APGAR – by Dr. Virginia Apgar 1952


What is the purpose?

Reports status of newborn immediately after birth and the response to resuscitation

Keeps a record of fetal to neonatal transition

Does not provide evidence of asphyxia

Cannot predict mortality, morbidity or prognosis

Taken at 1,5,10,15 minutes, until 20 minutes in infants who score <7.

if it remains 0 beyond 10 minutes –> consider discontinuation of resuscitative efforts, due to mortality and poor neurologic outcomes.

Keep in mind, an APGAR score is a snapshot and has subjective components (tone, colour, reflex irritability). It can also be influenced by maternal sedation/anesthesia, congenital malformations (cardiopulmonary/neurologic), gestational age, resuscitation, trauma.

What score is reassuring?

5 minutes –>  7 to 10, as this makes it unlikely to have an intrapartum HIE.

At 5+ minutes, a score of 0-3 may indicate early signs of encephalopathy, but cannot predict outcome of neurologic function.

Poor neurologic outcome if apgar is 0-3 at 10, 15 and 20 minutes.

If apgar of 0-5 at 5 minutes –> obtain UA gas (from a clamped section of umbilical cord) + send placenta for pathology.

Population studies: most infants with low apgars will not develop CP, but low apgar <5 at 5 minutes confers risk of CP as high as 20-200 fold over infants whose apgar at 5 minutes is 7-10.

Most with low apgars will not go on to develop CP.

A – appearance/colour – pink, screen-shot-2016-11-11-at-7-14-28-pm

P – pulse

G – grimace

A – activity (muscular/vigorous)

R – respirations

Remember to start resuscitation immediately, and not to wait until the 1 minute score, should there be concerns with the baby’s colour, tone, heart rate, breathing, cry.

Apgar alone does not rule in or out “Asphyxia” which is a marked impairment of gas exchange, that can lead to progressive hypoxemia, hypercapnia, and significant metabolic acidosis. Asphyxia describes a process of varying severity and duration, rather than an end point. Should only be applied if specific evidence of “markedly impaired intrapartum or immediate postnatal gas exchange can be documented on the basis of laboratory tests results”

In order to document an intrapartum hypoxic event, many factors including NRFHR, abnormal UA gas, EEG, neuroimaging studies, cerebral function, placental pathology, hematologic studies and multisystem organ dysfunction need to be considered in diagnosing an intrapartum HIE.

Normal or indeterminate FHR + Apgar 7 or higher at 5 minutes a normal umbilical artery gas is not consistent with HIE.

Reference: PEDIATRICS Volume 136, number 4, October 2015 http://pediatrics.aappublications.org/content/pediatrics/136/4/819.full.pdf

screen-shot-2016-11-11-at-7-06-22-pmThe expanded version is more useful as it can take into account resuscitative interventions. Documentation in the comments section can include delayed cord clamping (1) time of birth, (2) clamping (3) initiation of resuscitation.

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