Virginia Apgar, MD – Scoring for Newborns to Save Lives
Most parents will tell you there’s nothing like holding their newborn baby for the very first time.
However before that special moment, a critical event happens in the first minute of a baby’s life. The infant is given an Apgar score, a list of criteria that helps physicians and nurses assess the baby’s health, including heart rate, muscle tone, physical appearance and breathing. It is repeated five minutes after birth.
The Apgar score was developed in 1952 by Dr. Virginia Apgar, then a professor of anesthesiology at Columbia University College of Physicians and Surgeons, and director of obstetric anesthesia at Presbyterian Hospital, creating the first tool to scientifically assess a neonate’s health risks and need for potentially life-saving observation. To this day, the Apgar score is still used around the world for assessing the health of newborns as they take their first breaths.
The Apgar score has been described as “ridiculously simple,” but its impact is huge, according to Dr. Richard Smiley, currently the Virginia Apgar M.D. Professor of Anesthesiology at Columbia University Medical Center and chief of obstetric anesthesia at New York-Presbyterian/Columbia University Medical Center. Dr. Smiley explains the score has helped prevent the death of countless infants by requiring doctors and nurses to view the newborn via an organized method. Once they were required to assign a score to a newborn, it created an imperative to improve that score.
According to Dr. Smiley, “It was essentially the birth of clinical neonatology.”
Though hard to fathom now, prior to adoption of the Apgar scoring system newborns with breathing difficulties or who were small and blue were often labeled as stillborn. It was assumed they would be too sick to live and were simply left to die. There was no protocol for trying to resuscitate newborns or intervene medically.
“You took the baby out, cleaned it, and hoped it lived,” says Smiley. “A large number of neonates could have survived if they had simply been given oxygen or warmed up.”
Apgar’s score put the focus on the newborn as well as the mother, and by doing so revolutionized the entire birthing process.
Born in 1909 in Westfield, New Jersey, Virginia Apgar attended Mount Holyoke College in Massachusetts, where she majored in zoology, participated in team sports, and played the violin.
After graduating in 1929, Apgar became just one of nine women in a class of 90 students pursuing an M.D. from Columbia University College of Physicians and Surgeons. She graduated fourth in her class, and followed this with a two-year surgical internship at Presbyterian Hospital, now New York-Presbyterian/Columbia University Medical Center, where she performed brilliantly. Although Apgar was an excellent student, her mentor at New York-Presbyterian, chief of surgery Allen Whipple, worried that as a woman, she wouldn’t be able to establish a surgical practice, and encouraged her to pursue anesthesiology instead. Whipple also believed that innovations and improvements were needed in anesthesia (at that time handled mostly by nurses) if surgery was to advance, and he saw in Apgar “the energy, intelligence, and ability needed to make significant contributions in this area.”
After serving a one-year residency at the University of Wisconsin-Madison and Bellevue Hospital in New York, Dr. Apgar returned to Columbia University as the director of the division of anesthesia and an attending anesthetist. At this time surgeons did not accept anesthesiologists as equals, and the pay for the less well-respected specialty was low. Apgar was the only staff member until the mid-1940s. By 1946, anesthesia began to become an acknowledged medical specialty with required residency training, and in 1949, when anesthesia research became an academic department, Dr. Apgar was appointed the first woman full professor at the Columbia University College of Physicians and Surgeons.
Apgar began studying obstetrical anesthesia—the effects on a newborn of anesthesia given to a mother during labor. It was at this time that she developed the Apgar score, the first standardized method for evaluating the newborn’s transition to life outside the womb, her greatest contribution to the field. “Five points—heart rate, respiratory effort, muscle tone, reflex response, and color—are observed and given 0, 1, or 2 points. The points are then totaled to arrive at the baby’s score.” The score was presented in 1952 at a scientific meeting, and first published in 1953. The Apgar score was eventually widely accepted and is now used throughout the world. Apgar first planned the score to be taken one minute after birth, as a guide to the need for resuscitation. Others began to take measurements at longer intervals, to evaluate how the baby had responded to any necessary resuscitation. Eventually, the one- and five-minute Apgar Score became standard.
Apgar went on to relate the score more closely to the effects of labor, delivery, and maternal anesthetics on the baby’s condition. In collaboration with colleagues Dr. Duncan Holaday and Dr. Stanley James, they were able to demonstrate that babies with low levels of blood oxygen and highly acidic blood had low Apgar Scores, and that giving cyclopropane anesthesia to the mother was likely to result in an infant’s low Apgar Score. Finally, the Collaborative Project, a twelve-institution study involving 17,221 babies, established that the Apgar Score, especially the five-minute score, can predict neonatal survival and neurological development. After the creation of the Apgar score, the first neonatal intensive care units were started.
Apgar’s other great contribution was the creation of a clinical scoring system, a concept that has been applied in multiple other areas of medicine. Scoring is now used for everything from comas to the ICU.
Up to her death at age 65, Apgar never stopped working or learning. She earned a master’s degree in public health from the Johns Hopkins University in 1959 while on sabbatical leave, and made the decision not to return to academic medicine, opting instead to focusing on the prevention of birth defects through public education and fundraising for research. Apgar accepted a position as director of the division of congenital defects at the National Foundation for Infantile Paralysis (now the March of Dimes) and received many honors and awards for her work. With journalist and writer Joan Beck, she wrote the popular book Is My Baby All Right? (1972). She made her own musical instruments, performed with the symphony in Teaneck, New Jersey, and learned to fly a single-engine plane in her 50s.
Former U.S. Surgeon General Julius Richmond once said that Apgar had “done more to improve the health of mothers, babies, and unborn infants than anyone else in the 20th century.” Apgar not only championed newborn babies, she also broke barriers and paved the way for women to pursue careers in medicine.