B12. Resuscitation of the neonate, the Apgar-score
Apgar score
The Apgar score is a scoring system used to quantify the neonate’s condition at birth. More specifically, it provides information on the toleration of labour and adaptation to life outside the uterus. It’s named after obstetrician Virginia Apgar, who managed to come up with a scoring system which is not only named after herself but is also an acronym for the scored parameters. Each parameter gives a score of 0, 1, or 2. The scores are added to give a final score.
| Parameter | Parameter (detailed) | Score 0 | Score 1 | Score 2 |
|---|---|---|---|---|
| Appearance | Skin colour | Cyanotic or pale | Acrocyanosis | Pink all over |
| Pulse | Heart rate | No pulse | < 100 bpm | > 100 bpm |
| Grimace | Reflex response to stimulation | None | Grimace or whimpering | Sneezing, coughing, pulling away |
| Activity | Muscle tone | No movement, hypotonia | Some movement | Active movement |
| Respiration | Breathing/crying | No breathing | Weak/slow/irregular breathing | Strong cry |
The Apgar score is measured at 1, 5, and sometimes 10 minutes of life. The first Apgar score tells us how well the neonate tolerated the labour, while the other Apgar score tells us how well the neonate has adapted to the outside world after birth. The Apgar score does not tell us what to do next or what the outcome will be.
A score of 7 – 10 is healthy, and nothing more than basic care is necessary. A score of 4 – 6 indicates a moderately depressed neonate which may require some assistance or resuscitation. A score of 3 or less indicates a severely depressed or asphyxiated newborn, which requires intensive resuscitation.
Routine neonatal care
If all the following criteria are present:
- Gestational age 35 weeks or more
- Neonate is crying or breathing
- Neonate has good muscle tone
… then give the baby to the mother and keep it warm and dry. No other interventions are necessary. This is the case for the majority of newborns.
Neonatal resuscitation
Neonatal resuscitation is indicated in case of any of the above criteria are absent. The neonate should undergo the following steps:
1. Initial steps of stabilisation
Initial steps of stabilisation involve drying, keeping warm, clearing airways, and stimulating by rubbing the back. Airway suction is not routinely recommended, only used if there’s an obvious airway obstruction (blood, thick meconium). The heart rate should be measured with a stethoscope and the breathing should be examined. Open airways should be ensured. If the neonate is gasping or not breathing, or there is bradycardia (< 100), continue to the next step.
2. Ventilate and oxygenate
Ventilate with mask (30 – 60 inhalations/min). The administered oxygen concentration (FiO2) depends on the gestational age (21% for term, 30% for preterm). Ensure proper ventilation (no leakage, chest should move). The majority of neonates will respond to ventilation, as the respiration is usually the problem, not the cardiovascular system. An increasing heart rate is the most important sign of effective ventilation. Consider intubation. If after 1 – 2 minutes there is still bradycardia and the heart rate is not increasing, continue to next step.
3. Initiate CPR
CPR with a ratio of 3:1 (3 compressions, 1 ventilation), approximately 90 compressions and 30 ventilations per minute. Intubate if not already performed. Increase oxygen delivery to 100%. Evaluate the heart rate every 30 – 60 seconds. Continuously consider hypovolaemia and pneumothorax, and the need for interventions like adrenaline and fluids.