The above recording of a baby’s APGAR Score is a daily routine
in delivery rooms across the United States and in other
countries.2
3
4
5 In 1953, Virginia Apgar, M.D.,
developed the APGAR Score to provide medical science with a uniform
method of observation and evaluation of a newborn infant’s need
for resuscitation immediately after delivery at one minute and again
at five minutes. The score is significant because one person in the
delivery room evaluates the infant using five signs in an objective,
standard and measurable manner. James Nelson, M.D., a neonatologist
(specialist in newborns), reported that the development of the score
provided medical science with a “yardstick” to measure
critical functions of a newborn after
delivery.6 The five signs observed
and noted after birth were heart rate, respiratory rate, reflex
irritability, muscle tone and
color.7 Prior to the measure being
named the “APGAR Score,” the idea for such a measurement
was published in 1953, designated as “A Proposal for a New
Method of Evaluation of the Newborn
Infant.”8 Little did Apgar
realize that this method of evaluation would become a standard of
medical practice.9 Apgar maintained
that after nine months of observing the mother, at least a one minute
assessment of the baby was
warranted.10
The need to observe and assess a baby immediately after birth
played a major role in the development of the APGAR score. This
development was influenced by other historical and social changes
taking place in the United States. These were: World War II and the
post-war “Baby Boom”; more births occurring in a hospital
setting versus the home; the place of women physicians in medicine;
and the realization that the infant was actually a second patient in
the delivery room, not just an extension of the mother.
The genesis for the development of the APGAR Score began in 1929
as a young woman named Virginia Apgar began medical school at
Columbia University College of Physicians and Surgeons in New York.
Columbia had been admitting women to medical school for only twelve
years before Apgar enrolled.11 The
crash of the stock market on October 24, 1929, occurred two months
after she started medical school.12
The stock market crash led to America’s worst depression in
history from 1930-39.13 During this
time Apgar borrowed money from a family friend to finance her medical
school education.14 She graduated
fourth in her medical school class, which consisted of only four
women and sixty-nine men.15
Determined to be a surgeon, she began a coveted surgical internship
in October, 1933, at Columbia Presbyterian Hospital in New
York.16
Although successful in her internship, Apgar was discouraged from
continuing in this speciality by the late Alan Whipple, M.D.,
Chairman of Surgery at Columbia. According to Whipple’s
contemporary, George Humphreys, M.D., a retired surgeon who also
worked at Columbia when Apgar was an intern, Whipple had two reasons
for deterring her. First, Whipple felt Apgar needed financial
security since her family was not wealthy and she was not married. He
had previously trained four women surgeons who had not been
financially successful. Surgery was a crowded speciality in New York
City and this was the Depression. It was hard for a man to establish
a surgical practice, let alone a woman, and Apgar had to support
herself. Second, Whipple urged Apgar to enter anesthesia because it
was a new speciality area in medicine. It was a better choice for a
woman he told her, as most patients preferred male
surgeons.17 In her book,
Sympathy and Science, Morantz-Sanchez further elaborates that
the medical bureaucracy (male physicians) had informally agreed upon
certain specialities in which to limit womens’
participation.18 Apgar left no
record as to how she felt about this turn of events. However, one may
conclude that this restriction imposed upon her by society’s
beliefs at the time, encouraged her decision to train in anesthesia
as opposed to surgery. In anesthesia she found opportunities open to
her which would not have been available had she pursued surgery.
In 1936, she began her anesthesia training at Columbia
Presbyterian Hospital.19 Realizing
the need to seek the best anesthesia training program available at
the time, she later spent six months in Madison, Wisconsin, working
with Ralph Waters, M.D., a leader in anesthesia
education.20 After she moved to
Wisconsin, she faced a common problem for women physicians; a lack of
housing facilities.21 Men, but not
women, had access to housing facilities in training programs, which
made it difficult for women to secure
internships.22
After her training in Wisconsin, Apgar returned to Columbia and
organized the Department of
Anesthesia.23 In spite of her hard
work over the next several years building the department, she was not
named Head of Anesthesia. Instead, a male anesthesiologist from
Bellevue Hospital was hired in 1949 and named Head of the Anesthesia
Department, a position Apgar
wanted.24 Despite her
disappointment, she remained at Columbia and accepted an appointment
as a professor. This appointment made her the first female professor
at Columbia University.25 Apgar
channeled her energies into obstetric anesthesia, a developing
sub-speciality. Little did she know that her initial disappointment
over not heading the department would lead to her outstanding
contribution to medical science and to newborns. This contribution
came to be known as the APGAR
Score.26
By 1949, many changes were occurring in the United States.
Specialization was more common in medicine, especially in the areas
of obstetrics and pediatrics.27 The
birth rate in the United States increased from 20.4 million in 1946
to 25.0 million in 1953.28 The
“Baby Boom” years were
beginning.29 This was the same
year, 1953, that Apgar published her Newborn Scoring
System.30 A need for improved
maternal and child care became evident as births increased. Morbidity
and mortality statistics were recorded as more babies were born in
hospitals during this time.31 These
statistics showed that the highest incidence of neonatal (newborn)
death occurred in the first twenty-four hours of
life.32 Science became more
systematic and critical, reflecting the necessity and importance of
research as it related to the physician’s practice of
medicine.33 Anesthesia was a
developing speciality and training programs were becoming more
available, especially to women.34
The infant now became a second patient, no longer just a part of the
mother in the delivery room.35 The
stage was set for Apgar, who would not be a surgeon because she was a
woman, but who would nonetheless become a leader in anesthesia and
medical science by developing the APGAR Score.
The idea for this evaluation score for newborns occurred to Apgar
one morning in 1949 in the cafeteria at Columbia Presbyterian
Hospital College of Physicians and
Surgeons.36 According to Richard
Patterson, M.D., a colleague of Apgar, members of the Anesthesia
Department were discussing the day’s schedule. A medical student
asked Apgar how she would evaluate a newborn at delivery. She jotted
down signs important to observe in a newborn after birth and rushed
to the delivery room to try them
out.37 Her list included signs she
considered objective and measurable. Apgar narrowed her list to five
signs delivery room personnel could quickly evaluate without
interfering with the care of the infant. The five signs consisted of
heart rate, respiratory rate, reflex irritability, muscle tone, and
color. A rating of zero, one or two was given to each sign. Apgar
determined the critical time to judge each sign to be sixty seconds
after the birth of the baby. By this time, a newborn was completely
delivered and should be ready to breathe on its own. One person in
the delivery room, either a physician or nurse, was responsible for
assigning the score.38
To determine the APGAR Score, the first sign tested was heart
rate. An infant with a heart rate of 100 - 140 received a score of
two. An infant with a heart rate under 100 received a score of one,
while no heart beat received a zero. For respiratory effort, the
second sign, an infant who breathed and cried forcefully received a
score of two, while one with irregular breathing earned a one. An
infant not breathing received a zero. The third sign, reflex
irritability, was recorded as a response to physical stimulation. The
testing method used was suctioning the throat or nose or tapping the
foot. The infant who coughed or turned from the catheter or jerked
its foot away, scored a two. The infant with a facial grimace scored
a one, and an infant not responding received a zero. Muscle tone was
the fourth sign. An active infant with flexed arms and legs received
a two. One with extended arms or legs scored a one and a completely
limp infant scored a zero. Color of the skin was the fifth sign. A
completely pink infant received a two, which meant the baby was
oxygenating (able to breathe on its own), the infant with a pink body
and blue extremities a one, and the infant with an overall
bluish-gray color, a zero. The total number of points a newborn could
receive was ten, with each of the five categories having a maximum
value of two.39
The idea of assigning a “score” to a patient as a total
of objective findings was not new. Previous criteria used to assess
an infant at birth were breathing and crying
time.40 Other studies used the
terms mild, moderate, and severe depression (not breathing) to
signify the condition of the
infant.41 Apgar believed these
definitions were vague and not measurable. These studies did not
indicate the time resuscitation should begin. Many times these
infants would breathe once and then stop for several
minutes.42 The APGAR Score provided
a systematic and measurable assessment of the newborn.
