Abstract
Assessment of an infant’s condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed.
Impact
-
This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn’s postnatal condition.
-
A revised neonatal scoring system should account for infant maturity and the interventions administered.
-
Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Lara-Canton, I. et al. Oxygen supplementation during preterm stabilization and the relevance of the first 5 min after birth. Front. Pediatr. 8, 12 (2020).
Morton, S. U. & Brodsky, D. Fetal physiology and the transition to extrauterine life. Clin. Perinatol. 43, 395–407 (2016).
Apgar, V. A proposal for a new method of evaluation of the newborn infant. CurrRes AnesthAnalg 32, 260–267 (1953).
Madar, J. et al. European Resuscitation Council Guidelines 2021: newborn resuscitation and support of transition of infants at birth. Resuscitation 161, 291–326 (2021).
O’Donnell, C. P., Kamlin, C. O., Davis, P. G., Carlin, J. B. & Morley, C. J. Interobserver variability of the 5-minute Apgar score. J. Pediatr. 149, 486–489 (2006).
Rudiger, M. & Rozycki, H. J. It’s time to reevaluate the Apgar score. JAMA Pediatr. 174, 321–322 (2020).
Rudiger, M. et al. Neonatal assessment in the delivery room–Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatr. 15, 18 (2015).
Lundsgaard, C. Studies on cyanosis: Ii. Secondary causes of cyanosis. J. Exp. Med. 30, 271–293 (1919).
Kändler L. H. N. & Gorenflo, M. https://www.awmf.org/leitlinien/detail/ll/023-002.html. (2017). Accessed 2021.
O’Donnell, C. P., Kamlin, C. O., Davis, P. G., Carlin, J. B. & Morley, C. J. Clinical assessment of infant colour at delivery. Arch. Dis. Child Fetal Neonatal. Ed. 92, F465–F467 (2007).
Dawson, J. A. et al. Assessing the tongue colour of newly born infants may help to predict the need for supplemental oxygen in the delivery room. Acta Paediatr. 104, 356–359 (2015).
van Vonderen, J. J. et al. Measuring physiological changes during the transition to life after birth. Neonatology 105, 230–242 (2014).
Dawson, J. A. et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 125, e1340–e1347 (2010).
Oei, J. L. et al. Outcomes of oxygen saturation targeting during delivery room stabilisation of preterm infants. Arch. Dis. Child Fetal Neonatal Ed. 103, F446–F454 (2018).
Adams, B. N. & Grunebaum, A. Does “pink all over” accurately describe an Apgar color score of 2 in newborns of color? Obstet. Gynecol. 123, 36S (2014).
Kelman, G. R. & Nunn, J. F. Clinical recognition of hypoxaemia under fluorescent lamps. Lancet 1, 1400–1403 (1966).
Nuntnarumit, P., Rojnueangnit, K. & Tangnoo, A. Oxygen saturation trends in preterm infants during the first 15 min after birth. J. Perinatol. 30, 399–402 (2010).
Rabi, Y., Yee, W., Chen, S. Y. & Singhal, N. Oxygen saturation trends immediately after birth. J. Pediatrics 148, 590–594 (2006).
Vento, M. et al. Oxygen saturation after birth in preterm infants treated with continuous positive airway pressure and air: assessment of gender differences and comparison with a published nomogram. Arch. Dis. Child Fetal Neonatal Ed. 98, F228–F232 (2013).
Boddy, K., Dawes, G. S., Fisher, R., Pinter, S. & Robinson, J. S. Foetal respiratory movements, electrocortical and cardiovascular responses to hypoxaemia and hypercapnia in sheep. J. Physiol. 243, 599–618 (1974).
Giussani, D. A. The fetal brain sparing response to hypoxia: physiological mechanisms. J. Physiol. 594, 1215–1230 (2016).
Hooper, S. B., Polglase, G. R. & te Pas, A. B. A physiological approach to the timing of umbilical cord clamping at birth. Arch. Dis. Child Fetal Neonatal Ed. 100, F355–F360 (2015).
Barcroft, J., Flexner, L. B. & McClurkin, T. The output of the foetal heart in the goat. J. Physiol. 82, 498–508 (1934).
Lakshminrusimha, S., Van & Meurs, K. Better timing for cord clamping is after onset of lung aeration. Pediatr. Res 77, 615–617 (2015).
Rüdiger, M., Wauer, R. R., Schmidt, K. & Kuster, H. The Apgar score. Pediatrics 118, 1314–1315 (2006). author reply 5-6.
Kamlin, C. O., O’Donnell, C. P., Everest, N. J., Davis, P. G. & Morley, C. J. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation 71, 319–321 (2006).
