THE FIKST TWELVE MINUTES

VIRGINIA APGAR, M.D.

I'ROFLSSOR OF ANI-.STHESIOLOCY

COLUMBIA UYIVLRSITT

   ATTt.NUING ANESTHESIOLOGIST
    THE PRLSBYTERIAS HOSPITAL
COLUhlBlA-PRtSMYT~.RlAS MEDICAL ChSTk.R

NEW YORK, A`EW YORK

I AM very honored to be invited to Portland. Until your turnpike
was built, my main thoughts about Portland were that it was an
easy place to get lost, and not until last night, under the gracious
guidance of Mrs. McCann, was I able to appreciate the beauties of
your fine city. I am also honored to be asked, bcause I come from
New York, and seem to be the only one on the program south of
the Boston and Maine Railroad.
The first ten or twelve minutes of a baby's life are, in our opinion,
a very important time in his life. There are still plenty of dissenters
from this opinion. Higgins, of Woking, Surrey, is one.  He has
written, in 1951, in the Journal of Obstetrics and Gynecology of the
British Empire, that "NO one has proven that resuscitation did a
baby any good." How to prove or disprove this is difficult.  He
quotes the results of some 2,000 deliveries conducted or supervised by
himself, and it is true that his death fates are no better or no worse
than the average. His only treatment of the child is to shake it, and
put it in a slightly head-down position, with one arm behind its back.
The description of what happens in some cases is hair-raising.
One child at 7 minutes had no apical impulse, but by the 14th
minute was breathing well. Mr. Higgins must have strong coronary
arteries.

The only way to prove his statement would be to make a com-
pletely random selection of every patient on the obstetrical floor,
and do nothing to every other one, no matter how depressed the
infant is, while treating every other infant as indicated. Mr. Higgins
includes one paragraph which I think explains his success. In order
to make the series more uniform, he has omitted from the series
all forceps, breech, and section deliveries, all maternal diabetes and
other illness, all prematures. He is probably right that normal, full-
term infants do not need help.

39

40 TRANSACTIONS

There is growing evidence that if a baby survives the trauma of
birth, brain deficiency is not likely to occur. Usden and Weil in
Cincinnati examined all the children born in the Cincinnati General
Hospital, in 1938, who were apneic at birth. Fifteen years later,
some 80 or 90 of these children were followed at high school age.
Psychological studies resulted in the startling fact that those who
were apneic the longest were among the brightest! This fact just
missed being statistically significant, fortunately. However, no men-
tion is made of the treatment used for the apnea, and oxygen ad-
ministration is not mentioned. Apnea treated with ventilation with
oxygen is entirely different from untreated apnea. Several forward-
looking studies are under way to follow well-documented infants
at birth, and their results are awaited with interest.

Dr. Hallett has already mentioned the study carried out at Babies
Hospital in New York. In 1947, The Rockefeller Foundation pro-
vided funds for a serial study of the heel capillary blood of infants
at birth, and 404 unselected babies of ward patients were sampled
4 times during the first 2 hours. Gesell tests were given to some at
2 years of age, and Stanford Binet tests at 47 months. So far, we have
found no relation at all to heel blood oxygen saturation at birth
and later intelligence. The group is being re-examined at present
with a battery of tests.
Since such a series represents considerable financial outlay, we
tried to find a simple, clinical way to judge the condition of the in-
fant. Five signs were chosen, and given a score of zero, 1 and 2,
as shown in the following table. The signs are heart rate, respiratory
effort, muscle tone, reflex irritability, and color. These are evaluated
at 60 seconds after birth, and a total score given. This cannot exceed
10. The following 2 slides show the incidence of the total scores and
the death rates in each group.
At present, we have over 16,000 infants so rated at birth; 32 of
these scored 0 - not even a heart beat by auscultation. With prompt
treatment, 22 of these recovered and went home. The follow-up of
these and a sample of 4,000 in all, which will begin in 1960, should
be most interesting.
The scoring system is used in several ways. In general, no treat-
ment is needed for infants with scores of 5 or better other than indi-
cated pharyngeal suction. If the score is 4 or under, we believe
that artificial ventilation with oxygen-enriched air is indicated.  A
record of successive scores indicates how long depression is present,

'THE FIRST TWELVE M1NUI'F.S 41

and may be related to prognosis. An infant admitted to the nursery
with an initial low score gets more prompt pediatric care and oh-
servation than one with a good score, since we know that the death
rates are considerably higher with low-score babies.
Using scores as a criterion, we have found some differences in
choice of anesthetic technique and the result to the baby.  For
example, in elective Caesarean sections, babies delivered under spinal
anesthesia had an average score of 8.2, while those delivered under
general anesthesia (cyclopropane) average 5.2. Since the death rate
at score 5 is about five times that at score 8, we feel that spinal anes-
thesia is definitely superior to inhalation anesthesia for elective
sections. Also, in a large group of full-term, vaginal vertex de-
liveries, babies delivered after regional anesthesia were significantly
better, as judged by scores, than those following inhalation anes-
thesia. However, in breech deliveries, and in vaginal deliveries of
premature infants with vertex presentation, we could detect no
difference between regional and general anesthesia.

