to the canine specie by different studies, advantages and limits, as well as clinical application are presented and discussed

M. C. Veronesi

AIR Universita degli studi di Milano

Assessment of neonatal viability - the Apgar score 
Maria Cristina Veronesi  
Department of Health, Animal Science and Food Safety  
Università degli Studi di Milano, Italy; maria.veronesi@unimi.it 
 
Summary  
In dogs, perinatal mortality is relatively high, and deaths peak around birth and during the first week 
of age. Among the several causes, the long process of whelping plays an important role in canine 
perinatal mortality. Therefore, also in dogs the early neonatal assistance to puppies is mandatory. 
However, in comparison to humans, knowledge and technological ability in dog neonatology are 
tremendously scarce. The Apgar score for the newborn viability assessment at birth represent a 
feasible method for the prompt recognition of newborns that needs special assistance immediately 
after birth. The five parameters Apgar score, adapted to the canine specie by different studies, 
advantages and limits, as well as clinical application are presented and discussed. 
 
Text 
In mammals, the reproductive process is considered successful when a pregnant female gives birth 
to a live and viable offspring, at the end of a normal-course pregnancy. The majority of offspring 
losses can be addressed to the mortality occurring during the perinatal period. In dogs, perinatal 
mortality is considered as the sum of deaths related to stillborn, plus the puppies dead within the 
neonatal period. Canine perinatal mortality is relatively high, reaching values up to 40%, and deaths 
peak around birth and during the first week of age. Among the several causes responsible for a such 
high perinatal deaths percentage, the birth process plays an important role. In dogs, indeed, the 
process of parturition is relatively long, even under physiological conditions, and it could became 
even longer in case of dystocia. Thus, fetal asphyxia is thought to be one of the most common cause 
of perinatal puppies death. As in other mammals, the process of birth is challenging, and the first 
minutes after birth are the most life-threatening, and the quality of the first few minutes after birth 
has pivotal and long-term consequences on newborn’s life. Therefore, the assistance and care to 
each single newborn is mandatory, also in veterinary medicine, similarly to human medicine. 
In comparison to humans, knowledge and technological ability in dog neonatology are 
tremendously scarce. This can be due to the difficult to obtain biological samples for analysis, 
easily performed in human neonates, such as blood sampling, but also to adapt to the different 
general practices of veterinary assistance in comparison to humans hospitals. Moreover, the paucity 
of knowledge about dogs and cats neonatal physiologic features makes difficult to recognized 
newborns who need assistance. 
The transition from the fetal to the neonatal life involves an efficient multi-systemic adaptation 
process of the organism. The most critical change is related to the beginning of respiration that 
influences the early survival of the neonate. Breathing is the key function for the immediate 
neonatal survival. When the fetus is mature and read for birth, the passage through the birth canal, 
the blood oxygen to nitric oxide ratio, and the umbilical cord detachment, are the first stimuli to 
start the first breath. Consequently to the first breath, the lung inflate, and a number of changes 
concerning the respiratory and circulatory systems occur. As a consequence, a cascade of 
physiological changes leading to the first hours neonatal adaptation, is necessary for fetal-to-
neonatal viability and survival.  
The neonatal viability, that is the potential of the neonate to survive outside the uterus after birth, 
depends largely on fetal organ maturity, but also on environmental conditions and neonatal care. In 
addition, in comparison to human neonates or foals, calves or piglets, puppies and kitten are largely 
immature at birth, making them extremely vulnerable. Moreover, differently to humans, in most 
instances dogs and cats give birth under field conditions and only rarely in veterinary facilities, so 
that the techniques for neonatal evaluation and assistance should be adapted to every kind of 
environmental condition.  
The veterinarian assistance to the parturient bitch is recently highly requested from both pet-owners 
and especially from breeders, because of the high economic values of dams and litters. The survival 
of a number as much higher as possible of newborns is therefore wanted not only from an ethical 
perspective, but also from an economic point of view. 
The prerequisite for a prompt recognition of newborns that needs special assistance immediately 
after birth, is the availability of a simple method for newborn viability assessment. 
Since the 50s, the Apgar score proposed by Virginia Apgar for the quick assessment of neonatal 
viability in humans, was widely used all over the world, and still remains the most suitable method 
for the viability assessment and short-term survival prognosis in babies.  
In humans the Apgar score encompasses five parameters, easy to assess, for the clinical evaluation 