Beginning in 1949, Apgar collected data to validate her criteria
for a Newborn Score. Her initial study included 1,760
infants.43 One of these infants was
Mary Blunt, born in 1952; her APGAR Score was eight at one minute.
She received one score because at that time only the one minute score
was recorded.44 The data collected
from this initial study led to the publication in 1953, of the
Newborn Scoring System.45
As a scientist, Apgar continued her research with a follow-up
study in 1958 in which 15,348 infants were
evaluated.46 After six years of
collecting data, Apgar showed the score to be a predictor of the need
for resuscitation. Her data proved that the scoring method used with
the infant was objective, measurable, and easy to teach. The longer
the score stayed low, the worse the prognosis for survival. Infants
with scores between five and ten usually needed no extra treatment. A
score of four or below indicated the need for prompt diagnosis and
resuscitation immediately after the
evaluation.47 This early
intervention based on the APGAR Score led to improved infant outcomes
by identifying those infants that needed continued monitoring in the
newborn nursery.48 Personnel
involved in the care of the newborn now had a common
“language,” via the score, with which to communicate
regarding the infant’s condition.
The need for a simple method to rapidly evaluate the
newborn’s condition was the main reason for developing the
scoring system. In early 1962, Apgar continued collecting data on the
Newborn Scoring System, as it was known then.49
Other hospitals in the United States used the score, as did centers
in Winnipeg, Canada, and Helsinki, Finland. This use provided the
score with world-wide exposure.50
The score became known as the APGAR Score in
1962.51 L. Joseph Butterfield,
M.D., a pediatrician, had been using the letters APGAR to teach the
score to medical students to make it easier to
learn.52 The Newborn Scoring System
is taught as: A: appearance ( pink, mottled, or blue); P: pulse (>
100, < 100, or absent); G: grimace (response to suctioning of the
nose and mouth); A: activity (flexed arms and legs, extended limbs or
limp); and R: respiratory effort (crying, gasping, or absent). Use of
Apgar’s name for the Newborn Scoring System became common
practice all over the world.53
Apgar wrote to Butterfield she was pleased to see the score being
taught in this manner using the letters in her last
name.54 She shared with him that
she did not really care what the score was called, as long as someone
observed the newborn immediately after
delivery.55
Apgar planned the score to be recorded at one minute after birth
as a guide for the need for resuscitation. Other research centers
began to take measurements at longer intervals to evaluate how the
baby responded to the resuscitation. Eventually, the one and five
minute APGAR Scores became
standard.56 Today, forty-six years
later, delivery room personnel still use the APGAR Score to initially
evaluate all hospital-born infants in the United States and other
countries. In a hospital in Topeka, Kansas, the person assigned to
determine the APGAR Score is a pediatrician or neonatologist, where
in other places it could be a
nurse.57
The development of the APGAR Score was the greatest accomplishment
of Virginia Apgar, who died in her sleep on August 7, 1974, at the
age of sixty-five.58 Butterfield
wrote that an anonymous physician has been credited with the
statement that every newborn infant is seen through the eyes of Dr.
Virginia Apgar.59 Today readers
find continued reference to the APGAR Score not only in medical
journals, but also in magazines like
Parenting.60 T. Berry
Brazelton, M.D., writes about the APGAR Score in his popular
parenting books.61 The greatest
public recognition for her contribution to medicine and science
through the APGAR Score was the inclusion of Apgar in the Great
American Stamp Series in 1994, a rare
accomplishment.62
“A Legend Becomes a Postage Stamp,” was a fitting
tribute to a woman who faced obstacles in her pursuit of being a
physician, only because of her
sex.63 However, her entry into the
speciality of anesthesia, which many considered more appropriate at
the time for a woman, actually opened the door for her success with
the APGAR Score. Medical science underwent changes as well, that
allowed for and provided a need for this score. More babies were
being born in hospitals and the beginning of the “Baby
Boom” generation placed increasing demands on maternal and child
care. Virginia Apgar made a significant and lasting mark on medical
science with the APGAR Score which is an objective and measurable
test of a newborn’s need for resuscitation after birth.
