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A Minute for the Apgar

Anesthesiologist Virginia Apgar, M.D. developed the Apgar Score in 1952 as a “rapid method of assessing the clinical status of the newborn infant at 1 minute of age and the need for prompt intervention to establish breathing.” It quickly gained acceptance as a method assessing newborn well-being, and has been a standard element of newborn care ever since. So, imagine my surprise to see that the AAP and ACOG have jointly revised their statement on the use of Apgar. Published in the latest issue of Pediatrics, the full article is available (without a subscription) here.

The three main points messages in the statement are summarized nicely in the abstract: “The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant.” I’m okay with all of that.

There are, however, two elements I wish this statement addressed.

Sometimes, the Apgar score is assessed before a minute. I’ve seen it done in hospitals where I have worked. Lucky for me, when I was a young nurse, a veteran nurse impressed upon me the importance of waiting one full minute. I remember her exact words: “There’s a helluva lot you can do to spiff up that baby if you wait one full minute.” As I’m fond of saying that “One nurse’s observations do not a study make,” but I’ll bet research would show that the “1-minute Apgar score” is all too often assigned before 60 seconds of age. A “too soon” Apgar score combined with the subjectivity the AAP mentions, might render this measure less than useful.

Another thing that goes unaddressed in the statement is a phenomenon we called “post-asphyxia” before that term was seemingly banned. The current statement points out that the Apgar score is not evidence of, or a consequence of, asphyxia nor can it predict individual neonatal mortality or neurologic outcome. Okay, but as a nurse, my job is not about mortality or long-term neurologic morbidity. My responsibility is to take care of that baby in the hours immediately following birth. I see a baby with that characteristic stare that often occurs after prolonged oxygen deprivation, and that speaks volumes to me about my plan of care for that baby. I don’t need an Apgar score or a word for the behavior I observe. But I do need a strategy for how to take care of a baby who is likely to be very lethargic and have depressed reflexes, including poor feeding behavior. I need to know that bradycardia or apnea may be lurking around the corner.

Most days, our focus is less about words and theoretical consequences and predictions; it’s more about carrying out precise assessments and high-quality clinical care.

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