What’s an Aqua APGAR?

“What’s an Aqua APGAR?”

After I wrote a blog post sharing the results of some new studies highlighting the benefits of water in labour, a few people contacted us to ask for more information on the Aqua APGAR, which was used in one of the studies to evaluate the condition of the newborn babies. So here’s a bit of history and an overview for those who would like to know more.

Midwives who attend the births of babies born in water have long been aware that there are some differences in their behaviour compared to babies born on land. In a nutshell, they are often calmer, and to some people they can seem to take a little longer to acclimatise to the change of being born. Midwives will tell you, however, that this isn’t a disadvantage, or a bad thing. Their transition to earth is often gentle, and this is one reason why some women, midwives and birth folk are big fans of water as a medium for labour and birth.

At the same time, midwives also became aware that the usual method of evaluating the condition of newborn babies – the APGAR score – wasn’t always accurately reflecting the health and calmness of babies born in water, especially in the first minute or so after birth. That is partly because the scoring system was based on the (rather reasonable at the time it was created) assumption that all babies were born on land, or into air, depending on how you look at it. It expected the healthiest babies to be vigorous, and didn’t really account for these calm but very healthy and alert babies who were being born in the water.

As Dianne Garland (2017) notes in her book on waterbirth, the physiology of the first breath in a newborn is different in water than on land, and this is partly why German midwife Cornelia Enning developed the Aqua APGAR score. (Another notable issue that Garland raised is that the one-minute APGAR score is often not done at exactly one minute, generally because people guess the time and are inaccurate. This can lead to an underestimation of APGAR scoring in a water-born baby.)

Camargo et al (2017) further explain the rationale for using the Aqua APGAR (the elements of which can be seen in detail here) in their research study, noting that, when researchers use the traditional APGAR scoring system, “they did not consider that infants born in water manifest their vitality by moving their legs and arms, opening and closing their eyes, opening and closing their mouths, and swallowing, as presented by Cornelia Enning.” Carmargo et al (2017) concluded that, “This may be a differential in our study, in the excellence of the results obtained from our Aqua APGAR results in the first minute after birth.”

Midwifery wisdom often takes years to make its way into textbooks, and this sometimes never happens. For that reason and many others, if you know of other discussions on the Aqua APGAR score, or have experience of using it yourself, I would urge you to share your experiences here so that future readers can find these too. It is in this way that we can expand our knowledge and find ways of being with women and babies which reflect the reality of different situations rather than the centralised, standardised pathways which too many people are being forced to take.


Camargo JCS, Varela V, Ferreira FM et al (2018) The Waterbirth Project: São Bernardo Hospital experience. Women and Birth, online ahead of print. DOI: http://dx.doi.org/10.1016/j.wombi.2017.12.008
Garland D (2017). Revisiting waterbirth: an attitude to care. Palgrave Macmillan.
photo credit: MabyCakes Birth! via photopin (license)

Leave a Reply