Laceration of the Tissues During the Delivery of a Baby Apgar Score

Number 644 (Replaces Committee Opinion Number 333, May 2006. Reaffirmed 2021)

Commission on Obstetric Practice

American Academy of Pediatrics—Committee on Fetus and Newborn

This document reflects emerging clinical and scientific advances every bit of the engagement issued and is bailiwick to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. This certificate reflects emerging concepts on patient safety and is subject to alter. The information should not be construed every bit dictating an exclusive form of treatment or procedure to exist followed.

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ABSTRACT: The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after nativity and the response to resuscitation if needed. The Apgar score lone cannot be considered to be evidence of or a consequence of asphyxia, does non predict individual neonatal mortality or neurologic outcome, and should not be used for that purpose. An Apgar score assigned during a resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions.

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Introduction

In 1952, Dr. Virginia Apgar devised a scoring organization that was a rapid method of assessing the clinical condition of the newborn baby at ane minute of historic period and the demand for prompt intervention to constitute animate one. A second written report evaluating a larger number of patients was published in 1958 ii. This scoring organisation provided a standardized assessment for infants afterward delivery. The Apgar score comprises five components: 1) color, two) middle rate, 3) reflexes, 4) musculus tone, and 5) respiration, each of which is given a score of 0, one, or two. Thus, the Apgar score quantitates clinical signs of neonatal depression such as cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or gasping respirations. The score is reported at 1 infinitesimal and five minutes after nascence for all infants, and at 5-minute intervals thereafter until twenty minutes for infants with a score less than 7 3. The Apgar score provides an accepted and convenient method for reporting the condition of the newborn infant immediately after birth and the response to resuscitation if needed; yet, information technology has been inappropriately used to predict individual agin neurologic consequence. The purpose of this statement is to place the Apgar score in its proper perspective. This statement revises the 2006 College Committee Opinion and AAP Policy Argument to include updated guidance from Neonatal Encephalopathy and Neurologic Outcome, Second Edition, forth with new guidance on neonatal resuscitation.

The Neonatal Resuscitation Programme guidelines state that the Apgar score is

useful for conveying data about the newborn's overall status and response to resuscitation. However, resuscitation must exist initiated earlier the 1-minute score is assigned. Therefore, the Apgar score is not used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to apply them 3.

An Apgar score that remains 0 across 10 minutes of age may, however, exist useful in determining whether continued resuscitative efforts are indicated considering very few infants with an Apgar score of 0 at 10 minutes accept been reported to survive with a normal neurologic outcome 3 4 5. In line with this, the 2011 Neonatal Resuscitation Programme guidelines state that "if you can confirm that no heart charge per unit has been detectable for at least x minutes, discontinuation of resuscitative efforts may exist appropriate" 3.

Neonatal Encephalopathy and Neurologic Outcome, Second Edition, published in 2014 past the College in collaboration with the AAP, defines a v-minute Apgar score of 7–ten as reassuring, a score of 4–half dozen as moderately abnormal, and a score of 0–3 equally low in the term infant and belatedly-preterm babe half-dozen. That certificate considers an Apgar score of 0–3 at v minutes or more as a nonspecific sign of illness, which "may be ane of the first indications of encephalopathy" six. However, a persistently low Apgar score lone is non a specific indicator for intrapartum compromise. Further, although the score is used widely in upshot studies, its inappropriate use has led to an erroneous definition of asphyxia. Asphyxia is defined as the marked impairment of gas exchange leading, if prolonged, to progressive hypoxemia, hypercapnia, and meaning metabolic acidosis. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should non be applied to nascence events unless specific evidence of markedly impaired intrapartum or immediate postnatal gas substitution can be documented based on laboratory testing 6.

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Limitations of the Apgar Score

It is of import to recognize the limitations of the Apgar score. The Apgar score is an expression of the infant's physiologic condition at one betoken in time, which includes subjective components. There are numerous factors that can influence the Apgar score, including maternal sedation or anesthesia, congenital malformations, gestational historic period, trauma, and interobserver variability 6. In addition, the biochemical disturbance must exist pregnant before the score is affected. Elements of the score such as tone, color, and reflex irritability can exist subjective, and partially depend on the physiologic maturity of the infant. The score also may be affected by variations in normal transition. For case, lower initial oxygen saturations in the first few minutes need not prompt firsthand supplemental oxygen administration; the Neonatal Resuscitation Program targets for oxygen saturation are lx–65% at 1 minute and lxxx–85% at 5 minutes 3. The healthy preterm baby with no evidence of asphyxia may receive a low score simply because of immaturity 7 viii. The incidence of low Apgar scores is inversely related to birth weight, and a low score cannot predict morbidity or mortality for any private infant 8 9. Equally previously stated, information technology also is inappropriate to use an Apgar score alone to diagnose asphyxia.

