Who Was Virginia Apgar and How Good is Her Scoring System?

Patient Presentation
A medical student had seen a 6-month-old, former 32 week premature female in the clinic for a health supervision visit. The past medical history showed the infant had some mild respiratory distress at birth that was treated with nasal canula oxygen for 48 hours. She had done very well and was discharged at 32 days of life after she had learned to feed well orally. The pertinent physical exam revealed a smiling infant with growth parameters below the 5th percentile for chronological age but at the 5-10% when corrected for prematurity with a curve showing good catchup growth. The rest of her examination was normal including her development which found her to roll over from front to back, bring her hands to midline and starting to transfer objects, and she was cooing with various vowel sounds.
The diagnosis of a healthy former premature infant was made, and she was given routine health maintenance information. She had an appointment with the neonatal follow-up program in about a month to monitor her weight and development.

The medical student had several questions about premature infants, but in particular had noted the infant’s initial Apgar score was 6 and a 5-minute Apgar score of 8. He thought these were low and also asked how good the Apgar scores were for predicting how well the infant would do. The attending physician gave him a brief history of the Apgar score and emphasized that it was a measure of the status of the infant at that time only and wasn’t good for predicting outcomes. The attending said, “It really gives everyone an idea of how well the infant is transitioning from fetus to neonate at that point in time. The change in the score is even more important if the infant wasn’t doing very well to begin with and then we can see how the infant is responding to our resuscitation efforts. You always want to see the scores go up if they are initially low and you want them to remain high if they were high to begin with. Low scores aren’t good but they aren’t predictive by themselves. I suppose there are sensitivities and specificities for using the scores with certain groups of infants but I don’t think there is standard specificity and sensitivity overall as neonates are such a diverse group of patients.”

Dr. Virginia Apgar was the first woman at Columbia University College of Physicians and Surgeons to hold a full professorship. She was also the Chairman of the Department of Anesthesia and was interested in obstetrical anesthesia and newborn resuscitation. Although it is unclear how she developed the “Apgar score,” a peer of hers says she began to be upset at the lack of resuscitation and treatment efforts for “…apneic, small for age or malformed newborns…[She]began to resuscitate these infants and to develop a scoring system that would ensure observation and documentation of the true condition of each newborn during the first minute of life.” The first minute was used because clinical depression is often maximal at this time. Pictures and a fuller biography of Dr. Apgar can be found on the Changing Face of Medicine website from the National Library of Medicine.

The scoring system gives 0-2 points for 5 different signs. The scoring system using the mneumonic “APGAR” is

Sign						0			1					2
Appearance - Color			Blue or pale	Acrocyanosis			Completely pink
Pulse - Heart Rate			Absent		 100/minute
Grimace - Reflex irritability	 No response	Grimace				Cry or active withdrawal
Activity - Muscle tone		Limp	 		Some Flexion			Active motion
Respiration				Absent		Weak cry or hypovention	Good cry

Basic interpretation of the scores is

    0-4 = Severely depressed infants
    5-7 = Mildly depressed infants
    8-10 = Vigorous infants

Learning Point
The Apgar scoring system is very good because it is easy to learn, to apply, can be standardized and requires no special equipment. It focuses attention on the infant’s condition immediately after birth and can be a method to do ongoing assessment of the efficacy of the resuscitation efforts. There are problems with the scoring system though. Color, reflexes and muscle tone are subjective signs. Low birth weight and prematurity often have low scores. Congenital anomalies, hypoxia, hypovolemia, trauma and maternal drugs can also affect the score, as well as resuscitation efforts.

Initially the scoring system was used at 1 minute of life but was expanded to be used at 5 minutes, when it was shown to be correlated with neonatal mortality. A 5 minute score and particularly the change “…in the score between 1 and 5 minutes, is a useful index of the response to resuscitation.”

The scoring system was unfortunately abused. While low Apgar scores at longer time frames (ie. 5, 10, 15, and 20 minutes) after delivery indicate continued problems with the infant, they cannot by themselves indicate outcomes. More recent studies have found that low 5 minute Apgar scores (0-3 range) still correlate with neonatal mortality, but they do not correlate with neonatal morbidity with poor correlation with neurological outcomes in the future.

The American Academy of Pediatrics and the American College of Obstetrics and Gynecology in 1996 developed guidelines for determining hypoxic-ischemic encephalopathy.
All of the following must be present for the definition of asphyxia that is severe enough to result in neurological injury.

  • “Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained
  • Persistence of an Apgar score of 0-3 for longer than 5 minutes
  • Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
  • Multiple organ involvement (eg, kidney, lungs, liver, heart, intestines)”

The Apgar score continues to be an excellent scoring system for initial and ongoing assessment of the newborn in the very early perinatal period when properly used. The American Academy of Pediatrics recommends using an expanded scoring form which includes the 5 Apgar signs but with correlated documentation of the resuscitation efforts including amount of oxygen used, oxygen delivery method used (ie positive-pressure ventilation or nasal continuous positive airway pressure, intubation) chest compressions and epinephrine. A copy of the scoring form can be found in the To Learn More section below.

Questions for Further Discussion
1. What other pediatric subspecialties were started or influenced by non-pediatricians?
2. At what gestational age and/or weight is functional viability for preterm infants at your institution?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Newborn Screening

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Apgar V. A proposal for a new method of evaluation of the newborn infant. Anesth Analg 1953;32:260-7.

Committee on Fetus and Newborn, American Academy of Pediatrics and Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Use and Abuse of the Apgar Score. Pediatrics. 1996;98;141-142.

Changing the Face of Medicine Exhibition. National Library of Medicine. Virginia Apgar. Available from the Internet at http://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_12.html (exhibition closed 11/19/2005, cited 10/13/11).

Finster M, Wood M. The Apgar score has survived the test of time. Anesthesiology. 2005 Apr;102(4):855-7.

American Academy of Pediatrics, Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2006;117:1444-1447.

Zanelli SA, Rosenkranz T. Hypoxic-Ischemic Encephalopathy. Medscape. Available from the Internet at http://emedicine.medscape.com/article/973501-clinical (rev. 8/17/2011, cited 10/13/11).

ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    16. Learning of students and other health care professionals is facilitated.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital