It Happened Here: The Apgar Score

Ask any parents, and they’ll likely say there’s nothing like holding their newborn baby for the first time.

But before a mother or father can enjoy that cuddle, 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 doctors and nurses assess health, including heart rate, muscle tone, physical appearance, and breathing. An easy way to remember the criteria is by its acronym (Appearance, Pulse, Grimace, Activity, Respiration). It is repeated five minutes post-birth.

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, the Apgar score is used around the world for assessing newborns’ health 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, the Virginia Apgar M.D. Professor of Anesthesiology at Columbia University Medical Center and chief of obstetric anesthesia at NewYork-Presbyterian/Columbia University Medical Center. “The score gave physicians and nurses a requirement to look at the newborn in an organized method,” he says, “and it’s helped prevent the death of countless babies. Once physicians and nurses had to assign a score, it created an imperative to act to improve the score.

“It was essentially the birth of clinical neonatology,” Smiley says.

Before the scoring system was adopted, newborns who had trouble breathing or were small and blue were often labeled as stillborn. It was assumed they would be too sick to live and, unfathomably, were simply left to die. There was no protocol for trying to resuscitate newborns or intervene medically.

“Before, 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 revolutionized the birthing process, as it switched the focus to newborns as well as the mother.

It’s no surprise that the work of Virginia Apgar had a far-reaching impact. She was a standout from an early age.

Born in 1909 in Westfield, New Jersey, Apgar attended Mount Holyoke College in South Hadley, 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 NewYork-Presbyterian/Columbia University Medical Center. Although Apgar was an excellent student, her mentor at NewYork-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.

With her trademark intellectualism and dedication, Apgar threw herself into the field. She spent a year at Presbyterian’s nurse-anesthetist program, then attended residency programs at the University of Wisconsin and New York’s Bellevue Hospital. In 1938, when she was just 28 years old, Apgar returned to Presbyterian Hospital as director of the new division of anesthesia within the department of Surgery. Her role included clinical responsibilities as well as building the residency program.

Apgar continued to break barriers. From 1949 to 1959 she was a professor of anesthesiology at Columbia’s College of Physicians and Surgeons, the first female full professor there, and the first female physician to hold a full professorship at the college. When the division of anesthesia within the department of surgery became an independent department of anesthesiology under Dr. Emanuel Papper, Apgar became the director of obstetric anesthesia.

During this time, she attended countless births and began to lay the foundation for the Apgar score, as newborn circulatory or respiratory issues were not always physically apparent, often resulting in death. Apgar worked with colleagues to quickly assess a baby’s health in the first minute of life, looking for birth defects as well as the effects of labor, delivery, and maternal anesthesia.

According to medical legend, one day a student approached Apgar in the hospital cafeteria with a question. “You always tell us to look at the baby when it’s born, but what exactly are we looking for?” Apgar grabbed a napkin and wrote down five things, including heart rate, breathing, and muscle tone. The Apgar score was born. She presented the score at a national anesthesiology meeting in 1952 and published it in a full manuscript in 1953.

“Virginia Apgar triggered the formation of neonatology, which is the care of the just-born infant,” says Smiley. 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, an idea that has been applied in multiple other areas.

“Now we use scoring for everything from comas to the ICU,” says Smiley. The Glasgow coma scale, for example, provides the status of the central nervous system, while APACHE II attempts to predict the morbidity and mortality rate of intensive care unit patients.

Up to her death at age 65, Apgar never stopped working or learning. In 1959, she obtained a master’s degree in public health from Johns Hopkins School of Public Health, which led to a role at March of Dimes as the head of the new division of congenital malformations. 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. Apgar not only championed newborn babies; she also paved the way for women to pursue careers in medicine.