Content uploaded by Kristen Montgomery
Author content
All content in this area was uploaded by Kristen Montgomery on Jul 10, 2014
Content may be subject to copyright.
Apgar Scores: Examining the Long-term Significance
Kristen S. Montgomery, PhD, RNC, IBCLC
Abstract
The Apgar scoring system was intended as an evaluative
K
RISTEN
S
.
M
ONTGOMERY
is a recent doctoral graduate in
measure of a newborn’s condition at birth and of the
nursing at Case Western Reserve University in Cleveland,
need for immediate attention. In the most recent past,
Ohio. She resides in Clinton Township, Michigan.
individuals have unsuccessfully attempted to link Apgar
scores with long-term developmental outcomes. This
practice is not appropriate, as the Apgar score is cur-
rently defined. Expectant parents need to be aware of
the limitations of the Apgar score and its appropriate
uses.
Journal of Perinatal Education, 9(3), 5–9; Apgar
scores, newborn, birth, resuscitation.
Virginia Apgar, a physician and anesthesiologist, devel-
oped the Apgar scoring system in 1952 (Apgar, 1953)
to evaluate a newborn’s condition at birth. The Apgar
score is performed at 1 and 5 minutes of life. The purpose
of this paper is to discuss the appropriate use of the
Apgar score and to examine the appropriateness of using
the Apgar score to predict long-term developmental out-
comes.
The Apgar scoring system is a comprehensive screen-
ing tool to evaluate a newborn’s condition at birth (see
Table 1). Newborn infants are evaluated based on five
variables: heart rate, respiratory effort, muscle tone, re-
flex irritability, and color. A numerical score of 0–2 is
assigned in each category for a maximum score of 10.
Apgar scoring is best used in conjunction with additional
evaluative techniques such as physical assessment and
vital signs.
In recent years, many researchers have attempted to
correlate Apgar scores with various outcomes including
development (Behnke et al., 1989; Blackman, 1988;
5The Journal of Perinatal Education Vol. 9, No. 3, 2000
Apgar Scores: Examining the Long-term Significance
Table 1 The Apgar Scoring System (from Apgar, V.,
to support its use in predicting long-term outcomes.
1966)
Please see Table 2 for clarification of selected research
terms.
Score
Sign 0 1 2
Color Pale Blue Pink Body; Completely Pink
. . . there is also little scientific evidence to support
Blue Extremities
[the Apgar score’s] use in predicting long-term
Reflex Irritability None Grimace Vigorous Cry
Heart Rate Absent Slow (< 100) Above 100
outcomes.
Respiratory Effort Absent Slow (irregular) Crying
Muscle Tone Flaccid Some Flexion of Active Motion
Extremities
Review of the Literature
Score Status
According to the American Academy of Pediatrics’ Com-
7–10 Normal
mittee on Fetus and Newborn and the American College
4–6 Moderately Depressed
of Obstetricians and Gynecologists’ Committee on Ob-
0–3 Severely Depressed
stetric Practice (1996), the Apgar score should be used
to assess the condition of an infant at birth. These com-
mittees also warn that the Apgar score should not be
Riehn, Petzold, Kuhlisch, & Distler, 1998), later delin-
used as the only measure to evaluate the possibility that
quency (Gibson & Tibbetts, 1998), intelligence (Nel-
neurological damage occurred during the birthing pro-
son & Ellenberg, 1981), and neurological development
cess. In addition to low Apgar scores (3 or less for longer
(Sommerfelt, Pedersen, Ellertsen, & Markestad, 1996;
Wolf, M., Beunen, Casaer, & Wolf, B., 1998; Wolf, M.,
Beunen, Casaer, & Wolf, B., 1997; Wolf, M., Wolf, B.,
Bijleveld, Beunen, & Casaer, 1997) for the purposes of
Table 2 Glossary of Selected Research Terms
research. However, individuals have misinterpreted this
Causal Relationship
research and, in some instances, attempted to apply cau-
A relationship between two variables such that the presence or
sality (i.e., that low Apgar scores caused later delin-
absence of one variable (the ‘‘cause’’) determines the presence
quency or poor neurological outcomes). Causality has
or absence, or value, of the other (the ‘‘effect’’).
