Virginia Apgar, her name is chanted every time a new baby is born in the delivery room. Through a scoring system that takes its name after her, the APGAR score, every newborn is evaluated for its response to life out of the uterus. At a time when newborns were essentially ignored in the delivery room, it was this lady anesthesiologist’s brilliant idea to bring together a scoring system that was simple yet powerful in its ability to predict survival outcomes in a neonate.
Virginia Apgar used to carry resuscitative equipment with her at all times in case she encountered an emergency.
Google doodles celebrated Dr. Virginia Apgar's 109th Birthday in June 2018
Nobody, but nobody, is going to stop breathing on me.Dr. Virginia Apgar
Apgar score is a 10-point scoring system that evaluates observable features in a newborn to give an idea of the infant’s general well-being. It is very easy to watch and learn and hence is mostly determined by the nurses in the delivery room while the doctors are busy with the mother. It includes 5 features, namely:
· Appearance of the baby
· Pulse
· Grimace (response to pinching/stimulating)
· Activity
· Respiration (a strong cry being the highest score).
It has stood the test of time and has become a standard for newborn care in every hospital.
APGAR score is calculated at 1 minute and 5 minutes after birth. Out of a score of 10, 7 and above is considered normal, 4-6 requires monitoring, and a score <3 warrants the need for immediate resuscitation. But APGAR cannot be the exclusive deciding factor for initiating resuscitation; the final call rests on the physician. For instance, the decision to start resuscitation should be made within the first 1 minute of birth. Also, a score of 10 is mostly not seen as all newborn babies have some amount of cyanosis (bluish discoloration of the skin) at birth. In this regard, APGAR serves as a better tool for evaluating the infants' response to any resuscitation received over time.
American Academy of Pediatrics in its policy statement on the Apgar score stated that: “ The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose.” ACOG also reaffirmed the same in 2021.Dr Munish Raizada , Board certified neonatologist, Chicago, IL, USA
The clinical efficacy of the score was proven at the time it was first explained, through blood tests of neonates with low scores. Blood analysis showed the presence of acidosis in these neonates which occurs due to hypoxia, that is, low levels of oxygen in the blood, at and around the time of birth. And even though a low score at the first minute does not essentially indicate a poor outcome, a low score at 5 minutes can indicate a risk of brain damage leading to conditions like Cerebral Palsy. Apgar scores can also vary from case to case. It is lower than average in premature babies and can depend on factors like medications taken by the mother, drugs or anesthesia given to her, birth defects in the baby, and so on.
However, considering the test to be rather subjective, studies were conducted to see how individual physicians would score the same child and it was found that inter-physician consistency ranged from 55% to 82% with reporting of heart rate having the best rate of consistency at 82% for the 1-minute scores. Among various healthcare disciplines, pediatricians showed the most consistent scoring while community nurses came last. Studies have also shown that Apgar scores cannot be used to predict long-term outcomes in neonates with poor scores.
Even with these shortcomings, the Apgar score remains to be the favorite tool for the systematic evaluation of a baby in need of immediate attention at birth and also for the pediatrician's knowledge of the baby's first few hours of life. Apgar scores are complemented by blood gas analysis and monitoring of vitals. Future directions should be aimed at attaining uniformity among workers of various health disciplines regarding reporting of Apgar score.
SOURCES:
Simon LV, Hashmi MF, Bragg BN. APGAR Score. [Updated 2022 Aug 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470569/
Calmes, Selma H. MD. Dr. Virginia Apgar and the Apgar Score: How the Apgar Score Came to Be. Anesthesia & Analgesia 120(5):p 1060-1064, May 2015. | DOI: 10.1213/ANE.0000000000000659
https://profiles.nlm.nih.gov/spotlight/cp/feature/biographical-overview
Montgomery KS. Apgar Scores: Examining the Long-term Significance. J Perinat Educ. 2000 Summer;9(3):5-9. doi: 10.1624/105812400X87716. PMID: 17273212; PMCID: PMC1595023.