Variability in Apgar Score Assignment among Clinicians: Role of a Simple Clarification

Abstract

Objective We aimed to evaluate variability in Apgar score (AS) assignment among health care providers (HCPs) and to evaluate whether a simple clarification improves accuracy and consistency of AS assignment.

Study Design An electronic questionnaire survey was provided to pediatric residents, nurse practitioners, neonatal fellows, and faculty in level III neonatal intensive care unit and major academic centers in the United State to assign AS for three clinical scenarios. Next, we provided a simple clarification on various components of AS. After review of clarification, responders were asked to provide AS for the same scenarios. We also sought the opinion of responders on the subjectivity of five components of AS.

Results A total of 107 responses were collected. Correct assignment before and after clarification improved significantly: heart rate (78 vs. 90%, p = 0.02), reflex (63 vs.75%, p = 0.06), and breathing (82 vs. 96%, p = 0.003). Correct scoring for color and tone were 86 and 67%, respectively. Interobserver agreement improved significantly after clarification.

Conclusion There was variability among HCPs for AS assignment, with improvement in correct response as well as consistency after a simple clarification. Availability of this clarification, along with the AS table in delivery room, will improve the correct assignment and consistency of AS for high-risk infants.

Keywords

Apgar score - variability - premature - resuscitation

• References

• 1 Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anest Anal 1953; 32 (4) 260-267
• 2 Ramji S, Rasaily R, Mishra PK , et al. Resuscitation of asphyxiated newborns with room air or 100% oxygen at birth: a multicentric clinical trial. Indian Pediatr 2003; 40 (6) 510-517
• 3 Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics 1998; 102 (1) e1
• 4 Hellström-Westas L, Forsblad K, Sjörs G , et al. 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. Pediatrics 2006; 118 (6) e1798-e1804
• 5 Saugstad OD, Ramji S, Rootwelt T, Vento M. Response to resuscitation of the newborn: early prognostic variables. Acta Paediatr 2005; 94 (7) 890-895
• 6 Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981; 68 (1) 36-44
• 7 Moster D, Lie RT, Irgens LM, Bjerkedal T, Markestad T. The association of Apgar score with subsequent death and cerebral palsy: a population-based study in term infants. J Pediatr 2001; 138 (6) 798-803
• 8 O'Donnell CP, Kamlin CO, Davis PG, Carlin JB, Morley CJ. Interobserver variability of the 5-minute Apgar score. J Pediatr 2006; 149 (4) 486-489
• 9 Bashambu MT, Whitehead H, Hibbs AM, Martin RJ, Bhola M. Evaluation of interobserver agreement of Apgar scoring in preterm infants. Pediatrics 2012; 130 (4) e982-e987
• 10 American Academy of Pediatrics; Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists; Committee on Obstetric Practice. The Apgar score. Adv Neonatal Care 2006; 6 (4) 220-223
• 11 Rüdiger M, Wauer RR, Schmidt K, Küster H. The Apgar score. Pediatrics 2006; 118 (3) 1314-1315 , author reply 1315–1316
• 12 Lopriore E, van Burk GF, Walther FJ, de Beaufort AJ. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ 2004; 329 (7458) 143-144
• 13 Rudiger M, Braun N, Aranda J , et al. Neonatal assessment in the delivery room--Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatr 2015; 15: 18 ; doi:10.1186/s12887-015-0334-7
• 14 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (1) 159-174
• 15 Catlin EA, Carpenter MW, Brann IV BS , et al. The Apgar score revisited: influence of gestational age. J Pediatr 1986; 109 (5) 865-868
• 16 Committee on Obstetric Practice, ACOG; American Academy of Pediatrics; Committee on Fetus and Newborn, ACOG. ACOG Committee Opinion. Number 333, May 2006 (replaces No. 174, July 1996): the Apgar score. Obstet Gynecol 2006; 107 (5) 1209-1212
• 17 Dalili H, Nili F, Sheikh M, Hardani AK, Shariat M, Nayeri F. Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PLoS ONE 2015; 10 (3) e0122116
• 18 Goldenberg RL, Huddleston JF, Nelson KG. Apgar scores and umbilical arterial pH in preterm newborn infants. Am J Obstet Gynecol 1984; 149 (6) 651-654
• 19 Sykes GS, Molloy PM, Johnson P , et al. Do Apgar scores indicate asphyxia?. Lancet 1982; 1 (8270) 494-496
• 20 Natarajan G, Shankaran S, Laptook AR , et al; Extended Hypothermia Subcommittee of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Apgar scores at 10 min and outcomes at 6-7 years following hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 2013; 98 (6) F473-F479
• 21 Laptook AR, Shankaran S, Ambalavanan N , et al; Hypothermia Subcommittee of the NICHD Neonatal Research Network. Outcome of term infants using apgar scores at 10 minutes following hypoxic-ischemic encephalopathy. Pediatrics 2009; 124 (6) 1619-1626
• 22 Thorngren-Jerneck K, Herbst A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol 2006; 108 (6) 1499-1505
• 23 Lie KK, Groholt EK, Eskild A. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study. BMJ 2010; 341: c4990 ; doi: 10.1136/bmj.c4990
• 24 Topp M, Langhoff-Roos J, Uldall P. Preterm birth and cerebral palsy. Predictive value of pregnancy complications, mode of delivery, and Apgar scores. Acta Obstet Gynecol Scand 1997; 76 (9) 843-848