Apgar left her personal stamp on Mary Blunt born in 1952, APGAR 8
and Baby Boy Meeks born in 1998, APGAR 9 at one minute and APGAR 9 at
five minutes.64
65 These infants passed their first
test. From the two of them and to those who follow after them: Thank
you, Dr. Apgar, for seeing them through your eyes with the APGAR
Score.
1
Sarah Sellers, personal observation of APGAR Score after delivery of
Baby Boy Meeks, 20 Nov. 1998.
2
Maria Morales, telephone interview, 19 May 1999.
3
Tak Chen, telephone interview, 19 May 1999.
4
Julie Garlinghouse, telephone interview, 19 May 1999.
5
Ken Okano, telephone interview, 19 May 1999.
6
James Nelson, telephone interview, 31 Dec. 1998.
7
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,” Anesthesia and Analgesia July-Aug.
1953: 261-262.
8
Apgar 260.
9
American Academy of Pediatrics, “Care of Infants,”
Standards and Recommendations for Hospital Care of Newborn
Infants (Evanston, Illinois: The American Academy of Pediatrics,
1964) 79.
. 10
Virginia Apgar, “The Newborn (APGAR) Scoring System,”
The Pediatric Clinics of North America Aug. 1966: 645.
11
Willard Rappleye, letter to Bessie Grigg, Columbia University,
College of Physicians and Surgeons External Affairs Office, dated
February 20, 1950.
12
Ezra Brown and the Editors of Time-Life Books, This Fabulous
Century 1920-1930
(Morristown, New Jersey: Time-Life Books, 1969) 128.
13
Brown et al. 46.
14
Margaret Apgar, telephone interview, 2 Dec. 1998.
15
Columbia University, Announcement of the College of Physicians and
Surgeons for the Winter and Spring Sessions, Class of 1933, The
Augustus C. Long Health Sciences Library, Archives and Special
Collections.
16
Virginia Apgar, appointment letter as an Assistant in Surgery at
Columbia Presbyterian Hospital, signature not legible, Apgar Papers,
Mount Holyoke College Library Archives dated June 17, 1935.
17
George Humphreys, telephone interview, 5 Dec. 1998.
18
Regina Markell Morantz-Sanchez, Sympathy and Science: Women
Physicians in American Medicine (New York: Oxford University
Press, 1985) 234.
19
Matthew Fleming, letter to Virginia Apgar, Apgar Papers, Mount
Holyoke College Library Archives dated June 15, 1936.
20
Virginia Apgar, “ Careers......in Anesthesiology,”
Journal of the American Medical Women’s Association Aug.
1964: 675.
21
Selma Harrison Calmes, “Virginia Apgar: A Woman Physician’s
Career in a Developing Speciality,” Journal of the American
Medical Women’s Association Nov./Dec. 1984: 187.
22
Hedda Garza, Women in Medicine (New York: Moffa Press, 1994)
69.
23
Virginia Apgar, letter to Allen Whipple, Apgar Papers, Mount Holyoke
College Library Archives dated Nov. 29, 1937.
24
Gerorge Humphreys, telephone interview, 5 Dec. 1998.
25
Humphreys.
26
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,”Anesthesia and Analgesia July-Aug.
1953: 260.
27
Murdina MacFarquhar Desmond, Newborn Medicine and Society:
European Background and American Society 1750-1975 (Austin,
Texas: Eakin Press, 1998) 151.
28
United States, Dept. of Commerce, Bureau of the Census, Historical
Statistics of the United States - Colonial Times to 1970 1975:
49.
29
Paul C. Light, Baby Boomers. (New York: W. W. Norton and Co.,
1988) 19.
30
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,” Anesthesia and Analgesia July-Aug.
1953: 260.
31
James Nelson, telephone interview, 31 Dec. 1998.
32
Murdina MacFarquhar Desmond, Newborn Medicine and Society:
European Background and American Society 1750-1975 (Austin,
Texas: Eakin Press, 1998) 169.
33
J.D. Bernal, Science in History: The Natural Sciences Over
Time. (Cambridge, Massachusetts: The M.I.T. Press, 1969) 872.
