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A.P.G.A.R. Scores Related to Birth Injuries

Please note, that an A.P.G.A.R. score standing alone is not sufficient to establish or rule out a birth injury related to infant brain damage, oxygen deprivation, birth trauma, or cerebral palsy.

In determining whether or not a birth injury is related to oxygen deprivation during labor various scientific methods are used.  This is crucial because various components of the A.P.G.A.R. score are subjective and may not directly indicate a newborn’s clinical condition.

Low A.P.G.A.R. scores are a tool to identify the need for resuscitation and they may have some value when predicting long-term outcome, but scores above three do not exclude the presence of birth injury.

This is why at Latona Law we say “Every Birth Injury Deserves to be Investigated”.

A.P.G.A.R. Background

The A.P.G.A.R. score was developed in 1952 by Dr. Virginia Apgar, an anesthesiologist.  The test was designed to quickly evaluate a newborn’s physical condition and to see if there is an immediate need for extra medical or emergency care.

The test is usually administered at 1 minute after birth, and again at 5 minutes after birth.  At one-minute, a baby’s A.P.G.A.R. score indicates how well the baby tolerated the process of birth.  At five minutes, the second score, demonstrates how well the baby is doing in the world outside the mother’s womb. Five areas; Appearance, Pulse, Grimace, Activity and Respiration are assessed and assigned a value of 0, 1 or 2 points, and the score is the sum of the five areas.

A.P.G.A.R. Assessment Areas

Appearance – the color of the baby is assessed for any blue spots.  If the infant is born with entirely pale blue skin then the score is zero; bluish extremities will result in a 1 and entirely pink skinned body will result in a score of 2.

Pulse – if there is no heartbeat then a zero is assigned; a rate less than 100 beats per minute will score a 1 and a heart rate greater than 100 beats per minute will receive a 2. 

Grimace – the reflexes of the infant will be tested based on the grimace response or the irritability; this test will be carried out through physical stimulation such as a small pinch.  No reaction to the pinch will result in a zero score; if the infant grimaces in response a 1 is assigned; if the response is a sneeze, cough or loud cry then a 2 will be assigned.

Activity – baby should be moving around, not limp.  Loose muscles will lead to a zero in the test whereas a small amount of muscle tone will mean a score of 1; if the baby shows signs of active motion, then a 2 will be assigned.

Respiration – the breathing effort of the baby is checked to ascertain whether the child needs assisted breathing.  The test may be scored a zero in case the baby isn’t breathing; a 1 is allotted when the infant is taking slow or irregular breaths; a 2 is scored when the infant is crying without hindrance.

A.P.G.A.R. Evaluation System

The A.P.G.A.R. score is based on a total score of 0 to 10.  The higher the score, the better the baby is doing after birth.

A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health.  A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal after birth.

Any score lower than 7 is a sign that the baby needs medical attention.  The lower the score, the more help the baby needs to adjust outside the mother’s womb.  A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance, or in the form of suctioning if breathing has been obstructed by mucus.

With a score of 0-3 the newborn is unresponsive, pale, limp, and may not have a pulse; therefore, an infant with a score of 0-3 needs immediate resuscitation.  A newborn with an Apgar score in this range generally requires advanced medical care and emergency measures, such as assisted breathing, administration of fluids or medications, and observation in a neonatal intensive care unit.

The score is reported at 1 minute and 5 minutes after birth for all infants, and at 5 minute intervals thereafter until 20 minutes for infants with a score less than 7.  A low 5 minute A.P.G.A.R. score clearly confers an increased relative risk of cerebral palsy, reported to be as high as 20 fold to 100 fold over that of infants with a 5 minute A.P.G.A.R. score of 7-10.  The risk of poor neurologic outcomes also increases when the Apgar score is 3 or less at 10 minutes, 15 minutes, and 20 minutes.

However, it is important to remember the A.P.G.A.R. score describes the condition of the newborn immediately after birth and when properly applied, is a tool for standardized assessment and is not designed to predict the future health of the child.

Causes of Low A.P.G.A.R. Scores

Causes of a low A.P.G.A.R. score vary widely.  Anything that causes trauma or oxygen deprivation to the infant can cause a low A.P.G.A.R. score at birth.  Below are just a few possible causes:

Precipitous labor and delivery – Oxygen deficiency called Hypoxia can occur from a fast birth due to strong contractions or trauma to the baby’s head.  Excessive uterine activity can also be causes when Pitocin or other labor inducing medications are administered causing very strong and frequent contractions.

Nuchal cord – If the cord is wrapped around the fetal neck and obstructs blood flow.

Prolapsed cord – occurs when the cord becomes trapped in the birth canal before the fetus is delivered.

Uterine rupture – occurs when the wall of the uterus (womb) tears open during delivery

Placental abruption – can cause low infant scores because the placenta separates from the uterus before delivery, interrupting blood and oxygen flow.

Trauma – head trauma during the delivery of an infant can occur during the use of forceps or vacuum extractors; cephalopelvic disproportion (mother’s pelvis is too small for the size of the baby; Macrosomia (large baby); breech or face presentation; or shoulder dystocia (the shoulder of the infant is stuck on the mother’s pelvic bone)

Severe Preeclampsia – high maternal blood pressure

Meconium aspiration – fetal distress can cause a bowel movement (mecomium) in utero during which the infant may inhale some meconium into the lungs, thus causing respiratory problems.

Undiagnosed or improperly treated maternal infections– such as Group B Strep (GBS) and Herpes Simplex Virus (HSV)

Maternal analgesics and/or anesthetics – narcotic drugs (normally given within 4 hours before birth) that pass from the mother to the fetus can suppress the ability of the fetus to breath.

Preterm infants – immature lungs and hypoglycemia are a couple of problems that can occur with preterm infants.

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