The first test newborns have to pass is the Apgar score, a rating system from zero to ten used by healthcare providers to determine how thriving a newborn is.
Appearance (skin colour), Pulse (heart rate), Grimace (reflexes), Activity (muscle tone), and Respiration (breathing rate), these categories are each rated from zero to two so that midwives, nurses or obstetricians can quickly assess a baby’s condition after birth.
A score of seven or above indicates the baby is in good health. A lower score does not necessarily suggest that the newborn is unhealthy or will have health issues in the long term, but whether they might require immediate medical attention.
Low scores are usually standard in babies born prematurely, through a C-section, after a high-risk pregnancy, after complicated labour or delivery, etc. The Apgar score is generally taken at one minute after birth, then at five minutes, and potentially later if there are concerns about the newborn’s health condition.
Of course, there might be doubts about its effectiveness. For example, interventions for infants in visible need of resuscitation should not be delayed until the one-minute Apgar assessment.
Although the Apgar score looks like a mnemonic device, it is an eponym – named after a person. Born at the beginning of the 20th century, Virginia Apgar graduated from college intending to become a doctor. Armed with seemingly endless energy, she wrote in the college newspaper, played violin in the orchestra, played in theatre productions, was a member of seven sports teams, and still had remarkable academic results.
It is seldom that one finds a student so thoroughly immersed in her subject and with such a wide knowledge of it.
Perhaps now we will understand better the extraordinary vitality of Virginia Apgar. She managed to revolutionise anaesthesiology, laid the foundations of neonatology (a subspecialty of paediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn), and teratology (the study of congenital disabilities), switched careers in her fifties for a public health degree, was vice president for the non-profit organization March of Dimes where she was also an exceptional medical research fundraiser. And alongside being a talented violinist, Apgar made her own musical instruments, gardened, golfed and began flying single-engine planes in her fifties.
However, anaesthesiology and paediatrics weren’t the fields that Apgar specialised in during her medical training at Columbia University’s College of Physicians and Surgeons. After finishing her MD in 1933, Apgar started a two-year surgical internship. Although she had shown promising results in surgery, her mentor Allen Whipple worried that Apgar wouldn’t be able to find work as a surgeon, especially as a woman, during the Great Depression. So, he recommended that Apgar consider anesthesiology instead of surgery, a nascent medical speciality. Up to those times, anaesthesia was considered yet another duty for nurses. However, surgery innovations were hindered by a lack of progress in anaesthetic techniques and medication.
Maybe this wasn’t such a bad idea. To be a bigger fish medication in a smaller puddle, because it would take three or four more years in surgery and [so] it was purely financial that I changed to anaesthesia, which is not a bit dramatic, it’s the truth.
Leadership in Anaesthesia. Five Pioneers of the Deadly Quest for Surgical Insensibility with a chapter extract here
During the 1930s – 1940s, remarkable efforts were made to reduce maternal deaths. By the 1950s, the risks of death for expecting mothers were cut by more than ninety per cent, due partly to tighter medical standards and the discovery of penicillin and other antibiotics.
Unfortunately, for newborns, the odds of survival were extremely low. One in twenty-five babies still died at birth. Babies that struggled to breathe or were born blue were listed as stillborn and left to die as the general medical consensus at the time was those babies were too sick to live.
As an anesthesiologist, Virginia Apgar provided anaesthesia for expecting mothers and was exposed to heartbreaking deliveries.
Sitting together with a group of medical students in the hospital cafeteria early one morning after a particularly harrowing night on call; Virginia was asked a seminal question:
“Dr. Apgar, how would you evaluate a newborn?”
“That’s easy you do it like this.” Virginia replied, reaching over to grab a ‘Do Not Bus Your Trays’ sign left on a trolley alongside the table they were sitting at, and jotted it down.
“Five points—heart rate, respiratory effort, muscle tone, reflex response and color—are observed and given zero, one or two points. The points are then totalled to arrive at the baby’s score.” A total of nine or ten was optimal. Then she rushed off to try it for herself, her white coat flapping behind as she made her way upstairs to the obstetric unit.
Leadership in Anaesthesia. Five Pioneers of the Deadly Quest for Surgical Insensibility with a chapter extract here
Soon, it became evident that a baby born with a low Apgar score at one minute could often be resuscitated (oxygen or warming) and have an excellent score at five minutes. Then, using a straightforward questionnaire, Apgar filled a void of consensus on what a “normal” baby was.
The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept—the condition of a newly born baby—into a number that people could collect and compare. Using it required observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered.
Ten years after the initial publication of this assessment, a mnemonic device was invented to match Apgar’s name and honour her contribution: Appearance, Pulse, Grimace, Activity, and Respiration.
What Life Lessons Can We Take from Virginia Apgar?
As I wrote in What Holds Back Innovation, philosopher of science Thomas Kuhn discovered that either young people or people who initially trained in a different discipline bring most paradigm shifts in science. Novices, either young people or mature people who switched domains, haven’t been yet trained or conditioned to think and act like everybody else in that specific field. Thus, they are not biased towards the Einstellung effect.
Apgar never had a child of her own and never delivered a baby as she was an anaesthetist in the obstetrics world. Nevertheless, by devising the Apgar score, she managed to introduce powerful paradigm shifts regarding the well-being of newborns.
In essence, the Apgar score was revolutionary because it was the first clinical method to recognise the newborn’s needs as a patient.
Although Apgar remarked that “women are liberated from the time they leave the womb” and that being a woman didn’t impose limitations on her medical career, let’s not forget why she switched from a promising surgeon career to the terra incognita of anesthesiology.
Also, Apgar quipped that she never married because “I never found a man who could cook”, which is very similar to what artist Alice Neel said, “I could certainly have accomplished more with a good wife.”
Jokes aside, in the era in which Apgar lived, almost all care work was traditionally associated with women (cooking, cleaning, childcare, household admin duties). Could Apgar accomplish everything she did if she were to be a dutiful housewife? Would Apgar be a celebrated surgeon if she were allowed to continue in her initial career?
But I don’t think Apgar would have allowed herself to ponder too much on these questions, as she couldn’t stop telling things the way they were. Thinking of these hypothetical questions brings beautiful advice from Dear Sugar about ghost ships which Apgar would have wholeheartedly approved:
If I could go back in time I’d make the same choice in a snap. And yet, there remains my sister life. All the other things I could have done instead. […] I’ll never know and neither will you of the life you don’t choose. We’ll only know that whatever that sister life was, it was important and beautiful and not ours. It was the ghost ship that didn’t carry us. There’s nothing to do but salute it from the shore.
Apgar was also absurdly determined.
When she was a resident, a patient she had operated on died after surgery. “Virginia worried and worried that she might have clamped a small but essential artery,” L. Stanley James, a colleague of hers, later recalled. “No autopsy permit could be obtained. So she secretly went to the morgue and opened the operative incision to find the cause. That small artery had been clamped. She immediately told the surgeon. She never tried to cover a mistake. She had to know the truth no matter what the cost.”
Reading about this story, we might understand why Apgar carried basic resuscitation equipment with her at all times (pocket knife and rubber tubing for emergency airway) and managed to save sixteen lives in this way.
Nobody, but nobody, is going to stop breathing on me!
Virginia Apgar
Virginia Apgar saw the world through the eyes of a sculptor. She didn’t see challenges as blocks of stone but as what they could become. And perhaps, she wouldn’t mind if we were to borrow a bit of her spirit. We have quite a few modern obstacles that might need their own Apgar score.