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PubMed2001

Long-term outcome in term breech infants with low Apgar score--a population-based follow-up.

OBJECTIVE: To investigate the relation between low Apgar score in breech infants and handicap in childhood. STUDY DESIGN: A case-control study. A questionnaire to mothers of 323 non-malformed, singleton infants delivered in breech presentation at term, 105 cases with Apgar score below 7 at 5 min and 218 controls. RESULTS: Four cases (4.6%) and one control (0.5%) had cerebral palsy. In infants without cerebral palsy, speech/language problems were more frequent than controls (10.6 versus 3.2%) (P=0.02). There were no differences in rates of deficits in attention, motor control and perception (DAMP), epilepsy, cognitive developmental delay or learning disabilities. Absence of any handicap or disability was reported in 65 cases (75%) compared to 172 controls (92%) (OR: 3.9; 95% CI: 1.9-7.9). CONCLUSION: Even though low Apgar score indicates an increased risk of neurological sequelae, most (75%) breech infants with low Apgar score are without a handicap/disability at follow-up.

Apgar Score↗
PubMed2001

The association of Apgar score with subsequent death and cerebral palsy: A population-based study in term infants.

OBJECTIVE: To estimate the risk of adverse outcomes for newborns with a low Apgar score. STUDY DESIGN: Population-based cohort study. All 235,165 children born between 1983 and 1987 in Norway with a birth weight of at least 2500 g and no registered birth defects were followed up from birth to age 8 to 12 years by linkage of 3 national registries. Outcomes were death and cerebral palsy (CP). RESULTS: Five-minute Apgar scores of 0 to 3 were recorded for 0.1%, and scores of 4 to 6 were recorded for 0.6% of the children. Compared with children who had 5-minute Apgar scores of 7 to 10, children who had scores of 0 to 3 had a 386-fold increased risk for neonatal death (95% CI: 270-552) and an 81-fold (48-138) increased risk for CP. If Apgar scores at both 1 and 5 minutes were 0 to 3, the risks for neonatal death and CP were increased 642-fold (442-934) and 145-fold (85-248), respectively, compared with scores of 7 to 10. CONCLUSION: The strong association of low Apgar scores with death and CP in this population with a low occurrence of low scores shows that the Apgar score remains important for the early identification of infants at increased risk for serious and fatal conditions.

Apgar Score↗
PubMed2003

Effect of inter-twin delivery time on Apgar scores of the second twin.

OBJECTIVE: The aim of the present study was to analyse the effect of inter-twin delivery time on the Apgar scores of the second twin. MATERIAL: Women attempting vaginal delivery of second twins were studied in 2000. Deliveries before 25 weeks' gestation, complicated pregnancies, operative deliveries, and deliveries by regional or general anaesthesia were all excluded. RESULTS: A total of 37 out of 126 twin pregnancies had the criteria to be included in the present study. The major factor identified to influence Apgar scores was gestational age (P < 0.01). There was a linear relationship between delivery interval and the Apgar scores of the second twin, and the addition of delivery interval significantly improved the predictivity of gestational age. There was no influence of presentation and delivery mode of the second twin. Interval was found to be the only significant predictive factor of the Apgar scores in second twins of >1900 g and where the second twin is in a breech presentation. Caesarean section did not improve the outcome of the second twins. CONCLUSION: Gestational age is the most important factor influencing the Apgar scores of second twins. The addition of delivery interval improves the predictivity of second twin Apgar score by gestational age. Inter-twin delivery time of >15 min is particularly important in the second twin which presents by the breech method and in the second twin of more than 1900 g.

Apgar Score↗
PubMed2001

Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois.

