Apgar testing

Definition

The Apgar scoring system evaluates the physical condition of the newborn at one minute after birth and again at five minutes after birth. The newborn receives a total score (Apgar score) that ranges from 0 to 10 based on rating color, heart rate, respiratory effort, muscle tone, and reflex irritability.

Purpose

Virginia Apgar specialized in anesthesiology and childbirth . She developed the Newborn Scoring System, later called the Apgar score, in 1949 for practitioners to use in deciding whether or not a newborn needed resuscitation. This score provides a uniform method of observation and evaluation of a newborn infant's need for resuscitation immediately after delivery at one minute and again at five minutes. The score is significant because one person in the delivery room evaluates the infant using five signs in an objective, standard and measurable manner. Research published in The New England Journal of Medicine in 2001 concluded that the Apgar scoring system remains as relevant for the prediction of neonatal survival in the early 2000s as it was in 1949.

Description

Five factors are considered in the evaluation of a newborn and the word Apgar can be used as a mnemonic to remember them, i.e., A = Activity (or muscle tone); P = Pulse; G = Grimace (or reflexes to stimuli); A = Appearance (or skin color), and R = Respiration. Scores are given as follows:

• Activity: Limpness, no movement at all = 0; some flexion of the limbs = 1; active movement, vigorous movements of arms and legs = 2.
• Pulse: No pulse = 0; pulse below 100 beats per minute (bpm) = 1; pulse over 100 per minute = 2. This is the most important assessment and can be determined by auscultation with a stethoscope or palpation at the junction of the umbilical cord and skin. A newborn heart rate of less than 100 bpm indicates the need for immediate resuscitation.
• Grimace: No response to stimuli = 0; some response, a slight cry or grimace = 1; active response, coughing, sneezing, or vigorously crying = 2. The stimuli used to evoke a response can be the use of nasal suctioning, stroking the back to assess for spinal abnormalities, having the foot tapped.
• Appearance: The whole body is blue, gray, or very pale = 0; acrocyanosis, i.e., trunk and head have a pink skin color and hands and feet are blue = 1; pink all over = 2. Newborns with naturally darker skin color will not be pink, but pallor is still noticeable and especially in the soles of the feet and palms of the hands. Skin color is related to the newborn's ability to oxygenate its body and extremities and is dependent on heart rate and respirations.
• Respiration: No breathing, apnea = 0; slow and irregular respiration = 1; good regular respiration, especially accompanied by crying = 2. Respirations are best assessed by watching the rise and fall of the neonate's abdomen since infants are diaphragmatic breathers.

Preparation

Essentially no preparation is needed to determine an Apgar score. Clinicians have suctioning equipment available and may use it during the birth process for nasal and oral suctioning to remove mucus and amniotic fluid. This is usually performed when the head of the newborn is safely delivered while the mother rests for her final push. The Apgar score should not be performed by the individual doing the delivery, but by the labor and delivery nurse or nursery nurse.

Aftercare

The Apgar score is primarily observational in nature and its only purpose is to alert the healthcare provider that the baby may need immediate assistance or prolonged observation in the nursery. It provides a means of monitoring the effectiveness of interventions and a process of determining which interventions are valuable.

Normal results

It is important to note that an Apgar score is strictly used to determine a newborn's immediate condition at birth and that it does not necessarily reflect the future health of a baby. The maximum obtainable score is 10 and the minimum is zero. It is quite rare to receive a true 10 as some acrocyanosis is considered normal and not a cause for concern. A score of 7 to 10 is considered normal, and these infants are expected to have an excellent outcome. A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance or in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen referred to as "blow-by" may be placed near but not directly over the nose and mouth of the neonate during suctioning. A score in the 4–6 range indicates that the neonate is having difficulty adapting to extrauterine life, which in some cases may be related to medications given to the mother during labor, prematurity , or a rapid delivery.

A low Apgar score provides a warning signal that the baby may have hidden health problems, such as breathing difficulties or internal bleeding. With a score of 0–3, the newborn is unresponsive, pale, limp, and may not have a pulse; therefore, an infant with a score of 0—3 needs immediate resuscitation. An ongoing evaluation is continued during resuscitation and documented again at five minutes. In the event of a difficult resuscitation, the Apgar score is done at 10, 15, and 20 minutes as well. A newborn with an Apgar score in this range generally requires advanced medical care and emergency measures, such as assisted breathing, administration of fluids or medications, and observation in a neonatal intensive care unit (NICU) by a neonatologist. An Apgar score of 0–3 at 20 minutes of age, for example, is indicative of high rates of morbidity (disease) and mortality (death).

Risks

There are no risks involved with the Apgar scoring process. It is an evaluation of the baby at birth to determine if any resuscitation procedures are needed.

KEY TERMS

Acrocyanosis —A condition characterized by blueness, coldness, and sweating of the extremities. A slight cyanosis, or blueness, of the hands and feet of the neonate is considered normal. This impaired ability to fully oxygenate the extremities is due to an immature circulatory system which is still in flux.

Amniotic fluid —The liquid in the amniotic sac that cushions the fetus and regulates temperature in the placental environment. Amniotic fluid also contains fetal cells.

Apnea —The temporary absence of breathing. Sleep apnea consists of repeated episodes of temporary suspension of breathing during sleep.

Extrauterine —Occurring outside the uterus.

Neonate —A newborn infant, from birth until 28 days of age.

Neonatologist —A physician (pediatrician) who has special training in the care of newborn infants.

Pallor —Extreme paleness in the color of the skin.

Parental concerns

Parental concerns may be addressed if the Apgar score is low at five minutes and then again at 10 minutes. The healthcare provider should address the possible risks associated with a low score and advise the parents as to follow-up care. A persistently low Apgar score could indicate neurological problems and the parents would want to obtain additional treatment for the baby to ensure appropriate development. Children with cerebral palsy often have neurological damage at birth and the use of physical therapy or speech therapy enhances their outcome.

