One morning in 1952, when anesthesiologist Dr. Virginia Apgar was eating breakfast in a hospital cafeteria, a medical student commented on the need for a way to assess how well a baby has endured delivery. Dr. Apgar immediately wrote down five evaluation criteria: breathing, heart rate, muscle tone, reflexes, and skin color.
One year later, Dr. Apgar suggested that using these five criteria to generate a score is an effective way to determine which babies are likely to need medical attention after birth.
"A practical method of evaluation of the condition of the newborn infant 1 minute after birth has been described," she wrote in her 1953 proposal paper. "A rating of 10 points described the best possible condition with two points each given for respiratory effort, reflex irritability, muscle tone, heart rate and color."
This method was soon coined the "Apgar score," and the technique was rapidly adopted by clinicians across the globe.
In the first of a series highlighting female role models in medicine, we explore Dr. Apgar's life, career, and lasting legacy, particularly as they apply to healthcare professionals today.
A woman of firsts
Dr. Apgar's list of achievements is impressive. She was the first woman to direct a division at Presbyterian Hospital, the first woman to become a full professor at the College of Physicians and Surgeons of Columbia University, and the first woman to devise a critical tool for neonatal care, to name but a few.
She was also a great advocate for patients. Her relatively simple solution to an unmet clinical need made a key contribution to reducing infant mortality rates.
Importantly, the Apgar score also had a lasting effect on changing the perception of newborn babies. Previously viewed as a byproduct of birth, newborns were now at the center of care in the delivery room.
More than 60 years on, despite significant advances in technology, the Apgar score remains the first medical assessment of a newborn baby.
But why has Dr. Apgar's solution persisted, and what can modern clinicians learn from her approach?
The woman behind the Apgar score
Dr. Apgar graduated from Columbia University College of Physicians and Surgeons as an M.D. in 1933, as one of just nine women in a class of 90.
Despite her promising surgical skills, she specialized in anesthesia, as career opportunities for women in surgery were limited at the time.
Following her training, Dr. Apgar became the director of the newly established Division of Anesthesia at the New York-Presbyterian Department of Surgery - the first woman to hold such a position.
In 1949, Dr. Apgar became a professor of anesthesiology at the Columbia University College of Physicians and Surgeons, making her the first woman to hold a full professorship at the university.
As a professor, she was able to focus more of her attention on research. It was during this time that she developed her interest in obstetric anesthesia, which was an understudied field of medicine.
Dr. Apgar's breakthrough was to follow shortly.
Changing perceptions of newborn care
Though it may seem that the Apgar score was a spur-of-the-moment creation in a hospital cafeteria, evidence suggests that there was much more thought behind its development.
In 1950, there were more than 20 neonatal deaths per 1,000 live births in the United States, and Dr. Apgar was concerned by these figures.
Anoxia - primarily due to obstetric anesthesia - was to blame for the majority of neonatal deaths. However, in the delivery room, the presence of medical staff who were skilled in anesthesiology and resuscitation was sparse.
Furthermore, there was no consensus on what a "normal" newborn state was, nor were there any measures in place to determine which newborns required resuscitation.
The Apgar score filled this void, providing five criteria that clinicians could use to determine a baby's condition 1 minute after birth and whether they required medical assistance.
Most importantly, and as Dr. Apgar herself stated, the Apgar score "gets people to look at the baby." Finally, newborn babies were getting the attention they deserved.
As noted in the March of Dimes archives:
"In essence, the Apgar score was revolutionary because it was the first clinical method to recognize the newborn's needs as a patient. It helped spur the development of neonatology as a medical focus, establishing the need for protocols and facilities such as the newborn intensive care unit to provide specialized care."
Standing the test of time
By the early 1960s, the Apgar score was in use at many hospitals across the U.S.
Dr. Apgar pointed out in a review in 1966 that "five [signs] were chosen which could be evaluated without special equipment and could be taught to the delivery room personnel without difficulty." It is not surprising that the Apgar score quickly gained popularity, being easily implemented in delivery rooms worldwide.