OBJECTIVE: The national Neonatal Resuscitation Program (NRP), started in 1987, provided training to hospital delivery room personnel to standardize knowledge and skills to reduce neonatal morbidity and mortality and increase successful resuscitation during the first few critical minutes after birth. The Apgar score continues to be used as the best established index of immediate postnatal health. The purpose of this study was to evaluate the impact of the NRP instruction in Illinois hospitals by examining Apgar scores among high-risk infants who are likely to benefit from the NRP. METHODS: A retrospective 3-time period cohort design was used (before the introduction of the NRP, 1985-1988; transition when NRP training occurred, 1989-1990; and after NRP training was completed at least once for some delivery room personnel in each Illinois hospital, 1991-1995). Illinois computerized birth certificate files on a selected group of 636 429 high-risk neonates provided information on Apgar scores and maternal characteristics. The American Academy of Pediatrics provided instructor lists to determine when NRP training started and when it was fully implemented in Illinois. Illinois Department of Public Health provided data to categorize hospitals into levels based on type and intensity of neonatal services (Level I, II, II+, III). High-risk neonates were defined as meeting 1 of the following criteria: maternal age <20 years old or >35 years old, birth weight <2500 g or >4000 g, presence of a maternal medical risk factor, and no prenatal care or prenatal care started after the first trimester. Several exclusion criteria were applied including the following: birth records with missing data, multiple birth or congenital anomaly, and hospital information that indicate no birth deliveries in 1 of the 11 study years or delivery outside of a hospital. One-minute and 5-minute Apgar scores were divided into categories for analysis (0-3, 4-6, 7-10). No change or a decrease in a low (0-6) 1-minute Apgar when compared with the 5-minute Apgar was a primary measure to evaluate effect of NRP resuscitation. Variables examined included the following: race/ethnicity, maternal age, level of education, presence of maternal medical risk factor, trimester started prenatal care, complications of labor and delivery, and a low birth weight. Analysis consisted of chi(2) tests, relative risk calculations, and logistic regression to reveal independent associations with no change in low 1-minute Apgar score or continued low (0-6) 5-minute Apgar. RESULTS: A total of 636 429 high-risk birth records was selected for detailed analyses out of 2 077 533 births in Illinois between 1985 and 1995 for 193 hospitals. The number of active NRP instructors in Illinois changed dramatically during the study period; for example, 1 to 6 between 1987 and 1988 to 1096 to 1242 between 1991 and 1995. The percentage of neonates reported to have low (<7) 1-minute Apgar score decreased in 1991 to 1995 overall and for each of 4 hospital levels. Overall and by hospital level, there was a statistically significant lower proportion of high-risk newborns who showed a decrease or no change in their 5-minute Apgar scores after the NRP instruction. After adjusting for several maternal characteristics, logistic regression analysis revealed that high-risk newborns with a low 1-minute Apgar were more likely to increase their 5-minute Apgar after the NRP instruction in 1991 to 1995. Additional analyses indicated that very low birth weight and low birth weight newborns benefited the most from NRP instruction. CONCLUSION: Although previous research has shown that the NRP instruction improves knowledge and skill among health care personnel in the delivery room, both short-term and long-term, there has been little evidence to demonstrate NRP impact on infant morbidity. Several strategies were used in this study to control for bias and to adjust for secular trends in decreased infant morbidity during the study period. This study demonstrated sufficient support for the hypothesis that a significant improvement occurred among neonates in their Apgar score after the NRP instruction in Illinois. Empirical support is provided for the clinical effectiveness of NRP instruction.

Apgar Score↗
PubMed1988

Perinatal brain damage: predictive value of metabolic acidosis and the Apgar score.

To assess the predictive value for perinatal brain damage of acidosis at birth, alone or in combination with the Apgar score at 5 minutes, a cohort of 982 liveborn infants delivered over two months was studied prospectively. The umbilical cord was double clamped, and arterial acid-base values were successfully determined in 964 infants and lactate concentration in 931. Reference values defining acidosis (mean +/- 2 SD) were obtained from a subset of 127 term infants who had no complications. The incidence of a low pH was 12% (111 out of 964), high base deficit 7% (70 out of 964), high lactate concentration 9% (83 out of 931), and low Apgar score at 5 minutes (less than or equal to 7) 3% (32 out of 982). Twelve of the 111 infants (11%) with acidosis had a low Apgar score, and 12 out of 29 infants (41%) with low Apgar scores had acidosis. At one year of age 35 infants were lost to follow up and 22 had an adverse outcome unrelated to asphyxia; 883 infants showed normal development but the possible sequelae of asphyxia were four deaths, slight abnormalities in 28 infants, and clear abnormalities in 10. The sensitivity and the positive predictive value of low pH for adverse outcome were, respectively, 21 and 8%, of high lactate concentration 12 and 5%, and of low 5 minute Apgar score 12 and 19%. Metabolic acidosis determined in blood from the umbilical artery at birth is a poor predictor of perinatal brain damage.

