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September 1997
Volume 61 |
Number 9
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| And What About
The Baby? Virginia Apgar and the Apgar Score |
Selma Harrison Calmes, M.D.
Newborn babies were often neglected in the delivery room until
the Apgar Score was introduced in 1952 by anesthesiologist Virginia
Apgar, M.D., (1909-1974). The Apgar Score was developed to determine
which babies needed resuscitation but also led to many studies
of possible factors causing poor neonatal outcome. So, the Apgar
Score laid the groundwork for modern neonatology and our current
practice of obstetric anesthesia. This article briefly reviews
the pivotal studies and the many changes in practice which resulted
from the Apgar Score.
A previous ASA NEWSLETTER article documented Dr. Apgar's
life.1 Briefly, she graduated
from Columbia University's College of Physicians and Surgeons
in 1933, started anesthesia training in 1936 and became Chief
of the Division of Anesthesia at Columbia in 1938. After she established
medical anesthesia at Columbia, research became a critical issue.
Researcher-anesthesiologist E.M. Papper, M.D., came from Bellevue
in 1949 as Division Chief, and Dr. Apgar entered obstetric anesthesia.
Dr. Apgar entered obstetric anesthesia at the right time and
in the right place. At that time, obstetric anesthesia was a very
neglected area. There were not enough anesthesiologists to meet
obstetrical needs. Few, if any, residencies required training
in obstetric anesthesia. Little was written on obstetric anesthesia
so there was a great need. Apgar's location in New York City was
also fortuitous. From 1915 through 1933, maternal mortality in
the United States was among the worst in the world, and New York
City was at the center of efforts to improve this. The 1933 report
by a Subcommittee on Maternal Mortality of the New York Academy
of Medicine was especially influential. Columbia's obstetricians
were deeply involved in the subcommittee and the report.2
Although the study was over by the time Dr. Apgar went into obstetric
anesthesia, the atmosphere at Columbia's Sloane Hospital for Women
had to be one of concern for improving maternal mortality from
all causes.
Once Dr. Apgar entered obstetric anesthesia in 1949, anesthesia
residents began rotating in obstetrics. Apgar would teach informally
at the bedside or in the hallway in her enthusiastic, outgoing
teaching style. Teaching tools were a battered pelvis, a skeleton
and Dr. Apgar's own anatomy. Palpating her caudal canal, which
had an unusual angle, was standard. There were few reading assignments
because there was little to read. No didactic teaching took place
until 1958 when Frank Moya, M.D., who had rotated with Dr. Apgar
in 1955, became head of obstetric anesthesia.
During this time, obstetric anesthesia practice at Columbia was
spinal anesthesia or cyclopropane ("cyclo") by mask
for cesarean sections. Caudals were occasionally used for labor.
Saddle blocks, caudals and mask cyclo were used for vaginal delivery.
Curtis L. Mendelson had published his report on aspiration of
gastric contents in pregnant patients in 1946, and Dr. Apgar realized
the risk of aspiration. She and most anesthesiologists of the
time, however, felt that the airway could be managed adequately
by competent anesthesiologists using cyclopropane, even if the
patient was vomiting. It took another 10 years before intubation
was common.3
The idea for the Apgar Score came in 1949 at breakfast in the
hospital cafeteria. A medical student rotating in anesthesia made
a chance remark about the need to evaluate the newborn. Dr. Apgar
said, "That's easy, you would do it like this." She
grabbed the nearest piece of paper, jotted down the five points
of the Apgar Score and then rushed off to OB to try it out. The
Apgar Score was presented at an International Anesthesia Research
Society meeting in 1952 and published in 1953.4
Dr. Apgar originally intended that measurement be done one minute
after birth to see how the infant was making the transition to
extrauterine life. Others started measuring it at longer intervals
to see how the baby had responded to resuscitation, and the one-
and five-minute Apgar Scores became standard.1
She also intended that it be measured by the anesthesiologist
or circulating nurse. She felt the obstetrician always gave 10s
and so should not score.
Ever curious and always dreaming up new projects, which she called
"arbeits," Dr. Apgar identified other neonatal problems.
She developed a test using a suction catheter to rule out choanal
atresia, tracheo-esophageal fistula, duodenal atresia and imperforate
anus soon after birth. This led to her observation that polyhydramnios
was usually associated with congenital defects. This association
was documented for the first time in a 1960 article.4,5
Dr. Apgar was joined in 1955 by a New Zealand pediatrician, L.
Stanley James, M.D. Their first project was to study acid-base
and oxygenation in normal and asphyxiated newborns, with laboratory
support from researcher-anesthesiologist Duncan A. Holaday, M.D.
He had developed a more precise method to measure blood pH. (The
Astrup pH meter was not available until 1960.) Dr. James said:
"People were astounded at how low the (pH) values were.
The newborn infant had a metabolic acidosis as well as respiratory
acidosis ... people did not even believe you could have both
together! Of course you have both of them together in asphyxia!
