The Newborn (Apgar) Scoring System

Reflections and Advice

VIRGINIA APGAR, M.D.

   Almost two decades ago the need was felt for a way to judge
the condition of a newborn baby quickly and accurately shortly after
birth. In 1949 the criteria in use were `breathing time" and "crying time."
As a result of the frequent use of heavy medication during labor and
of general anesthesia for delivery, an initial gasp, a period of apnea and
finally established respiration were common. Should `breathing time"
be recorded as the first gasp, or respiration which followed the period
of apnea? Also, infants who had undergone more than usual birth
asphyxia, or who had anomalies of the central nervous system, often did
not cry at all. What, then, was the crying time?

Between 1949 and 1952 several signs easily observed in the new-
born were considered. Five were chosen which could be evaluated with-
out special equipment and could be taught to the delivery room per-
sonnel without difficulty.
The original intention of establishing a scoring system was to pre-
dict survival, to compare several methods of resuscitation which were
in use at the time, and through the infant's responsiveness after delivery,
to compare perinatal experience in different hospitals. The influence
of various obstetrical practices such as induction of labor, elective ce-
sarean section and maternal anesthesia and analgesia might well be
reflected in the score. It was furthermore hoped that the scoring system
would ensure closer observation of the infant during the fmt minute of
life. The value of the system for neonatal research and for predicting
neuromuscular deficit in early childhood was demonstrated later.
The system is working well in identifying infants who have severe
metabolic imbalance. It is not working well as a baseline for future
follow-up studies. There are two reasons for this inadequacy.
1. After receiving reports from many hospitals and visiting many
personally, experience has demonstrated that the person deliver-
ing the infant should not be the one to assign the score. He or she is
invariably emotionally involved with the outcome of the delivery and

645

646 VIRGINIA APGAR

Table 1.

The Collaborative Study on Cerebral Palsy, Mental Retardation and

Other Neurologic and Sensory Disorders of Infancy and Childhood

SCORE

ONE-MINWTX APOAR SCOW

27,176 SINCLE BIRTHS

TOTAL 1 2 3 4 5 6 7 8 9 10 11 12

0 ................  0.1   0.1   0.2  0.3  0.1   0.1  0.1  0.1  0.1  0.4  0.1  0.0  0.0
1. ..............  1.8  2.3  0.9  0.8  2.2  2.1   1.6  0.9  1.2  1.8  1.8  4.6  0.6
2 ................  2.0  2.2  1.7  2.4  3.2  1.8  2.0  1.6  1.4  2.1   2.1   2.1   1.0
3 ...........  2 2  2.8  2.5  1.9  2.4  1.8  1.6  1.0  2.3  2.1   2.3  2.3  1.6
4 ................  2.8  3.2  3.4  1.8  3.6  2.1  2.8  1.9  2.7  3.3  2.7  3.5  1.8
5 .............  4.5  5.0  4.3  3.9  7.4  4.6  5.1  4.5  3.7  5.4  3.6  7.0  2.3
6 ............  6.5  7.1   6.3  8.3  8.9  6.2  5.6  6.7  6.1   8.3  5.3  7.0  4.2
7... ...........  8.7  8.6  15.8  5.1  16.7  8.1   5.5  10.9  7.1  12.3  8.9  7.4  4.6
8 ...........   20.8  27.2  34.9  6.8  33.9  16.9  10.4  27.3  14.8  20.8  21.3  12.8  11.2
9 ............... 40.5  40 0  28.6  46.2  18.5  34.9  45.8  40.9  41.5  35.1  47.8  46.9  41.6

10 ................. 8.2 1.3 1.1 21.8 2.9 4.0 19.4 0.6 19.2 3.8 4.1 6.5 31.1

FIVE-MINUTE APGAR SCORES

27.176 JINCI.E BIRTHS

0 .................  0.0  0 0  0.0  0.0  0.1   0.0  0.0
1 ...............  0.6  0.5  0.5  0.2  0.0  0.9  0.6
2 ...........  0 5  0.4  0.2  0.9  0.1   0.3  0.6
3 ..............  0.6  0.6  0.5  0.6  0.5  0.9  0.5
4 .........  0.6  0.5  0.2  0.7  0.5   1.0  0.8
5 ................  0.9  0.7  0.6  0.9  2.2  1.5  0.5
6.. .............  1.7   1.3  1.4  2.6  2.7  2.4  1.1
7 .............  2.5  2.8  2.8  2.0  3.6  3.2  1.4
8 ................  8.3  10.1  11.2  2.3  20.7  9.7  2.2