Acidosis, Respiratory↗
PubMed2006

Earlier Apgar score increase in severely depressed term infants cared for in Swedish level III units with 40% oxygen versus 100% oxygen resuscitation strategies: a population-based register study.

OBJECTIVES: The aim of this study was to evaluate whether a resuscitation strategy based on administration of 40% oxygen influences mortality rates and rates of improvement in 5-minute Apgar scores, compared with a strategy based on 100% oxygen administration. METHODS: A population-based study evaluated data from 4 Swedish perinatal level III centers during the period of 1998 to 2003. During this period, the centers used either of 2 resuscitation strategies (initial oxygen administration of 40% or 100%). Live-born, singleton, term infants with 1-minute Apgar scores of <4, with a birth weight appropriate for gestational age, and without major malformations were included in the study (n = 1223). RESULTS: Infants born in hospitals using a 40% oxygen strategy had a more rapid Apgar score increase than did infants born in hospitals using a 100% oxygen strategy; however, no difference remained at 10 minutes. The mean Apgar score increased from 2.01 at 1 minute to 6.74 at 5 minutes in the 2 hospitals initiating resuscitation with 40% oxygen, compared with 2.01 to 6.38 in the 2 hospitals using 100% oxygen, with a mean difference in Apgar score increases of 0.36. At 5 minutes, 44.3% of infants born in the hospitals using 100% oxygen had an Apgar score of <7, compared with 34.0% of infants at the hospitals using 40% oxygen. At 10 minutes, the mean Apgar scores were 8.16 at the hospitals using 40% oxygen and 8.07 at the hospitals using 100% oxygen. There were no significant differences in rates of neonatal death, hypoxic ischemic encephalopathy, or seizures in relation to the 2 oxygen strategies. CONCLUSION: Severely depressed term infants born in hospitals initiating resuscitation with 40% oxygen had earlier Apgar score recovery than did infants born in hospitals using a 100% oxygen strategy.

Apgar Score↗
PubMed1985

The very low birthweight infant: incidence and significance of low Apgar scores, "asphyxia," and morbidity. Findings at delivery.

Cord blood gas determinations were made on arterial and venous blood from 78 babies weighing less than 2000 gm at birth, including 52 weighing 1500 gm or less. Correlations were made with Apgar scores and intrapartum events as well as with birthweight (BW) and gestational age (GA). Significant differences were seen between mean BW, GA, and Apgar scores for survivors versus nonsurvivors but only BW and GA were found to affect mortality. The incidence of low Apgar scores, which was high, was inversely related to BW and GA. Correlations between cord blood gases and Apgar scores were poor, most newborns showing normal gases irrespective of Apgar scores. The authors conclude that the term "asphyxia" is an overused explanation for low Apgar scores among very low birthweight babies; they believe it should be reserved for those depressed states proved to be associated with disturbed respiratory physiology.

Apgar Score↗
PubMedDate not supplied

Positive changes among very low birth weight infant Apgar scores that are associated with the Neonatal Resuscitation Program in Illinois.

OBJECTIVE: The American Academy of Pediatrics and American Heart Association sponsored Neonatal Resuscitation Program (NRP) was started in Illinois 1987 to standardize knowledge and skills for successful resuscitation to decrease newborn morbidity and mortality. This study evaluated the hypothesis that the statewide NRP in Illinois hospitals was associated with positive outcomes in the Apgar scores among very low birth weight newborns. STUDY DESIGN: A retrospective design was used to compare the (a) different rates of lower (0-6) and higher (7-10) 1- and 5-minute Apgar scores and (b) positive change from a lower 1-minute to a higher 5-minute Apgar score before and after NRP was started. Analyses included maternal characteristics, birth weight groups (grams: 500-749, 750-999, 1000-1249, 1250-1499), and hospital levels (I, II, III). RESULTS: A significantly higher proportion of infants had a higher 1-minute and a higher 5-minute Apgar score after NRP, overall, for Level II and II+ hospitals and for each weight group. Logistic regression indicated that newborns with low 1-minute Apgar scores were 81% more likely to have a higher 5-minute Apgar score after NRP. CONCLUSION: Significant improvement in Apgar score occurred after NRP. Empirical support is demonstrated for the clinical effectiveness of NRP instruction in Illinois hospitals.