been neither established nor a goal of the currently re-
Correlation
A tendency for variation in one variable to be related to variation
ported research in this area. Research in this area has
in another variable.
focused on establishing a correlation between these out-
Empirical Evidence
comes and an individual’s Apgar scores. The aim was
Evidence that is rooted in objective reality and gathered through
not to demonstrate that low Apgar scores caused or
the collection of data using one’s senses; used as the basis for
generating knowledge through the scientific approach.
predicted these conditions; however, some individuals
Population
have incorrectly interpreted the research as stating low
The entire set of individuals (or objects) having some common
Apgar scores could predict or actually caused certain
characteristic(s) (e.g., all RNs in the state of California);
behaviors or deficits. Not only is this inappropriate use
sometimes referred to as a universe.
Prediction
of the Apgar score, there is also little scientific evidence
One of the aims of the scientific approach; the use of empirical
evidence to make forecasts about how variables of interest will
behave in a new setting and with different individuals.
Relationship
Apgar scoring is best used in conjuction with
A bond or a connection between two or more variables.
Variable
additional evaluative techniques such as physical
A characteristic or attribute of a person or object that varies
(i.e., takes on different values) within the population under
assessment and vital signs.
study (e.g., body temperature, age, heart rate).
6 The Journal of Perinatal Education Vol. 9, No. 3, 2000
than 5 minutes), an infant who is asphyxiated prior to ranged from 36% to 100%, again heart rate having the
highest rate of consistency. Heart rate measures likelydelivery would demonstrate severe metabolic or mixed
acidemia (pH < 7.00) via umbilical artery blood sample have greater consistency due to the ease of understanding
and defining exactly what is being assessed. When consis-and additional neurological manifestations such as sei-
zure activity, coma, hypotonia, and finally, evidence of tency scoring was compared between full-term and pre-
mature newborns, health care providers were found tomultiorgan dysfunction (Committee on Fetus and New-
born, American Academy of Pediatrics, & Committee have better consistency when assessing full-term new-
borns (Livingston, 1990). Additionally, full-term new-on Obstetric Practice, American College of Obstetricians
and Gynecologists, 1996). Furthermore, research con- borns may represent the ‘‘normal’’ in health care
provider’s minds; hence, full-term newborns may beducted over 30 years ago (Apgar, 1966; Apgar & James,
1962) provided initial evidence to disclaim the reliability more likely to receive a ‘‘normal’’ score, which accounts
for the higher rate of consistency in term newborns thanof Apgar scores for predicting long-term outcomes of
any type (e.g., developmental and neurological). Predic- in preterm newborns.
Another concern is determining who has responsibil-tion of long-term outcomes was never a goal of the Apgar
scoring system. Rather, the goal was to make certain ity for assigning the Apgar score once the infant is born.
According to both Apgar (1966) and the Regan Reportthat infants were systematically observed for their need
for immediate care at birth. (1987), the person assisting with the delivery of the infant
should not assign the Apgar score. While in some respects
the delivering individual seems the most logical choice,
Reliability of Apgar Scores
bias may be introduced into the score value, because the
individual who attends the delivery may have a vestedAccording to Jepson, Talashek, and Tichy (1991), the
Apgar score as a ‘‘tool’’ (to measure newborn adaptation interest in the outcome.