of the infant soon after birth, usually within 1 minute after birth and again at 5 minutes after birth, 
and may be repeated later for newborns with low scores. These five parameters are resumed in an 
acronym built on the surname of its creator, so that APGAR recall easily the initials of the five 
parameters to be assessed: A, as appearance, P as pulse, G as grimace, A as attitude, R as 
respiration. To each one of these parameters a score ranging from zero to two is assigned, for a total 
sum ranging between zero and ten. On the base of the final sum, three classes of neonatal viability 
were defined: when the score is less than 3 the neonatal condition is considered as critical and the 
newborn need medical assistance; when the score is between 4 and 6 the condition of the neonate is 
considered as low, and the newborn should be supervised or submitted to medical assistance; when 
the score is 7 to 10 the newborn clinical condition is normal, and the neonate need only routine care. 
Because of its feasibility, the Apgar score was thereafter introduced also in veterinary medicine, and 
after adaptation according to the specific physiologic features, used for the neonatal evaluation of 
foals, calves and piglets, whereas in the dog, the Apgar score was not widely used until recently. 
However, thanks to its feasibility of execution and the limited use of instruments (only a 
stethoscope), this method appears to be useful for the neonatal evaluation under every clinical 
condition also in dogs.  
In 2009, Veronesi and co-authors proposed an Apgar score adapted for the neonatal viability 
assessment in dogs. Appearance was assessed by the evaluation of the mucous membranes color as 
follows: pink rated as 2, pale rated as 1 and cyanotic rated as zero. Pulse, referring to heart rate, was 
rated as 2 when it was > 220 beats per minute (bpm), rated as 1 when it was between 180 and 220 
bpm, and rated as zero when it was < 180 bpm. Grimace, indicating the reaction of the neonate to 
irritability, was assessed by the gentle compression of the tip of a paw, and evaluating the puppies 
reaction: rated as 2 when the puppy reacted with crying and quick leg retraction, rated as 1 when the 
leg was weakly retracted in association to weak or none vocalization, and rated as zero when no leg 
retraction and no vocalization were stimulated. Attitude was evaluated by neonatal motion as 
follows: rated as 2 when strength spontaneous movements of the neonate were observed, rated as1 
when mild movement were detected and rated as zero for the absent attempt of neonatal 
movements. Respiration was assessed taking in consideration both respiratory rate (rr) and 
vocalizations: respiratory efforts were rated as 2 when clear crying was associated to >15 rr, rated 
as 1 when mild crying was associated to 6-15 rr, rated as zero when no crying was associated to <6 
rr. Similarly to the classification used for humans, on the base of the final sum, also for the newborn 
puppies, three neonatal classes of viability were identified: 0 to 3, newborns with severe distress; 4 
to 6, newborns with moderate distress; 7 to 10, normal newborns with no distress. The Apgar score 
was highly positively correlated to puppies survival at 2 and at 24 hours after birth. The viability 
assessment allowed the recognition of puppies with Apgar score less than 7, requiring different 
degree of assistance. Three out of seven (43%) of severely depressed puppies recovered and 88% of 
moderately depressed puppies recovered after neonatal care. Apgar score was also positively 
associated to mammary gland searching and suckling/swallowing reflexes, other parameters 
indicative of newborn dogs vigour. In the same year, other two studies (Silva et al, 2009; Lucio et 
al, 2009) reported the use of an Apgar score in the evaluation of canine neonatal viability at birth, 
and 5 and 60 minutes after delivery, but no details about the method of evaluation or reference were 
reported. Silva et al (2009) found lower Apgar score at birth and at 5 minutes after birth in puppies 
born from cesarean section compared to vaginal delivery. Lucio et al (2009) evaluated the Apgar 
score associated to acid-base parameters in newborn puppies born at normal parturition, after 
obstetrical assistance or cesarean section, and born following oxytocin administration. The authors 
reported a low Apgar score in all the pups at birth, associated to a mixed acidosis; the Apgar score 
improved in all newborns after 5 minutes of birth, and carbon dioxide tension, base excess and 
venous blood pH improved at 60 minutes after birth, although a metabolic acidosis persisted. 
Subsequently, other authors focussed on the clinical application of the Apgar score for neonatal 
viability assessment, even with some modifications. 
The same protocol proposed by Veronesi et al (2009) was subsequently used to evaluate the effect 
of two different drugs for induction of anesthesia during emergency cesarean section in dogs by 
Doebeli et al (2013). The neonatal vitality, assessed by Apgar score at 5, 15 and 60 minutes after 
delivery was significantly higher when induction of anesthesia was obtained with alfaxalone as 
compared to anesthesia obtained with propofol, while the proportion of surviving puppies 60 
minutes after delivery was not different between the two groups. The authors concluded that the 
