A score for condition at birth
Virginia Apgar introduced her system for scoring the
condition of the newborn in 1953, noting that when
mothers receive an excessive amount of depressant
drugs during labor, it is common for an infant to
breathe once, but then become apneic for many
minutes. “A satisfactory cry is sometimes not
established even when the infant leaves the delivery
room ”
We need to ask why the umbilical cord should ever be
cut before a satisfactory cry is established. What was
the justification for abandoning the traditional
teaching that breathing must be clearly established
before ligation of the cord?
In 1958, Apgar (and her colleagues) wrote that
scoring at one minute was done because
this represented the time of most severe depression:
"In the Sloane Hospital the cord has been cut by
this time, and the infant is in the hands of an
individual other than the obstetrician. In many
hospitals, such is not the case. Those
obstetricians who practice slow delivery and
delayed clamping of the cord until pulsations of
the umbilical artery cease still have the infant in
the sterile field. However, if the obstetrician is
reminded of the passage of time by another
observer, he may assign a score even though
the cord is still attached," [Apgar et al.1958, p
1987]
Thus the Apgar score devised over 50 years ago
reflected the perceived need to remove
the newborn from the "sterile field" for repair of the
episiotomy, manage delivery of the placenta, and to
give the infant to neonatal specialists, often for
resuscitation.
Apgar et al. also wrote in the 1958 paper:
“All infants with a score of 8, 9,or 10 are vigorous
and have breathed within seconds of delivery. In
this group, scores of 8 or 9 reflect a lower score
for color. The infants with a score of 4 or less
are blue and limp and have failed to establish
respiration by one minute.” p 1987
The Apgar score is all about how well a newborn
establishes respiration. In contrast to the opinion
expressed by White in 1773, Apgar and her colleages
expected that the transition from fetal to neonatal
respiration should take place within seconds of
delivery.
If failure to breathe persists for five minutes, the
outcome is well recognized as ominous.
Apgar et al. (1958) pointed out that many
obstetricians at that time still practiced "slow delivery,"
waiting for pulsations of the cord to cease, and they
suggested that a score could still be assigned,
obtaining the heart-rate of the infant by palpating the
umbilical cord.
- Apgar V (1953) A proposal for a new method of evaluation of the newborn
infant. Current Researches in Anesthesia and Analgesia 32:260-267.
Online at: http://apgar.net/virginia/Apgar_Paper.html
- Apgar V, Holaday DA, James LS, Weisbrot IM. Evaluation of the newborn
infant – second report. JAMA 1958; 168(15):1985-9.
- Apgar V (1953) A proposal for
a new method of evaluation of
the newborn infant.
- Apgar V et al. (1958)
Evaluation of the newborn
infant – second report.