Neonatal deaths, according to the World Health Organization (WHO), are "deaths among live births within the first 28 full days of life [1]." Neonatal deaths can be further classified into two categories: Early neonatal deaths, which occur within the first seven days of life, and late neonatal deaths, that occur between days seven and twenty-eight following birth [2]. It has become essential to standardise the lifespan of a child into clearly defined ages in order to decide what care and treatments are required to improve the odds of a child's survival. The neonatal period, which is generally regarded as to start at birth and last for 28 full days of life, is considered to be the most vulnerable period of a baby's life [3].

Maternal variables, neonatal-related factors, maternal health services, and obstetrics-related factors all have an impact on early neonatal death [4]. Birth trauma, newborn hemorrhagic disease, Rhesus disease, and sudden infant death syndrome are less frequent causes [5]. The four preventable causes of early infant mortality include preterm, hypoxia, infections, and congenital defects [6].

To lower early newborn mortality, strategies have been put in place with a focus on the care packages offered during the prenatal, antenatal, intranatal, and postnatal periods. As a result, there hasn't been much progress in lowering early newborn mortality, even though it isn't satisfactory for under-five and neonatal mortality. Improved early identification of patients at risk of dying by deriving and applying early warning scores in hospitals is one of the solutions that have been put into practice to alleviate the global burden of newborn mortality [7].

Maternal and newborn characteristics are given a score in the neonatal intensive care unit (NICU) to createa composite score that identifies patients who require additional interventions and monitoring. Early infant fatalities would reduce if evidence-based procedures were   implemented   in both    high-income  and low- and middle-income countries (LMICs) [8]. Early warning scores have been shown to be helpful for both adult and paediatric patient populations in studies [9]. The Apgar score, one of the available ones, offers a recognised and practical way to report on the newborn infant's condition immediately following birth and their reaction to resuscitation, if necessary [10]. 

Birth asphyxia is a disorder that impairs gas exchange and can result in foetal hypoxemia and hypercarbia if left untreated [11]. Fetal acidity, as evaluated in umbilical arterial blood, serves as a telltale sign that it is present during the first and second stages of labour [12]. Unknown umbilical artery pH levels are indicative of hypoxia severe enough to result in brain damage, but if the imbalance persists, it can have major effects on the central nervous system, the respiratory system, the heart, and the kidneys [13]. Early newborn assessment, prediction of the neonatal problems, and quick intervention are vital to stop hypoxia from getting worse and to preserve the window of therapeutic chance for reducing its effects [14]. The oldest and most popular assessment tool for determining whether a baby needs interventions in the delivery room is the Apgar score system, which was first established in the 1950s [15]. The 5-minute Apgar score is still the most practical, useful, and reliable index for determining whether resuscitation was successful and how vital the infant was, even though it does not perfectly predict neurodevelopmental outcomes [16]. The Apgar score has a number of shortcomings that prevent it from being utilized as the only indicator of suffocation or as a predictor of unfavorable newborn outcomes [17]. The gestational age, neonatal maturity, medicines, etc. all affect the Apgar score. Additionally, the newborn's condition is not accurately assessed by the Apgar score that is given after resuscitation and intubation [18].  Another significant restriction is inter-observer variation [19]. According to certain studies, a low Apgar score alone should not be used to categorise preterm newborn children as asphyxiated [20]. In order to enable a more THOROUGH description of the neonate's postnatal status, Rüdiger et al. devised the Combined-Apgar score, which combines the Specified and Expanded Apgar scores. The scoring process takes into account CPAP, oxygen, bag and mask ventilation, intubation and ventilation, chest compression, exogenous medication administration, and surfactant treatment [21]. In a study by Hardani et al., it was found that combined Apgar scores, as opposed to standard Apgar scores, provided a better estimate of postnatal status in asphyxiated neonates [22].  However, the research populations in all of the aforementioned investigations included both term and preterm newborns. In the perinatal stage, premature neonates frequently need active interventions such as bag and mask breathing and the administration of exogenous medications like oxygen and adrenaline. Surfactant usage and the ensuing mechanical ventilation are widespread [23]. The combined Apgar score includes all of these interventions in its scoring methodology. While there was no statistically significant difference in the prognostication of convulsion and mechanical breathing, a low combined Apgar score performed better than the traditional Apgar score in predicting early infant mortality (within 7 days of life).

The Combined-Apgar score was found to be more accurate than the Conventional-Apgar in predicting bad neonatal outcomes, according to Dalili et al’s evaluation of the Combined-Apgar score in the prediction of asphyxia and early neurologic sequelae in asphyxiated newborns [24].  A depressed 5-minute Combined-Apgar score was independently linked to IVH and the need for mechanical ventilation in all hospitalised newborns and their gestational age subgroups, according to another study by Dalili et al. Additionally, they demonstrated that in very preterm, near term, and term admitted neonates, the Combined-Apgar score was more accurate at predicting negative neonatal outcomes than the Conventional-Apgar score [25]. 

Apgar score should not be used only to forecast unfavourable newborn outcomes because it has a number of limitations, including the fact that the neonate's maturity and the medical treatments made in the delivery room can affect it. Conventional-Apgar score seems to have poor reliability as an outcome measure at the present time, especially for the preterm and resuscitated neonates.

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3. Muduli J.K., Mitra M. and Banerjee A. "Comparison of conventional and combined APGAR score in predicting adverse early neurologic outcomes in term and near term babies with birth asphyxia." Ann. Int. Med. Den. Res., no. 5, 2019, pp. PE05–PE07.

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21. Rüdiger M. et al. "Neonatal assessment in the delivery room – trial to evaluate a specified type of Apgar (TEST-Apgar)." BMC Pediatr., 2015, p. 18.

22. Hardani A.K et al. "Conventional versus combined Apgar scores in neonatal asphyxia: a prospective study." Tehran Univ. Med. J., no. 10, 2015, pp. 717–722.

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24. Dalili H. et al. "Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes."PLoS One, 2015, e0122116.

25. Dalili H. et al. "Comparison of the combined versus conventional Apgar scores in predicting adverse neonatal outcomes." PLoS One, no. 2, 2016, e0149464.