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Apgar: The Newborn Score

Lacking a standardized test to assess a baby’s health at birth, anesthesiologist Virginia Apgar created a simple rubric that persists more than a half century later.

Spring 2012
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Elizabeth “Libby” Wilcox, Courtesy of Columbia University College of Physicians & Surgeons

Sixty years ago, Virginia Apgar confessed her disappointment to the annual Congress of Anesthetists meeting. “Seldom,” she said, “have there been such imaginative ideas, such enthusiasms and dislikes, and such unscientific observations and study about one clinical picture” as of the newborn in crisis. Doctors and nurses who delivered babies lacked a common language to decide whether a newborn would require more than routine medical care.

Apgar’s solution was a numerical scale that could predict which babies were likely to thrive and which needed immediate resuscitation. The following year, she published her scoring system in Current Researches in Anesthesia and Analgesia, revolutionizing neonatal care the world over. Virtually every baby born in a hospital today undergoes the Apgar test. The simple checklist assesses five physiological categories: heart rate; breathing; reflexes, particularly to irritating stimuli like a bulb syringe in the mouth to clear the airways; muscle tone and movement; and color (babies are born bluish but should turn pink as their heart pumps blood through their body). The score later was acronymized to APGAR: Appearance, Pulse, Grimace, Activity, Respiration.

For each of the five categories, a score of 0, 1 or 2 is possible, allowing for a maximum score of 10. Babies who receive a total score of three or less are in serious trouble; most newborns scoring in this range have high levels of acid in their blood, a condition that can lead to brain damage or death. Mechanical ventilation or even life support might be required.

“In the past, attention was concentrated on the mother’s survival,” says Linda Polley, a past president of the Society for Obstetric Anesthesia and Perinatology. “Apgar’s system focused attention on the condition of the newborn.”

Born in 1909, Apgar entered the emerging field of anesthesiology in the 1930s at a time when it was still largely the domain of nurses and male physicians. In 1937 she accepted a position at Columbia University’s Presbyterian Hospital to lead the new division of anesthesia.

An idea as effective yet simple as the Apgar score was destined to gain traction beyond the labor and delivery unit. A recent study in the journal Anesthesiology, for example, found that a modified Apgar score predicted mortality for patients undergoing most types of operations. In other words, a patient undergoing surgery might well owe a double debt to Apgar’s insight. Apgar is reported to have declared: “Nobody, but nobody, is going to stop breathing on me.”

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