Dr. Hallett has asked me to give some prognosis as to the margin
of safety following anoxia. That is a good question, and we are
trying to find some answer to it. For a year or two we have been
assembling a neonatal team, at present consisting of Drs. Stanley
James and Irwin Weisbrot, pediatricians, and Dr. Edward Prince,
a Macy Foundation Fellow in Obstetrics. We have a laboratory on
the obstetrical floor, and wonderful cooperation from the obstetrical
house staff and nurses to help us collect data during the perinatal
period. Fetal electrocardiograms, blood pressures at birth, even be-
fore the cord is cut, weighing the amount of placental transfusion
given in various positions, immediate collection of umbilical artery
and vein samples as well as maternal arterial samples, and uterine
vein samples in Caesarean sections are among our endeavors. After
birth, catheterization of the umbilical vein is easily performed and
bloobsamples, and pressure tracings are recorded from various parts
of the circulatory system.
So far we are unable to tell you just why a baby breathes. It is
not apparently related solely to oxygen tension or carbon dioxide
tension. We are quite sure that depressed infants, those with low
scores, have in addition to anoxia and hypercarga, a considerable
metabolic acidosis as determined from depression of buffer base.
Dr. Duncan Holaday's laboratory has perfected the micromanometry
necessary to study small blood samples. The rapidity of the de-

42 TRANSACTIONS

velopment of metabolic acidosis confirms our feeling that depressed
infants should not be left to their own devices but should be treated
promptly with ventilation to get rid of carbon dioxide, as well as to
oxygenate their tissues.
We are quite sure that all babies undergo a period of asphyxia
during delivery, whether from tonic contraction of the uterus, pla-
cental separation, or cord compression, or combinations of these
factors. If this period is short, the infant should be in good con-
dition. If intrauterine asphyxia is prolonged, a depressed baby with
metabolic acidosis is often the result. It is imperative that we learn
better how to diagnose intrauterine emergencies. The presence of
meconium-stained amniotic fluid and appearance of fetal tachycardia
or bradycardia are still excellent clinical guides.
Charles Steer and Arnold Fenton have just reviewed some 1,200
cases of fetal distress at the Sloane Hospital for Women, and have
found that the death rate of infants born with meconium having
been passed is twice that of those without this complication, while
in those with pulse changes in addition, over 180 or under 110 beats
a minute, the death rate rises to three times that of those without
these complications. The work of Ed Sothern, here in Maine, and
Hon and Hess, at Yale, on fetal electrocardiogrami is of great im-
portance.
During the usual vaginal delivery, the infanth delivered as ex-
peditiously as possible. Intentional delay after delivery of the head,
and suction of the mouth with a rubber bulb, has been widespread
teaching in the past, apparently to allow the uterus to express as
much placental blood to the baby as possible. It is questionable,
especially in premature infants, whether this extra, high viscosity
blood is desirable. Also, as the baby's pharynx and nares are stimu-
lated with the rubber bulb manipulation, he is often seen attempting
to respire. This is almost if not actually impossible, since the chest
is held snugly in the pelvic girdle and the uterus is contracting
tightly on the buttocks and feet, allowing no room for diaphragmatic
expansion either. During and after delivery, the baby is held down
at all times. The baby's first breath should be taken in the head-
down position so that pharyngeal contents of vaginal mucus and
blood will not be inspired with the first gasp. Gravity is the best
prevention of this serious emergency. The child is placed head
down in a bassinet, and the pharynx is gently and quickly suctioned
with a two-holed rubber catheter (Kausch, No. 12, Davol) connected

THE FIRST TWELVE MINUTES 43

to a DeLee trap. Prolonged suction will remove air (oxygen from
the pharynx) as well as stimulating the pharyngeal plexus to cause
bradycardia. After the pharynx is clear, the catheter is touched to
the nostrils, which should cause the baby to sneeze or cough.
Pharyngeal aspiration is repeated if the baby coughs up much ma-
terial.
If the infant is not crying by this time, a brisk but gentle slap on
the feet is adequate mechanical stimulation. After the cord is
clamped or tied, the stomach is emptied with the same catheter,
and its contents measured. Both atresia of the esophagus and upper
intestinal obstruction can be diagnosed by this simple maneuver.
Finally, the catheter is inserted into the rectum t(J rule out imper-
forate anus. Stethoscopic check of the chest will rule out dia-
phragmatic hernia, pneumothorax, and severe atelectasis.

