The birth of the Apgar Score and the woman behind it

20170419120000, Brenda Lau
'Did You Know?' seeks to uncover a variety of stories from all facets of medicine and healthcare.
In 1952, anaesthesiologist Dr Virginia Apgar was eating breakfast in a hospital cafeteria when a medical student commented on the need for a way to assess how well a baby has been delivered.

She proceeded to write down five evaluation criteria: breathing, heart rate, muscle tone, reflexes and skin colour. In that moment, Dr Apgar had touched the lives of billions of children the moment they were born.

After a year, she suggested that the usage of these five criteria to generate a score was an effective way to determine which babies were likely to need medical attention after birth.

"A practical method of evaluation of the condition of the newborn infant 1 minute after birth has been described," she wrote in her 1953 proposal paper. "A rating of 10 points described the best possible condition with two points each given for respiratory effort, reflex irritability, muscle tone, heart rate and colour."

She coined the method "Apgar score" and with that, she changed the course of neonatology by shifting the perception in which newborn babies are cared for.

A groundbreaking career fuelled by gender bias


Born in 1909, Apgar grew up in an era whereby women were still struggling to be recognised and respected in society, even more so in the arena of medicine.

Science however, did run in Apgar's family - her father was a devoted amateur astronomer and electrician. But her two brothers were sickly - one died of tuberculosis, the other struggled with childhood illness - so a sizeable inheritance allowed Apgar to study zoology at Mount Holyoke College and obtain her medical degree from Columbia University's College of Physicians and Surgeons.

Anesthesiologist Dr. Virginia Apgar, pictured in 1959. Photo credit: Library of Congress
Anesthesiologist Dr. Virginia Apgar, pictured in 1959. Photo credit: Library of Congress

But Apgar was perhaps born in the wrong generation. A decade before she was born, medicine was deemed as a low-ranked career to pursue and in addition, women never had much of a social standing, so there were only about 7,000 women doctors in the United States then.

However when Apgar was born, medicine became a more respected and regulated choice of career and so women were not permitted to study medicine in many schools. Those who did - Apgar was one of nine women in a class of 90 - were often discouraged by their male colleagues or pushed into less respected specialities.

Climbing the ranks to be the first female professor


Apgar was a talented surgeon, but she was discouraged by Allen Whipple, the chair of surgery at Columbia University as he worried that the economic prospects for female surgeons would be poor during the Depression. Apgar then took his advice and pursued anaesthesiology instead - which was just beginning to be a medical speciality instead of a nursing specialty.

She eventually climbed the ranks to be the director of Columbia University's department of anaesthesia and despite many challenges, she became the first woman to become a full professor at the Columbia University College of Physicians and Surgeons.

With her resources at disposal, she began to study how anaesthesia affected mothers and babies, a commonly neglected area of research. Even as the 20th century progressed, despite an increase in delivery of babies in hospitals, the newborn mortality rate was still high.

The Apgar score reduced infant mortality rates


"As late as the 1940s, delivery-room doctors focused on mothers and paid little attention to babies," said Melinda Beck, Apgar's friend. "Those who were small and struggling were often left to die, since doctors assumed little could be done for them."

All it took was a conversation in a hospital cafeteria and some testing for her idea. Over 17,000 births later, Apgar cemented the existence of the "Apgar score" into medical textbooks.

Dr. Apgar, pictured assessing a newborn baby in 1966.  Photo credit: Library of Congress
Dr. Apgar, pictured assessing a newborn baby in 1966. Photo credit: Library of Congress

The measure has allowed doctors to provide the right treatment for babies when it came to resuscitation to oxygen and heart monitoring. The score eventually became used throughout the United States and afterwards, Apgar was even able to connect the score to infant mortality rates - babies who scored the lowest had a death rate of 14%, compared to the highest with only 0.13%.

Apgar's score has been hailed as a lifesaver as it has seen a steady increase in neonatal survival rates after the implementation of the measure. Her work with newborns also helped her discover methods to detect birth defects within moments of a baby's birth as well.

She eventually obtained her Master's in public health and educated physicians and parents about birth defects later on. MIMS

Read more:
A five decade lie: The story of a female doctor who lived and died a man
Women in science: Tackling FGM, creating designer pigs and advancing cardiology
Healthcare delivery paradigms female doctors can inspire in male counterparts

Sources:
http://www.medicalnewstoday.com/articles/315798.php
https://profiles.nlm.nih.gov/ps/retrieve/Narrative/CP/p-nid/178
http://www.notablebiographies.com/An-Ba/Apgar-Virginia.html
https://americanmedicalhist.wordpress.com/2011/01/21/1900-1914-medicine/