Phillipos, E. et al. Heart rate assessment immediately after birth. Neonatology 109, 130–138 (2015).
Bjorland, P. A. et al. Changes in heart rate from 5 s to 5 min after birth in vaginally delivered term newborns with delayed cord clamping. Arch. Dis. Child Fetal Neonatal Ed. 106, 311–315 (2021).
Dawson, J. A. et al. Changes in heart rate in the first minutes after birth. Arch. Dis. Child Fetal Neonatal Ed. 95, F177–F181 (2010).
Javorka, K. et al. Heart rate variability in newborns. Physiol. Res. 66, S203–S214 (2017).
Rennie J. M. Robertson’s Textbook of Neonatology. (Elsevier, Churchill Livingstone, 2005).
Yanowitz, T. D. et al. Hemodynamic disturbances in premature infants born after chorioamnionitis: association with cord blood cytokine concentrations. Pediatr. Res. 51, 310–316 (2002).
van Henten, T. M. A. et al. Tactile stimulation in the delivery room: do we practice what we preach? Arch. Dis. Child Fetal Neonatal Ed. 104, F661–F662 (2019).
Shah, B. A. et al. Impact of electronic cardiac (ECG) monitoring on delivery room resuscitation and neonatal outcomes. Resuscitation 143, 10–16 (2019).
O’Donnell, C. P., Kamlin, C. O., Davis, P. G. & Morley, C. J. Crying and breathing by extremely preterm infants immediately after birth. J. Pediatr. 156, 846–847 (2010).
Linde, J. E. et al. Predictors of 24-h outcome in newborns in need of positive pressure ventilation at birth. Resuscitation 129, 1–5 (2018).
Hegyi, T. et al. The apgar score and its components in the preterm infant. Pediatrics 101, 77–81 (1998).
Minami, K. et al. Would omitting the assessment of heart rate be harmful to initial neonatal care? J. Matern. Fetal Neonatal. Med. 20, 477–480 (2007).
Walstab, J. E. et al. Factors identified during the neonatal period associated with risk of cerebral palsy. Aust. N. Z. J. Obstet. Gynaecol. 44, 342–346 (2004).
Cnattingius, S. et al. Apgar score components at 5 min: Risks and prediction of neonatal mortality. Paediatr. Perinat. Epidemiol. 31, 328–337 (2017).
Ensing S., et al .707: Association between value of the individual components of the 5 min apgar score and neonatal outcome. 35th Annual Meeting of the Society for Maternal-Fetal Medicine. San Diego, CA: American Journal of Obstetrics and Gynecology; S345 (2015).
Catlin, E. A. et al. The Apgar score revisited: Influence of gestational age. J. Pediatr. 109, 865–868 (1986).
American Heart Association, American Academy of Pediatrics. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: Neonatal resuscitation guidelines. Pediatrics. 117, e1029-e1038 (2006).
Dubowitz, L. M., Dubowitz, V. & Goldberg, C. Clinical assessment of gestational age in the newborn infant. J. Pediatr. 77, 1–10 (1970).
Paro-Panjan, D., Neubauer, D., Kodric, J. & Bratanic, B. Amiel-Tison Neurological assessment at term age: clinical application, correlation with other methods, and outcome at 12 to 15 months. Dev. Med. Child Neurol. 47, 19–26 (2005).
Datta, S. & Maclean, R. R. Neurobiological mechanisms for the regulation of mammalian sleep-wake behavior: reinterpretation of historical evidence and inclusion of contemporary cellular and molecular evidence. Neurosci. Biobehav. Rev. 31, 775–824 (2007).
Walker, D. W. Hypoxic inhibition of breathing and motor activity in the foetus and newborn. Clin. Exp. Pharm. Physiol. 22, 533–536 (1995).
Nylund, L., Dahlin, I. & Lagercrantz, H. Fetal catecholamines and the Apgar score. J. Perinat. Med. 15, 340–344 (1987).
Otamiri, G., Berg, G., Ledin, T., Leijon, I. & Lagercrantz, H. Delayed neurological adaptation in infants delivered by elective cesarean section and the relation to catecholamine levels. Early Hum. Dev. 26, 51–60 (1991).
Sarnat, H. B. & Sarnat, M. S. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch. Neurol. 33, 696–705 (1976).
Rudiger, M. et al. Variations of Apgar score of very low birth weight infants in different neonatal intensive care units. Acta Paediatr. 98, 1433–1436 (2009).
