EMS Recap: Apgar Scoring

There you are, in the bedroom of a brand-new mother who just delivered a full-term baby boy (7 lbs., 12 oz.) with some assistance from your partner. Your partner then hands this slick neonate to you for cleaning and scoring. Having been a bystander for the birth, you are the correct choice to determine the one- and five-minute Apgar scores. But the first thoughts rushing through your mind may be, Where is that copy of the Apgar scoring chart? and Why do we score newborns at one and five minutes?

First let’s discuss what was done before development of the Apgar score. Prior to 1949, newborn babies were assessed via pediatrician observation. This was often nothing more than noting the time that elapsed between delivery of the child and its first breath or cry.¹ It was definitely not the most scientific method of evaluating newly born babies.

In 1949, a medical student attending a breakfast meeting asked Dr. Virginia Apgar—a pediatric anesthesiologist and the first female professor at Columbia University—about properly assessing a neonate.² Apgar then proposed a scoring system for newborns that could be used to evaluate their physical condition within minutes of delivery.³ The five areas of importance were heart rate, respiratory effort, muscle tone, reflex irritability and color.^2,3 Apgar began using her scoring matrix in 1949, presented her findings in 1952 and officially published the scoring system in 1953.²

The Apgar scoring system encouraged delivery room personnel to devote more attention to neonates post-delivery.³ Her aim was to “establish a simple and clear classification of newborn infants which can be used to compare the results on obstetric practices, types of maternal pain relief and the results of resuscitation.”²

Each area assessed is assigned a value of 0, 1 or 2 points, and the score is the sum of the five areas.³ The first Apgar score is calculated one minute after birth, and the second at five minutes.³ The one-minute score is used to determine the need for resuscitation, and the five-minute score is used to predict survival and neurological development.² Apgar scores of 7 or greater are considered good to excellent, while scores of 3 or less are considered poor. The incidence of neonate death is highest among those with scores of 3 or less, regardless of gestational age.³ Low scores are often attributed to hypoxia and acidosis.²

The five-minute Apgar score has been shown to have better predictive value for survival than the one-minute score.⁴ Most infants have some degree of cyanosis of the extremities, making scores of 10 rare.⁵ Of the five areas evaluated, research suggests healthcare personnel are best able to score heart rates.⁵ Additionally, someone not directly involved in the birthing process should assess the neonate to avoid deliverer bias.⁵

Conclusion

In summary, Apgar scoring has been used to assess the condition of newborns since being developed in 1949.³ The scoring system is just as relevant today for predicting neonatal survival as it was 50 years ago.³ Apgar scoring is subjective, simple, rapid and does not require extensive training or the use of special equipment.¹ The goal of Apgar scoring is to make certain infants are systematically assessed for needed immediate care at birth; predicting long-term outcomes was not originally considered.⁵ Neonates with five-minute Apgar scores of 3 or less have the highest incidence of death, regardless of gestational age.³

References

1. Scanlon JW. How is the baby?: The Apgar score revisited. Clin Pediatr (Phila) 12(2): 61–3, Feb 1973.

2. Pearce JM. Virginia Apgar (1909–1974): Neurological evaluation of the newborn infant. Eur Neurol 54(3): 132–4, 2005.

3. Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 344(7):4 67–71, Feb 15, 2001.

4. Mori R, Shiraishi J, Negishi H, Fujimura M. Predictive value of Apgar score in infants with very low birth weight. Acta Paediatr 97(6): 720–3, Jun 2008.

5. Montgomery KS. Apgar scores: Examining the long-term significance. J Perinat Educ 9(3): 5–9, Summer 2000.

Robert E. Sippel, MS, MAEd, NREMT-P, LP, is an assistant professor and clinical coordinator in the Emergency Health Sciences Department at the University of Texas Health Science Center, San Antonio.