The treatment of infants with scores of 4 or below is the same,
with a few additions. After pharyngeal suction, if ventilation is
inadequate or absent, the heart rate slow and the baby limp, respira-
tion is\ assisted by inflating his lungs with oxygen-enriched air.
There are many ways to do this, such as using a hand-operated
inflaC-. (such as the Kreiselman type), or mouth-to-mouth respira-
tion, with oxygen in the operator's mouth. It is imperative to know
that oxygen actually is reaching the lungs, not the stomach. If the
chest is seen to rise or, better still, gas is heard to pass into the lungs,
with a stethoscope, the treatment should be effective in a few seconds.

Often, the tongue falls back and completely obstructs the airway.
This is treated by inserting an infant-size Berman plastic airway,
and repeating the inflation of the lungs. If the heart rate does not
speed up in a few seconds, direct laryngoscopy is indicated to rule
out glottic obstruction or anomaly. Use suction if necessary. When
the glottis and trachea are seen to be free, a No. 12 Cole infant
endotracheal tube is inserted into the trachea, and one or two
puffs blown into it. A simple, portable plastic device is being de-
vised by Dr. Richard Day, which will prevent contamination of
the baby by the operator's breath. Improvement in the heart rate
should follow very shortly.
If one has the misfortune to have an apparent intrapartum death,
and a speedy delivery is possible, the above form of management
should be instituted at once. Endotracheal intubation and inflation
of the lungs take about 3 seconds to perform if the equipment is
at hand and in working order. If then the heart-beat cannot be

44 TRANSACTIONS

auscultated, cardiac massage should be attempted. There are two
children living, without residual damage, following cardiac massage
at birth, and endotracheal ventilation.
Dr. Abramson mentioned the occurrence of polyhydramnios in
some cases of infant volvulus. This symptom should suggest to you a
number of anomalies in the infant, some of which are operable. The
best time to operate on a newborn infant is as soon as possible after
birth. Some of the anomalies associated with polyhydramnios which
can be corrected are bilateral choana1 atresia, congenital goiter,
tracheoesophageal fistula with atresia of esophagus, duodenal atresia,
volvulus, obstruction from an annual pancreas, obstructed dia-
phragmatic hernia. Some which cannot be corrected are complete
anencephaly, diffuse disease of the central nervous system, and so far,
some cases of congenital cardiac anomaly. Polyhydramnios which
accompanies diabetes and the second twin remain mysterious.

VIRGINIA APGAR, M.D.
COLUMBIA-PRESBYTERIAN MEDICAL CENTER
622 WEST 168~~ STREET
NEW YORK 32, NEW YORK

DISCUSSION

QUESTION: Is pulmonary hypertension related to the formation of
hyaline membrane?
DR. APCAR: Dr. McCann has asked that question, and he is probably
correct that this is one of the factors, though it remains to,be proven
in humans. Catheterization of the pulmonary artery is not easy in the
newborn, but Dr. Richard Rowe, in Toronto, has done it many times,
and we are practicing the technique in stillbirths and abnormal infants.

Dr. McCann also inquired about the use of varidase in hyaline
membrane disease. I have not had experience with this particular drug,
but if it is an aerosol similar to alevaire, the value oE its use has been
disproven by Dr. William Silverman in the premature nursery at the
Babies Hospital in New York City.
QULSTION: Compare cyclopropane with the other general anesthetic
agents for routine use in delivery.
Dw. APCAK: Cylopropane has the advantage of being able to be used
both in light analgesic levels as well as surgical anesthetic levels, with
adequate oxygen at a11 times. For analgesia alone, we prefer nitrous
oxide and oxygen because of its nonexplmiveness, but if operative de-

THE FIRST TWELVE MINUTES 45

livery of any type is considered. a quick change to cyclopropane is made.
It has failed us on two occasions this year for relaxing a tightly con-
stricted uterus. Chloroform was used successfully in both of these
patients. All the inhalation anesthetics traverse the uterus quickly, so
time of administration and depth should be kept to a minimum.

Dr. McSweeney has asked me if we use ether in normal deliveries.
Ether is an excellent inhalation agent, and we use it if (1) there is no
cyclopropane available; (2) if the personnel available to give anesthesia
has had no experience with cyclopropane; and (3) if there is a mechani-
cal defect in the anesthesia machine. All of these are very rare occur-
rences.