Resources

BOOKS

Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Tappero, Ellen, and Mary Honeyfield. Physical Assessment of the Newborn, 3rd ed. Santa Rosa, CA: NICU Ink Book Publishers, 2003.

PERIODICALS

Casey, B. M., et al. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants." New England Journal of Medicine 334 (February 15, 2000): 467–71.

ORGANIZATIONS

Association of Women's Health, Obstetric, and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: <www.awhonn.org>.

National Association of Neonatal Nurses. 4700 W. Lake Avenue, Glenview, IL 60025–1485. Web site: <www.nann.org>.

WEB SITES

"APGAR Scoring for Newborns." Available online at <www.childbirth.org/articles/apgar.html> (accessed November 28, 2004).

"What is the Apgar Score?" KidsHealth. Available online at <http://kidshealth.org/parent/pregnancy_newborn/medical_care/apgar.html> (accessed November 28, 2004).

Linda K. Bennington, RNC, MSN, CNS

Apgar score

The Apgar Score is a rating system used to evaluate the health of newborn infants. The test is administered one minute after birth and again five minutes after birth. A rating of zero, one, or two is given in each of these five categories: color, breathing, heart rate (pulse), muscle tone, and response to stimulation. A total score of three or lower is a signal that the baby's condition is critical and requires immediate attention. A score of seven or higher means that the baby's initial vital statistics are good. Studies of the extended Apgar Score (the five-minute recheck) have shown the test to be a fairly reliable indicator that the subject infant has a good chance for survival. Because the Apgar Score does not check for all possible complications (such as chromosonal damage), however, a high number does not guarantee that a child's long-term outlook is completely positive.

Apgar Develops System

Until the early 1950s, physicians had no reliable way to assess the health of newborns in the critical first minutes of life. Because of delays in diagnosis, conditions that might have been corrected sometimes proved fatal. In 1952 Virginia Apgar (1909-1974), a physician at the Columbia-Presbyterian Medical Center in New York City, developed a scoring system that became the standard tool for evaluation of newborns. Apgar was one of the first female graduates of Columbia University's College of Physicians and Surgeons; she was also the first woman ever to hold a full professorship at the college. She invented her scoring system after years of studying the effects of anesthesia in childbirth.

Apgar Scoring

The Apgar Score has five important components, each with its own set of acceptable standards. The individual categories and their ranges are listed below:

• Color: A baby who possesses a healthy pink skin tone receives two points, while a pale or bluish infant receives zero points. Most newborns have pink bodies and lips but bluish hands and feet. This coloring receives one point. An all-over bluish color can mean the baby has problems with his heart or lungs, has something blocking his airway, or has inhaled amniotic fluid.
• Breathing: A newborn should gasp and begin to breathe at birth. Regular breathing gets a score of two, while irregular breathing gets a score of one. A score of zero is given to a newborn who makes no effort to breathe. Irregular breathing can mean the infant lacks oxygen in his body, has an infection, has central nervous system damage, or has a depressed respiratory drive because of anesthesia given the mother during birth.
• Pulse: The normal heart rate at birth is between 120 and 160 beats per minute. A newborn with no detectable heartbeat is scored at zero; a heart rate of less than 100 beats per minute is scored one, and a two is given for a heart rate of 100 beats per minute or more.
• Muscle tone: An infant should move his arms and legs at birth. Limpness or poor muscle tone are usually caused by lack of oxygen, central nervous system trauma, or drugs given the mother during birth. A limp newborn is scored at zero. Some movement gets a score of one, and active movement gets a score of two.
• Response to stimulation: A newborn is stimulated at birth by inserting a tube through a nostril into the throat. This should cause the infant to grimace, cough, or sneeze. If he does not respond he is scored at zero; a grimace alone gets a one, and a grimace with a cough or sneeze is scored at two.

The highest possible total Apgar Score is ten. It is not unusual for infants to score a seven at one minute of age and nine or ten at five minutes of age. By this later time, babies generally have a healthier skin tone and are breathing better. With information provided by the Apgar Score, medical personnel can take immediate measures if needed to assure a new-born's survival.

Apgar score

An indication of a newborn infant's overall medical condition.

The Apgar Score is the sum of numerical results from tests performed on newborn infants. The tests were devised in 1953 by pediatrician Virginia Apgar (1909-1974). The primary purpose of the Apgar series of tests is to determine as soon as possible after birth whether an infant requires any medical attention, and to determine whether transfer to a neonatal (newborn infant) intensive care unit is necessary. The test is administered one minute after birth and again four minutes later. The newborn infant's condition is evaluated in five categories: heart rate, breathing, muscle tone, color, and reflexes . Each category is given a score between zero and two, with the highest possible test score totaling ten (a score of 10 is rare, see chart). Heart rate is assessed as either under or over 100 beats per minute. Respiration is evaluated according to regularity and strength of the newborn's cry. Muscle tone categories range from limp to active movement. Color— an indicator of blood supply—is determined by how pink the infant is (completely blue or pale; pink body with blue extremities; or completely pink). Reflexes are measured by the baby's response to being poked and range from no response to vigorous cry, cough, or sneeze. An infant with an Apgar score of eight to ten is considered to be in excellent health. A score of five to seven shows mild problems, while a total below five indicates that medical intervention is needed immediately.

Apgar score (ap-gar) n. a method of rapidly assessing the general state of a baby immediately after birth. A maximum of 2 points is given for each of the following signs, usually measured at one minute and five minutes after delivery: type of breathing, heart rate, colour, muscle tone, and response to stimuli.[ V. Apgar (1909–74), US anaesthetist]