When a baby joins our planet today, doctors or nurses evaluate them at one minute old and again at five minutes old, using a system called the Apgar Score.

Five attributes each receive a score of 0-2, making the overall score a range between 0 and 10. If you have a child in modern times, you’ll learn that each letter in Apgar corresponds to an important criterion: A is for activity; P is for pulse; G is for grimace; A is for appearance; and R is for respiration. The healthcare provider watches how easily a baby breathes, tests the heart rate, and examines the muscle tone, reflexes, and skin color. The Apgar examination gives doctors an indication of how the baby tolerated the birthing process and an early prognosis of any potential concerns in the future.

If Apgar sounds like an odd acronym, your grammatical senses are on point. The constituent parts of Apgar were retconned to fit the name of an obstetrics legend. Virginia Apgar developed the system in 1952 and it’s carried her name ever since.

Dr. Virginia Apgar in 1959 - photo from March of Dimes

Virginia was the third child born to Helen and Charles Apgar in Westfield, New Jersey, in 1909. Though her father worked as a business executive, he dabbled in astronomy and radio communication as hobbies. During World War I, he managed to intercept German signals. After decoding them, he uncovered a German espionage ring. One of Virginia’s brothers died of tuberculosis and the other suffered from chronic illnesses. This mixture of scientific background and personal tragedy seemed to inspire an intense desire in Virginia to become a doctor. By the time she graduated from high school, she had determined a path to medical school.

In 1929, Apgar graduated from Mt. Holyoke College after studying zoology, physiology, and chemistry. She moved on to Columbia University College of Physicians and Surgeons, finishing fourth in her class and then completing a residency in surgery there. At this point, she encountered an interesting confluence of the times.

The chair of the Columbia-Presbyterian Medical Center at the time was Allen Whipple, who also happened to become the namesake of medical happenings: the Whipple procedure is pancreatic cancer technique and Whipple’s triad is a set of signs that indicate hypoglycemia (he also has a fantastic middle name: Oldfather). Whipple actively discouraged Apgar from pursuing surgery “because other women he had trained in surgery failed to establish successful careers in the specialty.” Despite this disappointing lack of vision, Whipple simultaneously encouraged her to explore the boundaries of a field that, today, is paramount in health care but bordered on happenstance magic in the early 20th century: anesthesiology.

Virginia Apgar playing violin in 1920 - photo from Mount Holyoke College

Apgar opted to pursue anesthesiology, moving to the University of Wisconsin-Madison, where Ralph Waters had launched the first specialty department in the nation. She was the only woman in the program. In 1937, she earned certification in anesthesiology. A year later, she returned to Columbia, where she became the first director of a division created to improve the specialty.

That designation made her the first woman to head a department at the Columbia Medical Center. In 1949, she also became the first woman to be appointed a full professor at the Medical Center.

How does one go from a pioneer in the field of anesthesiology to developing a system for examining newborns?

Residents at the University of Wisconsin-Madison anesthesiology program - Mt. Holyoke

While advancing the burgeoning field, Apgar started to work with obstetrical anesthesia, administering the compounds to mothers in labor. Through this practice, she noted the overall infant mortality rate had plummeted in the United States between the 1930s and the 1950s, but the number of newborns dying within the first 24 hours had remained steady.

Her newly acquired knowledge provided insight into an unexpected area. As an anesthesiologist, one becomes an expert at the signs that someone isn’t doing well. Apgar believed some of the issues on the first day of a child’s life stemmed from doctors not recognizing the signs of struggle.

The Apgar score was born (insert your own natal pun here).

Virginia Apgar examining a newborn baby in 1966

The system probes a child in five areas.

A blueish tinge to the skin or complete paleness earns a zero, while blue just at the extremities garners a one. A lack of cyanosis, where the body is all pink, achieves two points.

An absence of pulse – big trouble – is an obvious zero; if the heartbeat is below 100 per minute, the baby nabs a one; greater than 100 per minute takes two.

If a child displays no grimace on a reflex irritability test, that’s a zero; if a grimace emerges only with suction or aggressive stimulation, the newborn gains one point; crying on stimulation is worth two.

If no muscle tone exists at birth, a baby gets zero points; some flexion achieves one, while flexed limbs that resist extension take the full two points.

The final examination regards respiration. No breathing is another clear zero. Labored or weak respiration is the middle level, while strong breathing mixed with crying attains two points.

Looks like this baby easily earns two points for respiration - photo by Ernest F

Though this system isn’t foolproof, if a child receives a score of three or lower on the one-minute test it indicates the child might need medical attention. However, a low score does not necessarily signify an issue, especially if the score improves at the five-minute mark. Obviously, if a score is low for heart rate or respiration reasons, immediate care is likely necessary. Typically, anything over seven is considered normal. If scores remain below this threshold, doctors might continue to administer the test every five minutes to see if conditions improve.

Perfect scores are rare because of the prevalence of cyanosis. Most babies display at least blue extremities, though it usually fades relatively quickly.

Although other factors have played a part, the Apgar score was vastly influential in the reduction of the infant mortality rate in the second half of the 20th century. By the 1960s, most hospitals had adopted the system and it remains ubiquitous today.

Apgar continued tirelessly to improve the lives of families via medicine. She became a vaccine advocate, thanks to the rubella pandemic of 1964. Her work displayed that preventing mother-to-child transmission of the disease via vaccine was critical to saving lives. She dedicated herself to the cause of birth defects, becoming the director of the division of congenital defects at the National Foundation of Infantile Paralysis, which is now known as the March of Dimes.

Apgar died on 7 August 1974, but, if there were a score for the impact one had on the world during life, she would have gone out with a 10 out of 10.

She earned a spot in the Great Americans postage stamp series. She was inducted into the National Women’s Hall of Fame. She received the Distinguished Service Award from the American Society of Anesthesiologists and the Elizabeth Blackwell Award from the American Women’s Medical Association. Ladies Home Journal named her the Woman of the Year in Science for 1973. Columbia University College of Physicians and Surgeons bestowed upon her the Alumni Gold Medal for Distinguished Achievement.

These notable triumphs and the positive influence on infant survivability easily earns Virginia Apgar a spot in the Woman Crush Wednesday Hall of Fame!

Further Reading and Exploration

Dr. Virginia Apgar – National Library of Medicine

Apgar score – Mount Sinai

The Apgar Score and Infant Mortality – National Library of Medicine

The Virginia Apgar Papers – National Institutes of Health

Dr. Virginia Apgar and the Apgar Score – Anesthesia & Analgesia

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