34
Selma Harrison Calmes, “Virginia Apgar: A Woman Physician’s
Career in a Developing Speciality,” Journal of the American
Medical Women’s Association Nov./Dec. 1984: 187.
35
Murdina MacFarquhar Desmond, Newborn Medicine and Society:
European Background and American Society 1750 - 1975 ( Austin,
Texas: Eakin Press, 1998) 169.
36
Richard Patterson, telephone interview, 30 Nov. 1998.
37
Patterson.
38
Virginia Apgar, Duncan A. Holaday, L. Stanley James, Irwin W.
Weisbrot, and Cornelia Berrien, “Evaluation of the Newborn
Infant - Second Report,” Journal of the American Medical
Association Dec. 1958: 1988.
39
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,” Anesthesia and Analgesia July-Aug.
1953: 262.
40
Fred B. Hapke and Allan Barnes, “The Obstetric Use and Effect on
Fetal Respiration of Nisentil,” American Journal of
Obstetrics and Gynecology Oct. 1949: 800.
41
James E. Eckenhoff, George L. Hoffman, and Robert D. Dripps,
“N-Allyl Normorphine: An Antagonist to the Opiates,”
Anesthesiology May 1942: 246.
42
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,” Anesthesia and Analgesia July-Aug.
1953: 262.
43
Apgar 262.
44
Elsie Moore Blunt, telephone interview, 30 Nov. 1998.
45
Virginia Apgar, “A Proposal for a New Method of Evaluation of
the Newborn Infant,” Anesthesia and Analgesia July-Aug.
1953: 263.
46
Virginia Apgar, Duncan A. Holaday, L. Stanley James, Irwin M
Weisbrot, and Cornelia Berrien, “Evaluation of the Newborn
Infant- Second Report,” Journal of the American
Medical Association Dec. 1958: 1985.
47
Virginia Apgar et al. 1986.
48
Murdina MacFarquhar Desmond, Newborn Medicine and Society:
European Background and American Society 1750-1975 (Austin,
Texas: Eakin Press, 1998) 169.
49
Virginia Apgar and L. Stanley James, “Further Observations of
the Newborn Scoring System,” American Journal of Diseases of
Children Oct. 1962: 419.
50
Apgar and James 421.
. 51
L. Joseph Butterfield, “Practical Epigram of the Apgar
Score,” Journal of the American Medical Association July
1962: 353.
52
L. Joseph Butterfield, telephone interview, 24 Oct. 1998.
53
L. Joseph Butterfield, “Virginia Apgar. M.D., MPhH.,”
Neonatal Network Sept. 1994: 82.
54
Virginia Apgar, letter to L. Joseph Butterfield, dated August 10,
1962.
55
L. Joseph Butterfield, telephone interview, 24 Oct. 1998.
56
Selma Harrison Calmes, “Virginia Apgar: A Woman Physician’s
Career in a Developing Speciality,” Journal of the American
Medical Women’s Association Nov-Dec. 1984: 184.
57
Robert Sidlinger, personal interview, 20 Nov. 1998.
58
Werner Bamberger, “Dr. Virginia Apgar Dies at Sixty-Five;
Devised Health Test for Infants” New York Times 8 Aug.
1974, late ed.: L36+.
59
L. Joseph Butterfield, “Virginia Apgar, M.D., MPhH.,”
Neonatal Network Sept. 1994: 82.
60
Pamela G. Kripke, “Baby’s First Tests,”
Parenting Aug. 1997: 157.
61
T. Berry Brazleton, What Every Baby Knows (Reading,
Massachusetts: Addison- Wesley Publishing Company, 1987) 169.
62
L. Joseph Butterfield, “Virginia Apgar, Physician,
1909-1974,” Perinatal Section News, American Academy of
Pediatrics Feb. 1994: 1.
63
Bonita Eaton Enochs, “Virginia Apgar: A Legend Becomes a Postage
Stamp,” Columbia University Physicians and Surgeons
Journal Fall 1994: 18.
64
Elsie Moore Blunt, telephone interview, 30 Nov. 1998.
65
Sarah Sellers, personal observation of APGAR Score after delivery of
Baby Boy Meeks, 20 Nov. 1998.