An Apgar Score of 4 Would Indicate That a Baby Is ______

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

Committee on Obstetric Practise

American Academy of Pediatrics—Commission on Fetus and Newborn

This certificate reflects emerging clinical and scientific advances as of the appointment issued and is subject to alter. The information should not be construed as dictating an sectional form of treatment or procedure to be followed. This document reflects emerging concepts on patient safety and is subject to modify. The data should not be construed equally dictating an sectional course of handling or process to be followed.

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Abstract: The Apgar score provides an accepted and convenient method for reporting the status of the newborn baby immediately subsequently birth and the response to resuscitation if needed. The Apgar score solitary cannot be considered to be show of or a consequence of asphyxia, does not predict individual neonatal bloodshed or neurologic issue, 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 babe. The American Academy of Pediatrics and the American Higher of Obstetricians and Gynecologists encourage utilise 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 system that was a rapid method of assessing the clinical status of the newborn baby at 1 minute of historic period and the need for prompt intervention to plant breathing one. A 2d study evaluating a larger number of patients was published in 1958 2. This scoring system provided a standardized assessment for infants after commitment. The Apgar score comprises five components: i) colour, 2) center rate, three) reflexes, iv) musculus tone, and 5) respiration, each of which is given a score of 0, 1, or ii. Thus, the Apgar score quantitates clinical signs of neonatal low such as cyanosis or pallor, bradycardia, depressed reflex response to stimulation, hypotonia, and apnea or gasping respirations. 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 3. The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed; withal, it has been inappropriately used to predict private agin neurologic issue. 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 Statement to include updated guidance from Neonatal Encephalopathy and Neurologic Effect, Second Edition, along with new guidance on neonatal resuscitation.

The Neonatal Resuscitation Program guidelines country that the Apgar score is

useful for conveying information about the newborn's overall condition and response to resuscitation. Still, resuscitation must be initiated earlier the 1-minute score is assigned. Therefore, the Apgar score is non used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to utilise them 3.

An Apgar score that remains 0 beyond 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 have been reported to survive with a normal neurologic effect 3 4 v. In line with this, the 2011 Neonatal Resuscitation Plan guidelines state that "if you tin confirm that no heart rate has been detectable for at least 10 minutes, discontinuation of resuscitative efforts may be advisable" 3.

Neonatal Encephalopathy and Neurologic Outcome, Second Edition, published in 2014 by the College in collaboration with the AAP, defines a 5-minute Apgar score of seven–10 as reassuring, a score of iv–6 every bit moderately aberrant, and a score of 0–three as low in the term baby and belatedly-preterm baby 6. That document considers an Apgar score of 0–iii at 5 minutes or more every bit a nonspecific sign of illness, which "may be one of the first indications of encephalopathy" half-dozen. Withal, a persistently low Apgar score alone is not a specific indicator for intrapartum compromise. Further, although the score is used widely in outcome studies, its inappropriate use has led to an erroneous definition of asphyxia. Asphyxia is defined equally the marked impairment of gas commutation leading, if prolonged, to progressive hypoxemia, hypercapnia, and significant metabolic acidosis. The term asphyxia, which describes a process of varying severity and duration rather than an cease indicate, should non be applied to birth events unless specific bear witness of markedly impaired intrapartum or firsthand postnatal gas exchange tin 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 baby'south physiologic condition at one point in time, which includes subjective components. In that location are numerous factors that can influence the Apgar score, including maternal sedation or anesthesia, congenital malformations, gestational historic period, trauma, and interobserver variability half-dozen. In addition, the biochemical disturbance must exist pregnant before the score is afflicted. Elements of the score such as tone, color, and reflex irritability tin can be subjective, and partially depend on the physiologic maturity of the baby. The score besides may be afflicted by variations in normal transition. For example, lower initial oxygen saturations in the first few minutes demand non prompt firsthand supplemental oxygen administration; the Neonatal Resuscitation Program targets for oxygen saturation are 60–65% at 1 minute and 80–85% at five minutes three. The healthy preterm infant with no prove of asphyxia may receive a low score only because of immaturity 7 eight. The incidence of low Apgar scores is inversely related to nascence weight, and a low score cannot predict morbidity or mortality for whatever individual infant 8 9. Every bit previously stated, information technology likewise is inappropriate to use an Apgar score solitary 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 7 at v minutes, the Neonatal Resuscitation Program guidelines state that the assessment should exist repeated every 5 minutes for up to xx minutes 3. Notwithstanding, an Apgar score assigned during a resuscitation is not equivalent to a score assigned to a spontaneously animate babe 10. There is no accepted standard for reporting an Apgar score in infants undergoing resuscitation after birth considering 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, but the predictive reliability has not been studied. In order to correctly describe such infants and provide authentic documentation and data collection, an expanded Apgar score report form is encouraged Effigy one. This expanded Apgar score likewise may prove to be useful in the setting of delayed string clamping, where the time of nascency (complete delivery of the baby), the time of cord clamping, and the time of initiation of resuscitation all tin can be recorded in the comments box.