10 ................. 29.7 6.3 14.1 48.4 29.6 17.7 74.7

9 ................ 54.3 76.8 68.6 41.4 39.7 61.9 17.5

0.1   0.1   0.1   0.0  0.0  0.0
0.4  0.5   1.4  0.7   1.7  0.4
0.5  0.2  1.0  0.7   1.2  0.2
0.2  0.2  0.5  0.7  1.0  0.4
0.3  0.8  0.5  0.8  0.7  0.5
0.4  0.8  1.4  0.9  2.5  0.8
0.9  1.6  2.8  1.8  3.0  1.4
3.0  1.7  4.2  2.5  3.2  0.9
8.7  3.8  8.5  9.7  2.7  2.8

74.4  13.1  61.0  51.5  56.6  34.2
10.5  77.2  18.1  30.8  27.3  58.4

with the family, and cannot or unconsciously does not make an accurate
decision as to the total score. I know of no reliable study which com-
pared scores given by various delivery room personnel, but my impres-
sion is strong that obstetricians give higher scores than anesthesiologists,
nurse anesthetists, pediatricians or delivery room nurses. A number have
claimed "never to have had a baby with a score less than 5." The data
from Finland1 in Figure 2 show an incidence of score 10 in 83 per cent
of births! These scores were assigned by the midwife delivering the baby.
In 27,176 infants who are part of the Collaborative Study for Neuro-
muscular Deficit being conducted by the National Instikute of Neuro-
logical Diseases and Blindness of the National Institutes of Health,7
score 10 ranged from 0.6 to 31.1 per cent in 13 hospitals. In almost all
cases specially trained personnel, not the obstetrician, decided on the
score (Table 1).
It is ideal to have a specially trained observer, whether physician or
nurse, but this happy situation is seldom practical. Until such time when
a pediatrically oriented person is routinely present for all deliveries, the
anesthesiologist or anesthetist is in a good position to ass'ign the score,
especially if the infant is placed in a bassinet near the head of the de-
livery table. With regional anesthesia he is entirely free to make the
necessary observations, and with general anesthesia the mother should
be nearly awake or at least light enough so that protective reflexes have
returned.

NEWBORN (APGAR) SCORING SYSTEM 647

More and more the ability and accuracy of observations of the cir-
culating nurse are coming to be appreciated. She usually has considera-
bly more experience with delivery room crises and discipline than an
intern or resident and is often the only other person present in addition
to the obstetrician. Her services should be encouraged. The only draw-
back is her multiplicity of duties at the time of delivery. This leads to
&e second point which needs clarification.
2. The time to assign the score was and still is 60 seconds after
birth. This interval was chosen in 1952 after observing several hundred
infants for the time of maximum clinical depression. Thirty-, 60-, 90-
and 120-second observations were made with two observers, who agreed
&at 60 seconds after both the top of the head and bottoms of the feet
were visible was the time to apply the score.2 Serial measurements of
&e infant's arterial acid-base state during the first minutes of life show
&at maximal acidosis is present several minutes later than 60 seconds6
The importance of the one-minute score cannot be overestimated, how-
ever, from the point of view of assisted ventilation.
There should be some automatic way to announce the passage of
60 seconds. Only clinicians in anesthesia have learned to live by the
second hand of a watch. To others, a minute is an unbelievably short
interval. On some occasions, such as cardiac arrest, it is a very long
interval. A simple automatic timer should be firmly fixed on the wall,
set for 60 seconds. Fifty-five seconds would be preferable, for observa-
tion of the five signs should take no longer than five seconds. A one-
minute timer is less expensive, however, and more available (e.g. from
General Electric Company).
  When the head and feet of the infant are both visible, the timer is
started and can be forgotten until the alarm sounds, whereupon the score
is assigned. The circulating nurse can add this brief chore to her list of
duties without difficulty. This method has worked well in several
hospitals.
One misconception has arisen which is easy to correct. In some
clinics no active resuscitation is done until after the score has been
assigned at one minute. This is, of course, wrong. It has been demon-
strated that pH can drop from 7.4 to 6.9 in less than five minutes6 Time
is of great importance in preventing or reversing such a sharp change.
With infants known to be suffering from unusual asphyxia due to such
complications as prolapse of the cord, impacted shoulders or a large
breech presentation, resuscitation should begin just as soon as a free air-
way has been assured. Saling'ss intrapartum method of sampling scalp
blood should aid greatly in identifying such babies. The first score is
decided at 60 seconds, even though resuscitation has been in progress.

The score at one minute does not reflect oxygenation itself.6.9 It is
rather a reflection of acid-base status. Obviously, samples should be
drawn from the umbilical artery rather than the vein, to judge the con-

648 VIRGINIA APGAR
dition of the infant. Umbilical venous blood reflects the state of placental
exchange, not the infant's arterial blood.