QUESTION: What are the criteria for determining the early stage
of labor, Dr. Abramson?

DR. ABRAMSON: If the patient has regular rhythmic, painful contrac-
tions, and on rectal examination the cervix is taken up but not dilated,
labor is still in the first phase of the first stage of labor, and the patient
would be a very good candidate for Relaxin therapy.

QUESTION: Is rupture of membranes a contraindication to the use of
Relaxin if the cervix is not dilated?

DR. ABRAMSON: It is not a contraindication. In fact, in our series of
40 patients presented today, 10 of them had ruptured membranes. Seven
of these had an increase of as much as 7 weeks of gestational age and
were delivered of live babies. Whether the patient comes in with rup-
tured membranes prior to the onset of labor, or simultaneously ruptures
membranes with the onset of labor, .as long as the cervix is not dilated,
it is worth a trial.

QUESTION: Discuss the cost of Releasin.

DR. ABRAMSON: The cost of Releasin at the present time, to be sure,
is high. Dr. Robert Kroc, who is here today representing the Warner
Chilcott Company, has assured me that the cost of Relaxin is on the
way down. I believe there has already been a 15% reduction this past
month. We do not know what the oral preparations of Relaxin, now
being used in other studies, will cost, but I am sure that it will be much
less than the parenteral preparations now on the market.

QUESTION: Dr. Hallett, what do you mean by avoidance of the use
of forceps?

DR. HALLETT: I don't feel that I'm really capable of discussing forceps
at all. I probably should not have mentioned it in my remarks, and
whatever I have mouthed is the written word that I have read, and I
merely meant that forceps should be used as little as possible in the de-
livering of premature babies. I am sure that there are certain obstetrical
indications for the use of forceps, but I would rather leave that decision
up to you. I merely included it in my remarks for purposes of com-
pletion.

'

46 TRANSACTIONS

QUESTION: What about human breast milk for premature babies?
DR. HALLETT: There is a considerable amount of evidence that prema-
ture babies gain better on a high-protein cow's milk formula than they
do on breast milk. However, although there is a great deal of evidence
that they gain weight better on cow's milk, there is no evidence that

this extra gain in weight is a good thing. I think that too much of our
research on premature feeding is based on this weight gain, but at the
present time they are investigating other aspects.
Just for one example, the absence of Vitamin B6 in some cow's milk
formulas has led to convulsions. Of course, Vitamin B6 is present in
breast milk. And this certainly may be true of other substances in breast
milk as yet undiscovered. I would certainly tend to think (this is purely
a matter of opinion, and there are many different opinions on the sub-
ject) that eventually breast milk will come into its own right and will
be proven to be the best milk for premature feeding. It is rather difficult
to obtain it in a community of this size. At least, we're not set up, from
the administrative point of view, to get it. I have heard that in Detroit
the Junior League of that city has made some kind of an organizational
attempt and, as a consequence, can obtain the breast milk. I don't think
it's from the Junior Leaguers themselves. (Laughter.) It is second-hand
breast milk. They can obtain it for use in hospitals.
Dr. Apgar has passed on to me this question:  How about the use of
varidase in hyaline membrane disease? Well, she has certainly answered
it in the same way that I would answer it, pamely, that we don't either
of us know anything about it. I think that our mistake in hyaline
membrane disease has been to treat it in the wrong way, based on the
wrong theory of the disease. Our theory in the past has been that we
should remove the item which is causing the hyaline membrane, and
we felt that this item was amniotic fluid. The strong evidence at the
present time is that this item is pulmonary effusion, and therefore we
should attack it from. that point of view rather than from the point of
view of the membrane itself. However, assuming that the membrane
is present and we have been unable to prevent it, how can we then treat
it? Perhaps varidase would be of some value, but one could liken the
situation to removing a diphtheritic membrane without actually treating
the disease diphtheria.

DR. APCAR: Dr. Abramson, I wonder if you would comment for us
on your opinion of the type of delivery of premature babies. At the Sloan
Hospital we have been brought up to do forceps in almost every case, with
wide episiotomy. This sounds awful in view of Dr. Hallett's remark.

DR. ABRAMSON: That was the point in which 1 was going to dbagree
with Dr. Hallett, because we have been brought up to believe that the
premature baby's best chance at the time of delivery is by the use of

THE FIRST TWELVE MINUTES 47

forceps with a wide episiotomy. I think that is particularly true when
the patient is a primipara with a good firm perineal body. I think there
is a greater chance of damage to the infant, through probable intercranial
hemorrhage caused by forceful uterine contraction, pounding the head
against a firm perineum. With the proper use of forceps at full dilatation
and a wide episiotomy, there is no pressure on the head and the baby is
less anesthetized.