The Apgar score solitary cannot exist considered to be evidence of or a upshot of asphyxia. Many other factors, including nonreassuring fetal eye rate monitoring patterns and abnormalities in umbilical arterial claret gases, clinical cerebral function, neuroimaging studies, neonatal electroencephalography, placental pathology, hematologic studies, and multisystem organ dysfunction need to be considered in diagnosing an intrapartum hypoxic–ischemic issue 5. When a Category I (normal) or Category II (indeterminate) fetal heart charge per unit tracing is associated with Apgar scores of 7 or higher at 5 minutes, a normal umbilical cord arterial claret pH (± 1 standard deviation), or both, information technology is non consequent with an acute hypoxic–ischemic event 6.

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Prediction of Outcome

A 1-minute Apgar score of 0–three does not predict any individual baby's effect. A v-minute Apgar score of 0–iii correlates with neonatal mortality in big populations 11 12, simply does not predict individual futurity neurologic dysfunction. Population studies accept uniformly reassured u.s. that almost infants with low Apgar scores will not develop cognitive palsy. Withal, a low five-minute Apgar score clearly confers an increased relative risk of cerebral palsy, reported to exist equally high as 20-fold to 100-fold over that of infants with a five-minute Apgar score of 7–10 9 13 14 xv. Although individual risk varies, the population risk of poor neurologic outcomes also increases when the Apgar score is 3 or less at 10 minutes, fifteen minutes, and twenty minutes 16. When a newborn has an Apgar score of 5 or less at five minutes, umbilical artery claret gas from a clamped section of the umbilical cord should be obtained, if possible 17. Submitting the placenta for pathologic exam may be valuable.

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Other Applications

Monitoring of low Apgar scores from a delivery service can be useful. Individual case reviews can identify needs for focused educational programs and improvement in systems of perinatal care. Analyzing trends allows for the assessment of the result of quality improvement interventions.

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Conclusions

The Apgar score describes the condition of the newborn infant immediately subsequently birth and, when properly practical, is a tool for standardized assessment eighteen. It also provides a mechanism to record fetal-to-neonatal transition. Apgar scores practice not predict individual mortality or agin neurologic outcome. Nevertheless, based on population studies, Apgar scores of less than 5 at 5 minutes and 10 minutes clearly confer an increased relative risk of cerebral palsy, and the caste of abnormality correlates with the risk of cerebral palsy. Most infants with depression Apgar scores, notwithstanding, will not develop cerebral palsy. The Apgar score is affected by many factors, including gestational historic period, maternal medications, resuscitation, and cardiorespiratory and neurologic conditions. If the Apgar score at v minutes is vii 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 apply the Apgar score alone to establish the diagnosis of asphyxia. The term asphyxia, which describes a process of varying severity and duration rather than an end point, should non be applied to birth events unless specific testify of markedly dumb intrapartum or immediate postnatal gas exchange tin be tin can exist documented.

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

• Perinatal health intendance professionals should be consistent in assigning an Apgar score during resuscitation; therefore, the American Academy of Pediatrics (AAP) and the American Higher of Obstetricians and Gynecologists (the College) encourage use of an expanded Apgar score reporting form 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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