But those were the days when we were just finding that out.
And we realized that all of these babies at birth were asphyxiated.
No one had appreciated that before. The cord blood at birth
was regarded as the normal intra-uterine environment, (so) it
was concluded that there was no need to correct this state,
as it was normal for the fetus. There was (also) a strong belief
in the protection offered by anaerobic metabolism. Our observations
played a major role in changing our approach to acid-base and
how well we should be oxygenating."6
Other studies followed. Their placental transfusion study led
to important observations. One study baby was born screaming,
then received placental blood and promptly stopped breathing.
The mother was getting cyclopropane, and they realized it had
to be the effect of the cyclopropane.6
Further studies on the effect of maternal anesthetics clearly
demonstrated that cyclopropane was more depressant to the baby
than other anesthetics. These led to the end of cyclo in obstetrics
and also documented for the first time that regional anesthesia
is safest for mother and baby.7,8
The placental transfusion study also led to our present use of
umbilical artery catheterization in neonates. Dr. James wanted
to measure venous pressure in relation to placental transfusion.
He said:
"We decided we would like to see what happened to the
venous pressure at 24 hours. So we recatheterized some infants
after the first day. The cord is somewhat dry at that time,
and Virginia was poking around trying to locate the umbilical
vein. Finally she inserted the catheter. I was recording. My
god! The pressure went off the paper. It was just jumping off
of the ceiling! I said, 'You are in the aorta!' And she said,
'Nonsense! Of course I'm not!' She pulled out the catheter and
there was a great gush of blood. So we got the first recording
ever of an umbilical artery catheterization. We demonstrated
these tracings when visiting the neonatology group in Boston.
Shortly after we had made these observations, the Boston group
used the method for monitoring sick babies and we followed shortly
after that. But there was a great deal of resistance from the
pediatricians and cardiologists."6
Infant resuscitation was poorly understood, and many bizarre
methods were used, as indicated by Dr. James' description:
"In 1955, half the world believed that the only
thing you needed to do to resuscitate a baby was to give him
intragastric oxygen. We proved that intragastric oxygen was
not effective. (We) taught (proper) techniques. Virginia took
me along to the meetings of a special committee on Infant Mortality
of the New York County Medical Society. We set out to review
all resuscitation procedures. A monograph was prepared and published
by the American Medical Association (AMA). Then we had an AMA
convention in New York. We had a whole booth on resuscitation.
Several hundred physicians went through to learn how to use
the laryngoscope. Then we made the movie (on newborn resuscitation,
sponsored by a drug company and widely circulated nationally)."6
These educational efforts led to improvement in infant resuscitation
throughout the country.
In 1959, Dr. Apgar became Director of the new Division of Congenital
Defects at the March of Dimes National Foundation. Her legacy
lives on, however. Previous residents Frank Moya, M.D., and Sol
M. Shnider, M.D., went on to become leaders in obstetric anesthesia.
Every day, clinicians throughout the world use concepts developed
from the research team's work. For example, "depressed babies
are acidotic and hypoxic and should be resuscitated," "neonatal
resuscitation should include airway management, including tracheal
intubation" and "regional anesthesia is safest for mothers
and babies" were all concepts developed by Dr. Apgar and
her team. The effectiveness, simplicity and low cost of Dr. Apgar's
standard evaluation of the newborn and her check for common congenital
defects are other examples of this legacy. Dr. Apgar received
many awards for her work, including the ASA Distinguished Service
Award in 1966.
References:
- Calmes SH. Virginia Apgar, MD:
At the forefront of obstetric anesthesia. ASA NEWSLETTER.
1992; 56(10):9-12.
- Antler J, Fox DM. The movement
toward a safe maternity: Physician accountability in New York
City, 1915-1940. Bull Hist Med. 1976; 50:569-595.
- Interviews with Drs. Frank Moya
and Sol Shnider (deceased); transcripts in possession of author.
- V.
A proposal for a new method of evaluation of the newborn infant.
Curr Res Anes Anal. 1953; 32:260-267.
- Moya F, Apgar V, James LS, Berrien
C. Hydramnios and congenital abnormalities. JAMA. 1960;
173:1552-1556.
- Interview with Dr. L. Stanley
James (deceased); transcript in possession of author.
- Apgar V, Holaday DA, James LS,
Weisbrot IM. Evaluation of the newborn infant - second report.
JAMA. 1958; 168:1985-1988.
- Apgar V, Holaday DA, James LS
et al. Comparison of regional and general anesthesia in obstetrics.
JAMA. 1957; 165:2155-2161.
Selma Harrison Calmes, M.D., is Chief
of Anesthesiology at Olive View Medical Center, Sylmar, California,
affiliated with the University of California at Los Angeles. She
is Clinical Professor of Anesthesiology at UCLA School of Medicine,
Los Angeles,
California.
E-mail the author.
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