Secondly, the newborn may be given to additionalto extrauterine life) lacks sensitivity and specificity. Sensi-
tivity measures how well the tool captures the infant’s personnel immediately after delivery. This makes de-
termining the Apgar score considerably more difficultcondition at birth (stable vs. depressed) and specificity
refers to how well the tool measures the differences be- for the health care provider who is assisting the delivery,
necessitating leaving the mother’s bedside briefly to as-tween the values of the scores (0–2 for each of the five
categories). Additionally, various authors have noted sign the score. Additionally, if the infant remains with
the mother for the first 5 minutes of life, the health carethat great variability exists in how individual health care
providers score the assessment (Clark & Hakanson, provider must later remember to document the score,
often from memory. Both circumstances have the poten-1988; Livingston, 1990). Clark and Hakanson (1988)
compared the consistency (inner-rater reliability) of tial to introduce further bias to the already poor consis-
tency of the Apgar score.Apgar scoring among various health care disciplines. In
their study, groups of health care providers were visually Often the nurse or someone from the department of
neonatology assigns the Apgar score. Most frequentlyshown case presentations and then asked to assign Apgar
scores to the infants who were presented. Pediatricians in a normal, full-term delivery, this would be the nurse.
Nurses, at least in the Clark and Hakanson (1988) study,and pediatric house staff had a consistency rating of
68%, obstetricians and obstetric house staff had a consis- had a poor consistency rate. Questions regarding the
accuracy of the Apgar score play a role in limiting thetency rating of 46%, intensive care nursery staff had a
consistency score of 42%, obstetric nurses 36%, and long-term predictive value.
community hospital nurses a consistency rating of 24%.
Livingston examined how consistent two health care
Intended Uses of the Apgar Score
providers were in assigning scores when compared to
one another. In this study, the consistency of scores As the Apgar score was developed and refined over the
years since its inception, the intended use has alwaysranged from 55% to 82% with heart rate having the
best rate of consistency at 82% for the 1-minute scores been the same: to evaluate a newborn’s condition at
birth. Some clinicians like to use the Apgar score as a(Livingston, 1990). For the 5-minute score, consistency
7The Journal of Perinatal Education Vol. 9, No. 3, 2000
Apgar Scores: Examining the Long-term Significance
guide to their resuscitative efforts; however, this is not need for immediate attention. In the most recent past,
individuals have unsuccessfully attempted to link Apgaran intended use of the Apgar score. The novice prac-
titioner may mistakenly believe that resuscitative efforts scores with long-term developmental outcomes. This
practice is not appropriate as the Apgar score is currentlyshould not begin until the 5-minute Apgar score is deter-
mined. Experienced clinicians realize this would severely defined. Expectant parents need to be aware of the limi-
tations of the Apgar score and its appropriate uses.delay resuscitative efforts and compromise the potential
for full recovery of neurological function. It is important
to be both careful and consistent with language.
Directions for Future Research
Future research is needed to increase the consistency
Educating the Public
among health care providers assigning Apgar scores.
Letko (1996) notes that much of the public, especially
This would take a training program and periodic practice
expectant parents, has some level of familiarity with the
sessions to establish and maintain inner-rater reliability
Apgar score. However, as Letko also points out, many
of each professional whose role is to assign the scores.
of these parents-to-be do not adequately understand the
Enhanced consistency would be a first step to evaluating
score or its capacities for predicting long-term outcomes.
the effectiveness of Apgar scores. At present, Apgar
Parents need to receive the appropriate education
scores serve as a somewhat useful screening tool for
through the popular media, childbirth classes, and health
health care providers to communicate with each other
care providers. It is imperative that parents have appro-
about what a newborn’s status was like at birth and as
priate information so they are not disappointed when
a mechanism to make certain that someone is systemati-
their child receives a score of 9, believing that their child
cally observing the condition of the new infant.
is somehow inadequate because he or she did not receive
a score of 10. Parents need to understand that a score
from 7–10 indicates a normal newborn at birth and that
Acknowledgement
it is rather infrequent for a newborn to receive a score
The author thanks Raquel Mayne, BSN, graduate of
of 10. For example, most infants have some level of
New York University Division of Nursing, for her assis-
blueness to their extremities and will not initially be
tance with article retrieval.
completely pink. This point can be covered when dis-
cussing the general appearance of a newborn. This
anticipatory guidance can assist the parents in their un-
References
derstanding and promote a positive birthing experience,
Anonymous. (1996) Use and abuse of the Apgar score. Com-
by avoiding potential disappointment.
mittee on Fetus and Newborn, American Academy of Pedi-
atrics, and Committee on Obstetric Practice, American
College of Obstetricians and Gynecologists. Pediatrics, 1,
It is imperative that parents have appropriate
141–142.