Bashambu, M. T., Whitehead, H., Hibbs, A. M., Martin, R. J. & Bhola, M. Evaluation of interobserver agreement of apgar scoring in preterm infants. Pediatrics 130, e982–e987 (2012).
Pavageau, L., Sanchez, P. J., Steven Brown, L. & Chalak, L. F. Inter-rater reliability of the modified Sarnat examination in preterm infants at 32-36 weeks’ gestation. Pediatr. Res. 87, 697–702 (2020).
Ahmed, M. I., Iqbal, M. & Hussain, N. A structured approach to the assessment of a floppy neonate. J. Pediatr. Neurosci. 11, 2–6 (2016).
Volpe, J. J. Neonatal encephalopathy: an inadequate term for hypoxic-ischemic encephalopathy. Ann. Neurol. 72, 156–166 (2012).
Ojumah, N. et al. Neurological neonatal birth injuries: a literature review. Cureus 9, e1938 (2017).
Abboud, T. K. et al. Comparison of the effects of general and regional anesthesia for cesarean section on neonatal neurologic and adaptive capacity scores. Anesth. Analg. 64, 996–1000 (1985).
Al-Husban, N. et al. Anesthesia for cesarean section: retrospective comparative study. Int J. Women’s Health 13, 141–152 (2021).
Jain, L. & Dudell, G. G. Respiratory transition in infants delivered by cesarean section. Semin. Perinatol. 30, 296–304 (2006).
Lopriore, E., van Burk, G. F., Walther, F. J. & de Beaufort, A. J. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ 329, 143–144 (2004).
Dekker, J. et al. Tactile stimulation to stimulate spontaneous breathing during stabilization of preterm infants at birth: a retrospective analysis. Front. Pediatr. 5, 61 (2017).
Chowdhury, T. et al. Trigeminocardiac reflex: the current clinical and physiological knowledge. J. Neurosurg. Anesthesiol. 27, 136–147 (2015).
Kuypers, K. et al. The effect of a face mask for respiratory support on breathing in preterm infants at birth. Resuscitation 144, 178–184 (2019).
Olver, R. E., Walters, D. V. & Wilson, S. M. Developmental regulation of lung liquid transport. Annu Rev. Physiol. 66, 77–101 (2004).
Hooper, S. B., Te Pas, A. B. & Kitchen, M. J. Respiratory transition in the newborn: a three-phase process. Arch. Dis. Child Fetal Neonatal Ed. 101, F266–F271 (2016).
Joshi, S. & Kotecha, S. Lung growth and development. Early Hum. Dev. 83, 789–794 (2007).
Hooper, S. B. & Harding, R. Fetal lung liquid: a major determinant of the growth and functional development of the fetal lung. Clin. Exp. Pharm. Physiol. 22, 235–247 (1995).
Bekedam, D. J. & Visser, G. H. Effects of hypoxemic events on breathing, body movements, and heart rate variation: a study in growth-retarded human fetuses. Am. J. Obstet. Gynecol. 153, 52–56 (1985).
Page, D. V. & Stocker, J. T. Anomalies associated with pulmonary hypoplasia. Am. Rev. Respir. Dis. 125, 216–221 (1982).
Nimrod, C., Varela-Gittings, F., Machin, G., Campbell, D. & Wesenberg, R. The effect of very prolonged membrane rupture on fetal development. Am. J. Obstet. Gynecol. 148, 540–543 (1984).
Pike, K., Pillow, J. & Lucas, J. S. Long term respiratory consequences of intrauterine growth restriction. Semin Fetal Neonatal Med. 17, 92–98 (2012).
Knox, W. F. & Barson, A. J. Pulmonary hypoplasia in a regional perinatal unit. Early Hum. Dev. 14, 33–42 (1986).
Moessinger, A. C. et al. Time-trends in necropsy prevalence and birth prevalence of lung hypoplasia. Paediatr. Perinat. Epidemiol. 3, 421–431 (1989).
Husain, A. N. & Hessel, R. G. Neonatal pulmonary hypoplasia: an autopsy study of 25 cases. Pediatr. Pathol. 13, 475–484 (1993).
Hapke, F. B. & Barnes, A. C. The obstetric use and effect of fetal respiration of nisentil. Am. J. Obstet. Gynecol. 58, 799–801 (1949).
Ramji, S. et al. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr. Res. 34, 809–812 (1993).
Saugstad, O. D., Rootwelt, T. & Aalen, O. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics 102, e1 (1998).
Andersson, O. et al. Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 min of birth (Nepcord III) - a randomized clinical trial. Matern. Health Neonatol. Perinatol. 5, 15 (2019).