Recently it has been demonstrated that the five-minute score is more
predictive of survival than the one-minute score? This is not surprising,
for it is to be expected that the longer asphyxia exists, the more likely
that death or permanent damage will occur. A comparison of infants
with one- and five-minute readings with respect to their neurologic
abnormalities at one year of age also shows significantly more predictive
value of the five-minute score.7 Nevertheless, if the first observation is
made as late as five minutes, an appreciable number of infants will have
their asphyxia untreated because of lack of an earlier observation, with
subsequent higher mortality and morbidity. A study of those infants
with low five-minute scores in relation to what treatment, if any, was
administered would be of interest.
  The distribution of scores from 12 institutions in the Collaborative
Project at five minutes (Table 1) again indicates extensive differences
between the various centers. These might be a reflection of differences
in obstetric practice or in maternal analgesia or anesthesia among insti-
tutions; it could also be due to variations in the application of the scoring
system. In comparing the details of score distribution and neonatal
deaths in three institutions, Sloane Hospital for Women, University
Hospital at Puerto Rico and the University Hospital at Helsinki, con-
siderable differences are again demonstrated (Figs. 1, 2). Even within
one institution there have been changes over several years (Fig. 3).
Yet when the score distributions are grouped 0 to 3, 4 to 6, 7 to 10,
the differences become negligible (Fig. 3, lower).

"b. 0 1 2 3 I. 4 5 I b - 7 8 9 10

157733 15 13 18 3

12 13 12 19

SLOANE

111111. 0 12 3 4 5 b 7 8 910

69 Dea!hs/5000 Live B~rtlis

WINNIPEG

-

01

L 4 5 b 78 910

00233372529

FINLAND

Figure 1.

Neonatal deaths by score.

1

I

I. 11

0 1 2 3 4 5 6 7 8 910 0 1 2 3 4 5 6 7 2

71 601 850 1720 64303728  2 40 36 132 501 94
535 843 1127 2929 8881    46 22 50 175 1975

SLOANE PUERTO RlCO

d 0123456789

SLOANE HOSPITAL FOR WOMEN

0 2 9 31 96 1626

0

Figure 2.

Distribution of scores, all births.

012345678910 012345678.

1960

1952 - 1959

27,715

21.968

3 797

L

10

649

5 10 48 120

FINLAND

01 2 3 456 7

1964

3.872

I
10

1952-1959 1960

Figure 3.

Variation in scores in the same hospital.

1964

650 VIRGINIA APGAR

These differences might indeed be real. Nevertheless, unless inter-
pretation of the clinical signs and the time at which the score is given
are standard for all institutions, conclusions will not be valid. This be-
comes even more important when the scoring system is being used for
correlations with subsequent neurologic development.

SUMMARY

It is strongly advised that an observer, other than the person who
delivers the infant, be the one to assign the score.
An automatic method of announcing the passing of 60 seconds is
recommended.

AIthough mortality and the presence of signscant neurologic dam-
age correlate better with the five-minute than the one-minute score, the
one-minute score should nevertheless be retained. It is essential to
observe the infant from the moment of birth in order that prompt treat-
ment can be given if necessary. Nine months' observation of the mother
surely warrants one-minute observation of the baby.

ACKNOWLEDGMENTS

  Grateful acknowledgment is made to the following for their assistance: Dr. Heinz
Berendes, Dr. Marguerite Gates, Dr. Margaret Giannini, Dr. Helen Rodriques de Curet,
Dr. N. J. Briggs, Dr. Louis Salerno, Mrs. Thomas Mulvahill and Miss Martha Baker.

REFERENCES

1. Ahvenainen, E. K., and Verstola, T.: Evaluation of the Newborn Infant. Ann.
  Pad. Fenn., 5:27, Fasc. 1,1959.
2. Apgar, V.: A Proposal for a New Method of Evaluation of the Newborn Infant.
  Anesth. 6 Anal., 32:260,1953.
3. Apgar, V., and James, L. S.: Further Observations on the Newborn Scoring System.
  Am. J. Dis. Child., 104:419, 1962.

4. Chase, C. L., and Greenberg, B. G.: Diagnostic and Prognostic Value of the Apgar
  Index and Its Components. Am. Public Health Assn., October 20,1965, Chicago.
5. James, L. S.: Acidosis of the Newborn and Its Relation to Birth Asphyxia. Bull.

  Sloane Hosp. for Women, Vol. V, No. 4, 1959.
6. Idem: The Effect of Pain Relief for Labor and Delivery on the Fetus and Newborn.
  Anesthesiology, 21 :405, 1960.

7. NINDB Collaborative Study on Cerebral Palsy, Mental Retardation and Other
  Neurological and Sensory Disorders of Infancy and Childhood: Unpublished
   data.

8. Saling, E. : Mikroblutuntersuchungen am Feten:  klinischer Einsatz und erste
  Ergebnisse. Ztschr. f. Geburtshilfe u. Gyniik., 162:56, 1964.
9. Stenger, V., and others: A Study of the Oxygenation of the Fetus and Newborn and
  Its Relation to That of the Mother. Am. J. Obst. &+ Gynec., 93:376, 1965.

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