Today, it remains the "gold standard" of newborn evaluation.
The past 60 years have seen some significant advances in neonatal care, such as the introduction of mechanical ventilation and surfactant replacement therapy.
Unsurprisingly, attempts have also been made to improve the Apgar score. In 2010, researchers from Stanford University reported the creation of what they claim is a more "reliable, electronic version of the Apgar score," called PhysiScore.
When tested in preterm babies, PhysiScore demonstrated greater accuracy than the Apgar score, according to study results.
Whether PhysiScore or another form of neonatal assessment will one day supersede the Apgar score remains to be seen, but it seems that its simplicity is holding it in good stead.
"Its convenience, ease of use and applicability in identifying babies that need immediate support helps explain its endurance," Dr. Yasser El-Sayed, of the Department of Obstetrics & Gynecology - Maternal Fetal Medicine at Stanford and member of the American Congress of Obstetricians and Gynecologists, told Medical News Today.
"[...] several investigators have proposed adding to or changing the Apgar score, but so far there hasn't been a major effort to do so," noted Dr. Kristi Watterberg, professor of pediatrics and neonatology at the University of New Mexico and a member of the American Academy of Pediatrics.
"I think that it's so well-known and relatively easy to perform (even though subject to individual variation) that it would be hard to easily change," she told MNT.
Beyond the Apgar score
The development of the Apgar score inspired a wealth of research related to the prevention and treatment of birth defects, much of which Dr. Apgar was involved in.
In 1959, she became director of the division of congenital defects at the National Foundation for Infantile Paralysis (now known as March of Dimes) - a position she held until her death in 1974.
"She also popularized use of the term 'birth defects,' which was more accessible to the public than the medical term 'congenital anomalies,' used by doctors," Dr. Edward R.B. McCabe, chief medical officer of the March of Dimes, told MNT.
"Drawing national attention to birth defects led to the recognition that these conditions are significant contributors to infant mortality," he added. "Dr. Apgar's work at the March of Dimes led to nationwide activities to prevent birth defects and thus reduce infant mortality."
By finding a practical solution for communicating complex medical problems to the public, Dr. Apgar once again demonstrated how a change in perception can have a profound impact on health.
'A powerful role model for women in medicine'
Despite practicing medicine at a time when gender inequality was at a peak, Dr. Apgar claimed that being a woman had not posed any serious limitations on her career.
"Women are liberated from the time they leave the womb," she once said, explaining her decision not to take part in the women's movement.
Behind closed doors, however, Dr. Apgar sometimes spoke of her frustration surrounding disparities among men and women in medicine, particularly when it came to differences in pay - an imbalance that remains evident to this day.
"She was a remarkable woman," Dr. Watterberg told us. "She provided a powerful role model for women in medicine."
Since 1950, the neonatal death rate in the U.S. has fallen dramatically, standing at around 5 per 1,000 live births in 2010.
While the improvement in neonatal survival cannot solely be attributed to Dr. Apgar, there is no doubt that her work played a significant role, and it continues to be pivotal in neonatal care and research.
Her approach to innovation speaks of empathy for the patient and a drive to develop practical solutions that not only raise awareness and change perception, but that can also be effectively translated into clinical practice.
By designing the Apgar score in a way that could be easily implemented in delivery rooms worldwide, Dr. Apgar demonstrated that simple solutions, capable of addressing complex problems, can stand the test of time.
"She [...] left us a lasting tool, the Apgar score, providing a structured approach to evaluate newborns. Her score serves as a common language among the various specialties, including anesthesiology, that care for newborns.
Her score led to better treatment of newborns and to great advances in anesthesia for their mothers. Her score was a unique contribution to anesthesiology, to maternal and child health, and to a generation of researchers dedicated to improved neonatal outcomes."
Dr. Selma H. Calmes, David Geffen School of Medicine, UCLA