¶ APGAR Scores Introduction and Clinical Case
Hi everyone, welcome back to the MedBullets Step 2 in 3 podcast. In today's episode, we cover the topic of APGAR scores found under the obstetrics section at MedBullets.com. Let's begin with a clinical snapshot. A 30-year-old G2P1 woman at 39 weeks of gestation is in active labor. She undergoes a vaginal delivery and gives birth to a baby boy.
The baby is vigorously dried and he begins to cry. At one minute after delivery, the baby is crying. He has a pink body and somewhat gray extremities and his pulse is 130 beats per minute. He is moving all four limbs and grimaces in response to nasal suction. The nurse calculates an APGAR score of 8. At 5 minutes after delivery, the nurse notes that the baby continues to show good breathing.
with intermittent crying, is now pink all over and his pulse is 134 beats per minute. The baby coughs and pulls away in response to nasal suction and continues to move all four extremities with good tone. The nurse calculates a new APGAR score of 10. Given the baby's strong APGAR scores, he does not undergo any intervention or resuscitation after the 5-minute mark. Let's continue with an introduction to APGAR scores.
¶ Decoding the APGAR Scoring Criteria
As a general overview, this is a scoring system used to assess the newborn at 1 minute and 5 minutes after delivery. 90% of neonates will have an APGAR score between 7 and 10. An APGAR score of less than 7 at 5 minutes indicates the need for further intervention or resuscitation. The 1-minute score is designed to assess neonates and the uterine environment.
The 5-minute score is designed to assess the neonate status and adaptation to the external world. Now let's quickly review the actual scoring system. The A stands for appearance, which refers to the skin color. 0 points are given for a blue body, 1 point for a pink body with blue extremities, and 2 points if the body and all extremities are pink. The P stands for pulse. 0 points are given if it is absent.
one point if it is less than 100 beats per minute, and two points if it is greater than 100 beats per minute. The G stands for grimace, which refers to irritability. Zero points are given if there is no response to nasal suction. one point if they grimace in response to nasal suction, and two points if there is coughing, sneezing, and pulling away to nasal suction. The A stands for activity, which refers to muscle tone.
Zero points are given if the baby is flaccid, one if they have weak muscle tone but some movement, and two points if they are moving all four limbs with good tone. The R stands for respiration. 0 points are given if breathing is absent, 1 point if it is slow and irregular, or 2 points if there is good breathing and crying. Now let's go through some case examples. For example 1.
There is a newborn infant at one minute that has acral cyanosis and weak respiratory effort and respirations are 30 breaths per minute. The pulse is 105 beats per minute and a systolic murmur is heard. She has weak reflexes in all four extremities only after external stimulation. When her nose and mouth are suctioned, there is no response. Her eyes are closed. Her total APGAR score is 5.
she receives one point for appearance, two points for pulse, zero points for grimace, one point for activity, and one point for respiration. For the second example, consider the following. At one minute, A newborn's pulse is 90 beats per minute. There's good respiratory rate with crying, a pink body with blue extremities, weak muscle tone with flexion of the extremities, and a facial grimace response to nasal suction.
but no coughing or sneezing. This patient receives an APGAR score of 6. They get 1 point for appearance, 1 point for pulse, 1 point for grimace, 1 point for activity, and 2 points for respiration.
¶ APGAR Score Application and Neonatal Management
Now that we've discussed the major points relating to APGAR scores, let's walk through a question to apply what we've learned and get a sense of how the topic might be tested. For this question, consider the following clinical scenario. A newborn male is evaluated one minute after birth. He was born at 38 weeks gestation to a 28-year-old gravidate 3 via vaginal delivery. The patient's mother received sporadic prenatal care.
and the pregnancy was complicated by gestational diabetes. The amniotic fluid was clear. The patient's pulse is 70 beats per minute, and his breathing is irregular with a slow and weak cry. He whimpers in response to a soft pinch on the thigh and he has moderate muscle tone with some flexion of his extremities. His body is pink and his extremities are blue. The patient is dried with a warm towel.
and then placed on his back on a flat warmer bed. His mouth and nose are suctioned with a bulb syringe. Which of the following is the best next step in management? And the answer choices are, choice one. chest compressions and bag mask ventilation. Choice two, intravenous epinephrine and reassessment of APGAR scores at five minutes. Choice three.
positive pressure ventilation and reassessment of APGAR score at five minutes. Choice four, supplemental oxygen via nasal cannula and reassessment of APGAR score at five minutes. Or choice five, endotracheal intubation, and mechanical ventilation. The best answer to this question is choice three.
positive pressure ventilation, and reassessment of APGAR score at 5 minutes. This patient presents at 1 minute of life with a pulse less than 100 beats per minute, irregular breathing, moderate muscle tone with flexion, acrocyanosis, and whimpering in response to irritable stimuli, which give him an APGAR score of 5. The best next step in management is positive pressure ventilation and reassessment of his APGAR score at 5 minutes.
All neonates should be evaluated using the APGAR scoring system at 1 and 5 minutes of life. The APGAR scoring system can be remembered with the acronym APGAR, which stands for appearance, pulse, grimace, activity, and respiratory effort. Each sign is given a value of 0, 1, or 2 and added together to compute the overall APGAR score. Positive pressure back mask ventilation should be initiated.
in patients with a weak respiratory effort or pulse of less than 100 beats per minute. Let's also discuss why the other choices are incorrect. Choice one, chest compressions would not be appropriate for this patient. because his pulse is greater than 60 beats per minute. Chest compression should be initiated in patients with a pulse persistently less than 60 after 30 seconds of adequate ventilation. Choice two.
intravenous epinephrine should be administered to patients with a pulse of less than 60 that failed to respond to both a 30-second trial of adequate ventilation and chest compressions. Choice four. Supplemental oxygen via nasal cannula is not used in neonatal resuscitation. Respiratory support should be provided with positive pressure bag mask ventilation. Choice 5.
Endotracheal intubation and mechanical ventilation should be pursued if positive pressure bag mask ventilation is ineffective or prolonged. Finally, a bullet summary. APGAR scores should be assessed for all newborns at one and five minutes of life, and newborns with weak respiratory effort or pulse less than 100 per minute should be resuscitated with positive pressure back mask ventilation.
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