Apgar Score↗
PubMed1977

Correlation of biochemical data with Apgar scores at birth and at one minute.

A prospective study of 66 unselected neonates revealed a better correlation of umbilical artery blood biochemical data with the Apgar score at birth compared with the score at 1 min. The data confirmed also that inclusion of the score for "colour" detracts from the value of the total score. An Apgar score at birth is more valuable than the score at 1 min.

Apgar Score↗
PubMed1980

Continuous fetal pH monitoring and neonatal Apgar score.

Results of continuous fetal tissue pH monitoring were compared to neonatal APGAR scores one minute after delivery in 81 successful tissue pH recordings. The sensitivity of the method (i.e. the ability of the method to find the low APGAR neonates) was 67 per cent using an APGAR score limit between 8 and 9 and a pH limit between 7.20 and 7.21. The specificity (i.e. the ability of the method to find the high APGAR neonates) was 73 per cent using the same limits. The sensitivity and specificity of continuous pH monitoring was equal to or better than the sensitivity and specificity of cardiotocography and discontinuous pH measurements on fetal scalp blood using APGAR score limits between 6 and 7. It is concluded that all fetal monitoring should include monitoring of the fetal pH when a pH electrode which can be used as a routine instrument has been developed. Unfortunately, such an electrode has not been developed yet.

Apgar Score↗
PubMed2002

Joint association of Apgar scores and early neonatal symptoms with minor disabilities at school age.

OBJECTIVE: To examine whether the combination of a low five minute Apgar score and symptoms of neonatal encephalopathy is associated with minor impairments at school age. DESIGN: Population based cohort study. SETTING: Norway. PARTICIPANTS: All 727 children of the cohort were born between 1983 and 1987, had normal birth weights, no congenital malformations, and no major neurological abnormalities. The cohort comprised three groups with five minute Apgar scores of 0-3, 4-6, and 7-10, and were followed from birth to 8-13 years of age by combining data from The Medical Birth Registry, questionnaires, hospital discharge summaries, and the National Insurance Scheme. MAIN OUTCOME MEASURE: Neurodevelopmental impairments such as learning, behavioural, and minor motor difficulties. RESULTS: Children with a five minute Apgar score of 3 or less and signs consistent with neonatal encephalopathy had a significantly increased risk of developing minor motor impairments (odds ratio (OR) 12.8, 95% confidence interval (CI) 2.6 to 63.2), epilepsy (OR 7.0, 95% CI 1.3 to 39.2), need of extra resources in kindergarten (OR 7.0, 95% CI 1.3 to 39.2) or at school (OR 3.4, 95% CI 1.8 to 6.3), and had reduced performance in reading (OR 4.6, 95% CI 2.3 to 9.5) and mathematics (OR 3.3, 95% CI 1.5 to 7.3), compared with children with normal Apgar scores and no neonatal symptoms. They also more often had problems related to tractability, aggressivity, passivity, anxiety, academic performance, and fine motor development. CONCLUSION: Children with low Apgar scores and subsequent signs of cerebral depression who do not develop cerebral palsy may still have an increased risk of developing a variety of neurodevelopmental impairments and learning difficulties.

Apgar Score↗
PubMedDate not supplied

[Discrepancy between Apgar score and umbilical artery pH value in the newborn infant. (Correlation to mode of delivery and fetal outcome?)].