Apgar, V. (1953). A proposal for a new method of evaluation
information so they are not disappointed when their
of the newborn infant. Current Researches in Anesthesia
child receives a score of 9, believing that their child
and Analgesia, 32, 260–267.
Apgar, V. (1966). The newborn scoring system: Reflections and
is somehow inadequate because he or she did not
advice. Pediatric Clinics of North America, 113, 645–650.
receive a score of 10.
Apgar, V., & James, L. (1962). Further observation of the
newborn scoring system. American Journal of Diseases of
Children, 104, 419–428.
Behnke, M., Eyler, F., Carter, R., Hardt, N., Cruz, A., &
Resnick, M. (1989). Predictive value of Apgar scores for
Summary
developmental outcome in premature infants. American
Journal of Perinatology, 6, 18–21.
The Apgar scoring system was intended as an evaluative
measure of a newborn’s condition at birth and of the
Blackman, J. (1988). The value of Apgar scores in predicting
8 The Journal of Perinatal Education Vol. 9, No. 3, 2000
developmental outcome at age five. Journal of Perinatology, Fetal acidemia and neonatal encephalopathy. Zeitschrift fur
Geburtshilfe und Neonatologie, 202, 187–191. (abstract).8, 206–210.
Sommerfelt, K., Pedersen, S., Ellertsen, B., & Markestad, T.
Clark, D., & Hakanson, D. (1988). The inaccuracy of Apgar
(1996). Transient dystonia in non-handicapped low-
scoring. Journal of Perinatology, 8, 203–205.
birthweight infants and later neurodevelopment. Acta Pae-
Gibson, C., & Tibbetts, S. (1998). Interaction between mater-
diatrica, 85, 1445–9.
nal cigarette smoking and Apgar scores in predicting of-
. Watch those Apgar scores: Evidence. (1987).
fending behavior. Psychological Reports, 83, 579–586.
Regan Report on Nursing Law, 27, 4.
Jepson, H., Talashek, M., & Tichy, A. (1991). The Apgar
Wolf, M., Beunen, G., Casaer, P., & Wolf, B. (1998). Neonatal
score: Evolution, limitations, and scoring guidelines. Birth:
neurological examination as a predictor of neuromotor out-
Issues in Perinatal Care, 18, 83–92.
come at 4 months in term low-Apgar-score babies in Zim-
Letko, M. (1996). Understanding the Apgar score. Journal
babwe. Early Human Development, 51, 179–186.
of Obstetrical, Gynecological, and Neonatal Nursing, 25,
Wolf, M., Beunen, G., Casaer, P., & Wolf, B. (1997). Neurolog-
299–303.
ical findings in neonates with low Apgar in Zimbabwe.
Livingston, J. (1990). Interrater reliability of the Apgar score
European Journal of Obstetrics, Gynecology, & Reproduc-
in term and premature infants. Applied Nursing Research,
tive Biology, 73, 115–119.
3, 164–165.
Wolf, M., Wolf, B., Bijleveld, C., Beunen, G., & Casaer, P.
Nelson, K., & Ellenberg, J. (1981). Apgar scores as predictors
(1997). Neurodevelopmental outcome in babies with a low
of chronic neurologic disability. Pediatrics, 68, 36–44.
Apgar score from Zimbabwe. Developmental Medicine &
Child Neurology, 39, 821–826.Riehn, A., Petzold, C., Kuhlisch, E., & Distler, W. (1998).
9The Journal of Perinatal Education Vol. 9, No. 3, 2000