In 1953, Dr. Virginia Apgar published a paper proposing a scoring system to evaluate newborns at one minute of life. She believed that the same signs that were traditionally used by anesthesiologists to monitor a patient's condition during surgery could be adopted to assess a baby's condition at sixty seconds after birth and to predict the likelihood of survival. Dr. Apgar selected five criteria that could be easily evaluated by delivery room personnel: heart rate, respiratory effort, reflex irritability, muscle tone, and color. Each criterion was scored 0, 1, or 2, with a total score of 10 indicating that the baby was in the best possible condition.
To validate her scoring system, Dr. Apgar initially reviewed the records of 1025 infants and assigned scores at one minute of life. She found that infants receiving a score of 0-2 had a neonatal death rate of 14%; those receiving a score of 3-7 had a death rate of 1.1%, and those scoring 8-10 had a death rate of 0.13%. Initially, Dr. Apgar grouped her infants as poor (0-2), fair (3-7), and good (8-10).
As more data was accumulated, Dr. Apgar modified the groups to include infants with a score of 3 in the "poor" group and infants with a score of 7 in the "good" group. In 1958, she published a follow-up study of more than 15,000 infants and suggested a modified version of the criteria for assigning Apgar scores. This was followed by more study and refinement in 1962, when Dr. Apgar published a study summarizing her experience with the newborn scoring system from 1952 to 1960. At that time, she confirmed that the Apgar scoring system was a valuable guide both in teaching and in clinical practice in deciding which infants to resuscitate. Dr. Apgar envisioned that her scoring system would help researchers compare the neonatal effects of various obstetric practices and methods of maternal pain relief, as well as the effectiveness of the neonatal resuscitation techniques available at the time (the Apgar scoring system was developed before the modern practice of intubation).
Subsequent studies suggested that the Apgar score did provide some information about infant mortality, but the most significant fact about the one-minute Apgar score is that it became a standard tool in the delivery room for the assessment of a newborn infant. The five-minute Apgar score did not assume a prominent role in neonatal medicine until after a report from the Collaborative Study on Cerebral Palsy showed that the five-minute score was more reliable than the one-minute score in showing neonatal mortality.
Dr. Apgar neither envisioned nor intended that her scoring system would be used as a litigation tool for establishing or negating intrapartum hypoxia or birth asphyxia, or as a prognostic marker for subsequent brain damage and cerebral palsy. Despite this fact, the American College of Obstetricians and Gynecologists has routinely included the Apgar score among its published litigation criteria. The rationale for using the Apgar score as a litigation criterion is predicated on a scientifically invalid hypothesis, namely, that all newborns who suffer hypoxia (or asphyxia) proximate to delivery must have low Apgar scores (0-3) at one, five, and ten minutes. Recent studies have demonstrated that ACOG's self-serving Apgar score criterion does not objectively demonstrate the full range of cases in which an infant with cerebral palsy suffered damaging intrapartum fetal asphyxia.
In cerebral palsy litigation, it is critical that experts rely on objective scientific methods and clinical markers to determine if a child with permanent brain damage was exposed to damaging fetal asphyxia during labor or proximate to the time of birth. Experts should perform a differential diagnosis to determine the timing and etiology of the events leading to a child's cerebral palsy or other neurologic injury.
It is important to note that some of the components of the Apgar score are subjective and may be inconsistent with the newborn's clinical condition, as documented in the chart. In the final analysis, low Apgar scores work well as a tool for the identification of newborns in need of resuscitation and they may have some value when predicting long-term outcome, but scores above three (3) do not exclude the presence of birth asphyxia or damaging intrapartum hypoxia.
© Copyright. Dov Apfel. May 2005. All Rights Reserved.
This web site is not intended as legal advice on cerebral palsy, and is not a substitute for obtaining guidance from your own legal counsel about cerebral palsy litigation. It provides general educational information about the standards of care and causation issues that can arise in obstetrical malpractice and cerebral palsy litigation. Readers of the articles contained within this web site should not act upon the cerebral palsy information without first consulting with a lawyer who is experienced in evaluating and litigating cerebral palsy and obstetrical malpractice cases. Mr. Apfel is admitted to practice law in Maryland and the District of Columbia. When Mr. Apfel is asked to participate in cerebral palsy
litigation filed in other states, he will associate with, and act as co-counsel with, an attorney licensed in that state who is familiar with the local laws and procedures.