In a retrospective study data from more than 9000 live births were analyzed. Our aim was to compare the significance of Apgar-Score and umbilical artery pH in predicting the condition and development of the newborn. We were particularly interested in three groups of patients: "Group A" included patients with a 5 minute Apgar-Score < or = 7 and a normal pH > 7,2. In "Group P" the pH was < 7,10 combined with a normal Apgar-Score (8 to 10). Both groups were compared with a "normal group" (pH > 7,20 and Apgar-Score between 8 and 10). There was a higher percentage of operative deliveries in group A (38%) and group P (20%) compared to the normal group (15%). The only predictor of a low Apgar-Score was meconium stained amniotic fluid (Group A 16%). A poor condition of the newborn correlated much better with a low Apgar-Score than with a low umbilical artery pH. In group A the rate of newborns transferred to the neonatology unit was 43% and the perinatal mortality rate was 50%. The poor correlation of a low umbilical artery pH and the fetal outcome is partly explainable by the standard cut off level of 7,20 for acidosis, which seems to be too high.

Acid-Base Equilibrium↗
PubMed1987

Umbilical cord acid-base state and Apgar score in term breech neonates.

Umbilical cord acid-base state and Apgar score were compared in neonates after breech and vertex term birth. The breech group comprised 149 consecutive newborns, 91 born vaginally and 58 by cesarean section. The control group consisted of a random sample of 150 newborns in vertex presentation: 100 born vaginally and 50 by cesarean section. Among vaginally born babies, the 1-min Apgar score was more often depressed in the breech presentation group than in the vertex group; after 5 min the Apgar scores were comparable in both groups. No difference was found in umbilical cord values of pH and base excess between the breech and the vertex groups when comparison was made within each delivery mode. In both groups, umbilical cord values were lower after vaginal than after abdominal delivery. It is concluded that in selected cases, uneventful vaginal breech labor and delivery at term is not associated with an increased risk of asphyxia.

Acid-Base Equilibrium↗
PubMed1982

The effect of general and epidural anesthesia upon neonatal Apgar scores in repeat cesarean section.

One-hundred and ninety-five elective cesarean deliveries were studied to determine the effects of general and epidural anesthesia upon the neonatal condition, as reflected by the one and five minute Apgar scores. Ninety were performed under general anesthesia, 0.5 per cent halothane, 50 per cent nitrous oxide and 50 per cent oxygen; 105 used the epidural technique, 3 per cent chloroprocaine plus 0.75 per cent bupivacaine. All patients were tilted to the left during operation. No statistically significant difference was found between the two groups in terms of mean Apgar scores at one and five minutes, p less than 0.1. Neither was a significant difference noted in terms of depressed infants, Apgar score less than 7, at one or five minutes, p greater than 0.1. More significantly, no correlation was noted between the duration of anesthesia and the Apgar scores in either group, p greater than 0.1. Specifically, no significant increase was found in depressed infants in the prolonged, greater than or equal to 15 minutes, incision to delivery group, p greater than 0.05. These data seem to suggest that the use of general anesthesia, in the technique described, yields infants with Apgar scores as good as those of infants delivered under regional block anesthesia and that prolonged duration of general anesthesia is not associated with a depression of the Apgar scores.

Anesthesia, Epidural↗
PubMed1989

[Aldolase activity and the lactate level in the cord blood as objective indicators of the status of newborn infants by the Apgar score].

In 63 newborns with general clinical status evaluated by means of the Apgar score the lactate level and aldolase activity were determined in cord blood. A greatly raised mean level of both these biochemical indicators of tissue hypoxia was demonstrated in newborns with low Apgar score. A considerable scatter of the determined biochemical parameters was noted in newborns born in serious condition and having identical low Apgar score.

Apgar Score↗
PubMed1999

Correlation of basal ganglia magnetic resonance spectroscopy with Apgar score in perinatal asphyxia.