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Apgar Score and Resuscitation

The 5-minute Apgar score, and particularly a change in the score between 1 minute and 5 minutes, is a useful index of the response to resuscitation. If the Apgar score is less than seven at 5 minutes, the Neonatal Resuscitation Program guidelines state that the assessment should be repeated every v minutes for up to 20 minutes 3. However, an Apgar score assigned during a resuscitation is not equivalent to a score assigned to a spontaneously animate babe 10. In that location is no accepted standard for reporting an Apgar score in infants undergoing resuscitation after birth because many of the elements contributing to the score are altered by resuscitation. The concept of an assisted score that accounts for resuscitative interventions has been suggested, only the predictive reliability has not been studied. In lodge to correctly depict such infants and provide accurate documentation and data collection, an expanded Apgar score report course is encouraged Figure 1. This expanded Apgar score too may prove to exist useful in the setting of delayed cord clamping, where the time of nascence (complete delivery of the infant), the fourth dimension of string clamping, and the time of initiation of resuscitation all can exist recorded in the comments box.

The Apgar score alone cannot be considered to be evidence of or a consequence of asphyxia. Many other factors, including nonreassuring fetal heart rate monitoring patterns and abnormalities in umbilical arterial blood gases, clinical cerebral part, neuroimaging studies, neonatal electroencephalography, placental pathology, hematologic studies, and multisystem organ dysfunction demand to be considered in diagnosing an intrapartum hypoxic–ischemic consequence 5. When a Category I (normal) or Category Two (indeterminate) fetal eye rate tracing is associated with Apgar scores of 7 or college at five minutes, a normal umbilical cord arterial blood pH (± 1 standard difference), or both, information technology is non consistent with an acute hypoxic–ischemic event 6.

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Prediction of Outcome

A 1-minute Apgar score of 0–3 does not predict any individual infant'southward issue. A 5-minute Apgar score of 0–3 correlates with neonatal mortality in large populations 11 12, but does not predict individual hereafter neurologic dysfunction. Population studies have uniformly reassured the states that most infants with low Apgar scores will not develop cognitive palsy. However, a low five-infinitesimal Apgar score clearly confers an increased relative risk of cognitive palsy, reported to be as high as 20-fold to 100-fold over that of infants with a 5-infinitesimal Apgar score of 7–10 9 xiii xiv 15. Although individual run a risk varies, the population risk of poor neurologic outcomes also increases when the Apgar score is iii or less at ten minutes, 15 minutes, and 20 minutes 16. When a newborn has an Apgar score of v or less at 5 minutes, umbilical artery blood gas from a clamped section of the umbilical cord should be obtained, if possible 17. Submitting the placenta for pathologic examination may be valuable.

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Other Applications

Monitoring of low Apgar scores from a delivery service tin can be useful. Private case reviews tin can identify needs for focused educational programs and improvement in systems of perinatal intendance. Analyzing trends allows for the cess of the effect of quality improvement interventions.

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Conclusions

The Apgar score describes the condition of the newborn infant immediately later on nascence and, when properly applied, is a tool for standardized assessment eighteen. It also provides a mechanism to record fetal-to-neonatal transition. Apgar scores exercise not predict individual mortality or adverse neurologic outcome. Still, based on population studies, Apgar scores of less than 5 at 5 minutes and 10 minutes clearly confer an increased relative risk of cognitive palsy, and the degree of aberration correlates with the risk of cerebral palsy. Most infants with low Apgar scores, even so, will not develop cerebral palsy. The Apgar score is affected by many factors, including gestational age, maternal medications, resuscitation, and cardiorespiratory and neurologic weather condition. If the Apgar score at 5 minutes is 7 or greater, information technology is unlikely that peripartum hypoxia–ischemia caused neonatal encephalopathy.

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Recommendations

• The Apgar score does not predict individual neonatal mortality or neurologic outcome, and should not be used for that purpose.

• It is inappropriate to use the Apgar score alone to constitute the diagnosis of asphyxia. The term asphyxia, which describes a procedure of varying severity and duration rather than an cease point, should not be applied to birth events unless specific prove of markedly impaired intrapartum or immediate postnatal gas substitution tin be can be documented.

• When a newborn has an Apgar score of five or less at 5 minutes, umbilical avenue blood gas from a clamped department of umbilical cord should be obtained. Submitting the placenta for pathologic examination may be valuable.

• Perinatal health care professionals should exist consistent in assigning an Apgar score during resuscitation; therefore, the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (the College) encourage use of an expanded Apgar score reporting class that accounts for concurrent resuscitative interventions.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score

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