APGAR scoring for newborn delivery

The system is a widely used, standard method to assess a newborn infant


Most EMS agencies can expect to deliver a baby in the field at some time or another. This article will discuss the APGAR scoring for a newborn assessment. It should be noted that the decision to begin resuscitation should not be delayed until an APGAR score is obtained. Instead, resuscitation decisions are based on the clinical triad of respiration, heart rate, and color.1, 2 This article will not be discussing neonatal resuscitation, but rather the APGAR scoring.

The APGAR score is a widely used, standard method to assess a newborn infant. This assessment is easy to do, takes little time, and is consistent between health care providers. It also allows consistent documentation of the newborn's condition at critical times of one and five minutes after delivery.

History
The APGAR score was developed by Dr. Virginia Apgar in 1952 and introduced in 1953. Dr. Apgar was an anesthesiologist and pediatrician who sought a consistent method to evaluate newborn infants. Over a seven-and-a-half month time frame, Dr. Apgar reviewed the births of 2096 infants born in the Sloane Hospital for Women.

It was during this time that she developed the concept of a rating scale of 10 points describing the best possible condition, scoring two points each for each criteria of respiratory effort, reflex irritability, muscle tone, heart rate and color. 3  The first scoring was only done at one minute post delivery, and later done at both the one and five minute post delivery timeframe.

Interestingly, the term "APGAR score" was non-existent for 10 years. Rather, it was referred to as many things, depending on the facility that delivered the infant. As many health care providers began to develop their own set of mnemonics to remember the vast number of facts, Dr. Joseph Butterfield developed the mnemonic APGAR as a way to recall the five criteria of the scoring and used it in his hospital. 

His "APGAR" was the learning aid to recall; Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. Interestingly, in correspondence between Drs. Apgar and Butterfield in 1961, Dr. Apgar thought of the mnemonic (or epigram) as clever but when she contacted his hospital, no one there was aware that "APGAR" was an actual person but rather thought it was a scoring system. He wrote an article 27 years later describing his mnemonic. 4 After Dr. Apgar's death, Dr. Butterfield led a 10-year campaign that persuaded the Postal Service to issue a commemorative stamp in her honor.

APGAR scoring
After birth, the newborn infant's body must change to adapt to life outside the womb. These changes can occur when the infant is most vulnerable and may potentially die or be severely compromised. It is estimated that between 5-10 percent of newborns require some degree of active resuscitation at birth (stimulation to breathe) and 1-10 percent of newborns delivered in the hospital require assisted ventilations.

Generally, most newborns only require basic interventions such as suctioning, drying, stimulation, and perhaps supplemental oxygen. 5 Some may require resuscitation, which should be immediately done and not delayed by the getting an APGAR score. Resuscitation decisions should be based on the clinical triad of respiration, heart rate, and color. 2, 5   

The APGAR score is taken at both one minute and five minute intervals post delivery and is considered the standard in newborn evaluation. The score offers providers a consistent method to determine the overall status of the newborn. Generally, higher APGAR scores will correlate with an infant in better condition. 2, 6 

APGAR scores between 7 and 10 are considered normal. If scores are less than 7, the appropriate resuscitation actions should be taken or continued. With scores less than 7, the APGAR scoring should be every five minutes until the infant is stabilized. 8 A prehospital APGAR score offers the receiving hospital a consistent and vital assessment of the newborn. This will also provide the receiving hospital the opportunity to prepare for the newborn.

Sign

0

1

2

Appearance – Color

Blue, pale

Body Pink, extremities blue

Completely pink

 Pulse - Heartrate

Absent

Slow <100 bpm

>100 bpm

Grimace – Reflex  
             irritability

No response

Grimace

Vigorous  cry

Activity – Muscle tone

Flaccid

Some flexion of extremities

Active motion

Respiratory Effort

Absent

Slow, irregular

Good, crying

 

APGAR evaluation
Once the infant is delivered, and the umbilical cord is clamped and cut, the infant is dried. If suctioning is needed to clear the airway, a bulb syringe works well. The bulb should be compressed prior to suctioning of secretions. Suctioning should be done first from the mouth then the nose. This order will prevent the infant from aspirating any secretions. The process of drying and suctioning are usually an effective way to stimulate the respirations in the newborn. 1

Appearance and evaluation of color
Newborn infants who are uncompromised will maintain a pink color of mucous membranes without the need of supplemental oxygen. 7 A normal newborn will have pink mucous membranes and be scored a 2. If the newborn has blue extremities with a pink body, this would be scored a 1, and a completely cyanotic newborn would be scored a zero.

Pulse
With a newborn, the heart rate may best be determined by palpation or auscultation at the base of the umbilical cord. The rate for a normal newborn should be at greater than 100 beats per minute, and this would result in a score of 2. Heart rates less than 100 beats per minute result in a score of 1, and providers should be initiating oxygenation of the newborn. An absent pulse rate would score a zero, and providers should be initiating chest compressions.

Grimace or reflex irritability
Normal newborns will cry, especially when stimulated by drying. When this is normal and vigorous crying, it would score a 2. If the newborn is making faces or grimacing, but not crying, the score is a 1, and if there is no response the score is a zero.

Activity
Most newborns are active and have good muscle tone. The active moving of all extremities would score a 2. Limited movement with some flexion would score a 1, and if the newborn is flaccid or limp, the score would be zero.

Respiratory effort
Most newborns normally breathe and begin to cry almost immediately after birth. 6 This would score a 2. If the newborn has a slow or irregular rate of breathing, the score would be 1 and necessitate the need for assisted ventilation. If the breathing is slow or irregular, brief stimulation may be attempted while 100 percent oxygen is administered. 2, 5 An absent respiratory effort is a zero and requires provider to initiate ventilations.

Conclusion
The APGAR scoring is not designed to determine if resuscitation is needed. However, it is a valuable tool for both prehospital responders and providers in the receiving hospital. The APGAR scoring allows consistent evaluation at the critical times of one and five minutes. The scoring can be compared to determine if the newborn's status is remaining the same, improving, or deteriorating. If this is not done in the field, hospital providers will not have any idea of the newborn's condition post delivery in a prehospital environment. The APGAR scoring is easy to recall, and can even be taped or laminated and placed on OB kits. This ensures crews are ready to gather the important data needed.

Bonus tip
Each OB kit should have a small cap to help the newborn retain body heat. An easy PR tip is to have them monogrammed with your organization's name, like "delivered by your organization." This will be a keepsake and likely end up in a child's school "show and tell" for years. It is a great way to market your organization.

References
1. Pediatric Working Group of the International Liaison Committee on Resuscitation: Neonatal resuscitation. Circulation 2000; 102:343.
2. Newborn resuscitation. In: Chameides L, Hazinski MF, ed. Pediatric Advanced Life Support, Dallas: American Heart Association; 1997:9.
3. Apgar, V. (1953). A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 32 (4): 260–267.
4. Butterfield, J. (1989). Practical epigram of APGAR score. Pediatrics Vol. 84 No. 5 November 1989, pp. 778.
5. Pediatric Working Group of the International Liaison Committee on Resuscitation: Neonatal resuscitation. Circulation 2000; 102:343.
6. Normal labor and delivery. In: Cunningham FG, Leveno KJ, et al ed. Williams Obstetrics, 22nd ed. McGraw-Hill; 2005.
7. Roberts Clinical Procedures in Emergency Medicine, 5th ed., Saunders; 2009.
8. Textbook of Family Medicine, 7th ed., Saunders; 2007.

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