Apgar score was very suitable for assessing neonatal vitality in puppies, and reported the usefulness 
of repeated evaluations during the first hour of life to assess individual improvement. Moreover, the 
impact of different drugs used for induction of anesthesia in dogs submitted to emergency cesarean 
section on neonatal viability, was reported. 
Recently, Batista et al (2014) used the same Apgar score proposed by Veronesi et al (2009), with 
some modifications adapted to brachycephalic dog breeds (English and French Bulldog) for the 
clinical evaluation of puppies delivered by elective cesarean section at 5 and 60 minutes after birth. 
The slight variations included a lower heart rate considered as normal: >180 bpm rated as 2, 
between 120 and 180 bpm rated as 1, and < 120 bpm was rated as zero. Respiration was evaluated 
considering only the respiratory rate, and the mucous membrane color was rated as 2 when reddish, 
rated as 1 when pink and rated as zero when cyanotic or pale. The authors reported a 24 hours 
survival rate close to 100% in puppies with Apgar score ≥ 4, while neonatal mortality resulted 
concentrated in puppies with low Apgar score (0-3). The authors reported also the utility of the 
Apgar score to recognize neonates requiring immediate care and to choose the more appropriate 
resuscitation procedure intensity in relation to the degree of puppies viability. Moreover, the 
repetition of Apgar score at 60 minutes after delivery allowed to evaluate the improvement of the 
individual viability after intensive care 
In another study (Groppetti et al, 2010) a different Apgar score was used, considering seven 
parameters and was associated to the umbilical blood lactate assessment for newborn puppies 
viability evaluation. The authors reported a close relationship between the Apgar score and 
umbilical blood lactate, but no relation was found between Apgar score and neonatal survival at 48 
hours after birth. 
None of the studies performed on dogs evaluated the relation between Apgar score at birth and 
long-term survival or neurologic outcome in survivors. However, several studies in humans 
demonstrated that the Apgar score is neither suitable for long-term neonatal survival prognosis nor 
for long-term neurological or mental impairment. 
In conclusion, all the studies demonstrated the suitability of the Apgar score in the neonatal viability 
assessment immediately after birth and in the first hours of life. The value of the Apgar score to 
predict the short-term survival remains to be clarified, even if in two studies a close relationship 
between high Apgar score and survival at 24 hours after birth, was found. Although there is no 
guarantee that all puppies showing high Apgar score will surely survive, survival is more likely in 
pups with high Apgar score. The type of delivery has a significant impact on Apgar score, as well as 
the type of drug used for induction of anesthesia. However, for these last two parameters it is 
necessary to underline some considerations. Firstly, it is difficult to compare results according to the 
type of birth, because of the different protocols for anesthesia and for the surgical procedures used 
in case of elective cesarean section in the different studies. Secondly, in the studies performed on 
litters born by emergency cesarean section, many variables can had affected the neonatal viability, 
so that it is impossible to consider only the effect played by the type of parturition. 
Further studies are required in order to define possible, if any, other breed-specific different 
parameters for Apgar score neonatal viability assessment in dogs and to better understand the effect 
of type of birth and possible influence of different anesthetic and surgical protocols used in case of 
elective cesarean section, while in litters delivered after emergency cesarean section, all the 
variables that could affect the neonatal viability should be taken in consideration. 
References 
Veronesi MC, Panzani S, Faustini M, Rota A. An Apgar score system for routine assessment of 
newborn puppy viability and short-term survival prognosis. Theriogenology, 2009, 72: 401-407. 
Silva LCG, Lucio CF, Veiga GAL, Rodrigues JA, Vannucchi CI. Neonatal clinical evaluation, 
blood gas and radiographic assessment after normal birth, vaginal dystocia or caesaeran section in 
dogs. Reprod Dom Anim 2009, 44(2): 160-163. 
Lucio CF, Silva LCG, Rodrigues JA, Veiga GAL; Vannucchi CI. Acid-base changes in canine 
neonates following normal birth or dystocia. Reprod Dom Anim 2009, 44(2): 208-210. 
Doebeli A, Michel E, Bettschart R, Hartnack S, Reichler IM. Apgar score after induction of 
anesthesia for canine caesarean section with alfaxalone versus propofol. Theriogenology 2013, 80: 
850-854. 
Batista M, Moreno C, Vilar J, Golding M, Brito C, Santana M, Alamo D. Neonatal viability 
evaluation by Apgar score in puppies delivered by cesarean section in two brachycephalic breeds 
(English and French bulldog). Anim Reprod Sci 2014, 146: 218-226. 
Groppetti D, Pecile A, Del Carro AP, Copley K, Minero M, Cremonesi F. Evaluation of newborn 
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Assessment of neonatal viability : the Apgar score

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Assessment of neonatal viability : the Apgar score

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