BACKGROUND: Brain metabolite levels are measured by proton magnetic resonance spectroscopy (1H MRS) and include N-acetylaspartate (NAA), creatine (Cr), choline (Cho), and lactate and the ratios NAA to Cho and Cr (NAA-ChoCr), NAA-Cr, NAA-Cho, and Cho-Cr. Brain metabolite levels may correlate with the degree of neonatal asphyxia. OBJECTIVE: To determine which brain metabolite ratios have the strongest correlation with the Apgar scores in infants with possible asphyxia; whether the correlation is stronger with basal ganglia (BG) or anterior border-zone metabolites; and whether a combined approach using routine MR imaging (MRI), diffusion-weighted MRI, and MRS can be used to evaluate the severity of neonatal asphyxia. METHODS: Twenty infants with 1-minute Apgar scores of 6 or less were studied at 2 to 28 days of age. The MRS variables were compared with routine and diffusion-weighted brain MRI. Clinical variables and MRS findings were subjected to factor analysis and stepwise multiple regressions to determine interrelationships. RESULTS: The BG region NAA-Cho and NAA-ChoCr ratios correlated with the 1-minute (P<.001) and 5-minute (P = .01 for NAA-Cho; P = .006 for NAA-ChoCr). There was no correlation between metabolite levels and the 10-minute Apgar scores. The stongest predictions exist between the 1-minute Apgar scores and the NAA-Cho and NAA-ChoCr ratios. In the anterior border zone, the only correlation was between the 1-minute Apgar score and the NAA-Cho ratio, but there was a strong age effect in these data. Lactate was found in the BG of 3 infants, all of whom had 5-minute Apgar scores of 6 or less. Three patients had focal lesions on MRI; 2 of these had elevated lactate levels in the abnormal region; and the third, who had an intrauterine stroke, had no lactate in the region. CONCLUSIONS: Correlations between NAA-Cho and NAA-ChoCr ratios and the 1- and 5-minute Apgar scores are stronger in the BG region than in the frontal border zone. The presence or absence of lactate may indicate the severity of the brain insult, and the combination of MRS, MRI, and diffusion-weighted MRI may assist in localizing and predicting a long-term brain injury.

Apgar Score↗
PubMed1999

Fetal erythropoietin levels in growth-restricted and appropriately grown neonates with and without abnormal fetal heart rate tracings: a comparison with cord blood gases and Apgar scores.

OBJECTIVE: To determine if umbilical cord plasma erythropoietin (EPO) levels in combination with cord blood gases and Apgar scores can distinguish between subacute and chronic uteroplacental insufficiency. METHODS: A total of 184 neonates delivered between 1993 and 1997 at Tampa General Hospital were studied. Cord plasma EPO levels, cord blood gases, and Apgar scores were determined prospectively and compared in four subgroups that were defined based on the presence or absence of fetal growth restriction (FGR; chronic fetal hypoxia), abnormal fetal heart rate tracings during labor (FHR; subacute/acute fetal hypoxia), or both. RESULTS: Both growth-restricted and appropriately grown newborns with abnormal intrapartum FHR tracing had elevated umbilical cord plasma EPO (183.5 and 135.2 mIU/ml, respectively; normal = 20.7 mIU/ml) and base deficit, whereas pH, Po2, and 1-minute and 5-minute Apgar scores were significantly lower, compared with appropriately grown newborns with a normal intrapartum course. Among newborns with normal heart rate tracings and FGR, the mean plasma EPO levels were elevated (89.5 mIU/ml), whereas the other parameters were not different from normal. CONCLUSION: Our findings suggest that, although cord blood gases and Apgar scores may reflect subacute and acute events, they are not good predictors of chronic uteroplacental insufficiency. The supplemental use of umbilical cord plasma EPO levels may improve our ability to identify chronic uteroplacental insufficiency.

Apgar Score↗
PubMed1990

Comparison of umbilical artery pH and 5-minute Apgar score in the low-birth-weight and very-low-birth-weight infant.

The division between "normal" and low Apgar scores is based largely on data obtained from term newborns and may not apply to the premature infant. Umbilical artery pH has been suggested as a better indicator of intrapartum asphyxia. We examined the charts of 558 infants with birth weights less than or equal to 2500 gm with respect to umbilical artery pH, 5-minute Apgar scores, and birth weight percentiles. A positive correlation between birth weight and 5-minute Apgar score was noted. No such relationship existed between birth weight and umbilical artery pH. Within birth weight groups, small-for-gestational-age infants have higher Apgar scores and lower umbilical artery pH values than their appropriate-for-gestational age counterparts.

Apgar Score↗