Ersdal, H. L., Mduma, E., Svensen, E. & Perlman, J. M. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: A prospective descriptive observational study. Resuscitation 83, 869–873 (2012).
van der Heijden, M. E. & Zoghbi, H. Y. Development of the brainstem respiratory circuit. Wiley Interdiscip. Rev. Dev. Biol. 9, e366 (2020).
Dawes, G. S., Jacobson, H. N., Mott, J. C., Shelley, H. J. & Stafford, A. The treatment of asphyxiated, mature foetal lambs and rhesus monkeys with intravenous glucose and sodium carbonate. J. Physiol. 169, 167–184 (1963).
American Academy of Pediatrics. Guide for implementation of Helping Babies Breathe (HBB). https://www.healthynewbornnetwork.org/resource/guide-for-implementation-of-helping-babies-breathe-hbb/ (2011). Accessed 2021.
Somannavar, M. S. et al. Evaluating time between birth to cry or bag and mask ventilation using mobile delivery room timers in India: The NICHD global network’s Helping Babies Breathe trial. BMC Pediatr. 15, 93 (2015).
Wilson, G. M. et al. Helping Babies Breathe (2nd edition) implementation on a shoestring budget in Zanzibar, Tanzania. Matern Health Neonatol. Perinatol. 6, 3 (2020).
Lakshminrusimha, S. & Jobe, A. H. Baby’s first cries and establishment of gas exchange in the lung. Am. J. Respir. Crit. Care Med. 204, 11–13 (2021).
Shardonofsky, F. R., Perez-Chada, D., Carmuega, E. & Milic-Emili, J. Airway pressures during crying in healthy infants. Pediatr. Pulmonol. 6, 14–18 (1989).
Siddalingappa, H., Murthy, M. R. N., Kulkarni, P. & Ashok, N. C. Prevalence and factors influencing perinatal mortality in rural mysore, India. J. Clin. Diagn. Res. 7, 2796–699 (2013).
Zafeiriou, D. I. Primitive reflexes and postural reactions in the neurodevelopmental examination. Pediatr. Neurol. 31, 1–8 (2004).
Amiel-Tison, C. Neurological evaluation of the maturity of newborn infants. Arch. Dis. Child 43, 89–93 (1968).
Allen, M. C. & Capute, A. J. The evolution of primitive reflexes in extremely premature infants. Pediatr. Res. 20, 1284–1289 (1986).
Allen, M. C. & Capute, A. J. Tone and reflex development before term. Pediatrics 85, 393–399 (1990).
Jurdi, S. R., Jayaram, A., Sima, A. P., Hendricks & Munoz, K. D. Evaluation of a comprehensive delivery room Neonatal Resuscitation and Adaptation Score (NRAS) compared to the Apgar score: A pilot study. Glob. Pediatr. Health 2, 2333794X15598293 (2015).
Apgar, V., Holaday, D. A., James, L. S., Weisbrot, I. M. & Berrien, C. Evaluation of the newborn infant; second report. JAMA 168, 1985–1988 (1958).
Rüdiger, M. et al. Neonatal assessment in the delivery room–Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatr. 15, 18 (2015).
Dalili, H. et al. Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PLoS ONE 10, e0122116 (2015).
Dalili, H. et al. Comparison of the Combined versus Conventional Apgar Scores in Predicting Adverse Neonatal Outcomes. PLoS ONE 11, e0149464 (2016).
Witcher, T. J. et al. Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability. J. Perinatol. 38, 1476–1482 (2018).
American Academy of Pediatrics Committee on Fetus Newborn, American College of Obstetricians Gynecologists Committee on Obstetric Practice. The Apgar score. Pediatrics 117, 1444–1447 (2006).
Author information
Authors and Affiliations
Consortia
Contributions
M.N. drafted the initial version of the paper and all authors participated in the further writing and critical revision of the paper for important intellectual content. All authors approved the final paper as submitted and agree to be accountable for all aspects of the work.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Niemuth, M., Küster, H., Simma, B. et al. A critical appraisal of tools for delivery room assessment of the newborn infant. Pediatr Res 96, 625–631 (2024). https://doi.org/10.1038/s41390-021-01896-7
Received:
Accepted:
Published:
Issue date:
DOI: https://doi.org/10.1038/s41390-021-01896-7
This article is cited by
-
Impact of in situ simulation training on quality of postnatal stabilization and resuscitation—a before-and-after, non-controlled quality improvement study
European Journal of Pediatrics (2024)
-
Trends in Apgar scores and umbilical artery pH: a population-based cohort study on 10,696,831 live births in Germany, 2008–2022
European Journal of Pediatrics (2024)
