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Tom Sharon
A self-limiting assessment tool, not to be blindly trusted


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APGAR Scoring Form for Newborns

Sign

0

1

2

Birth Score

5-Minute Score

A -Activity         (muscle tone)

Absent

Arms and legs flexed

Active movement

P -Pulse

Absent

Below 100 bpm

Above 100 bpm

G -Grimace       (reflex             irritability)

No response

Grimace

Sneezes, coughs, pulls away

A -Appearance     (skin color)

Blue-gray, pale all over

Normal, except for extremities

Normal over entire body

R -Respiration

Absent

Slow, irregular, feeble cry

Good cry

Total score


 

The doctors usually base their decision to place the infant in the well-baby nursery on the Apgar score at birth and five minutes after. With an acceptable score, this assessment tool does not enable the physicians to detect any potentially lethal clinical conditions. Additionally, the nurses usually do not transfer the babies until they complete the paperwork and footprints. The child also spends a little time with its mother, so it takes at least thirty minutes to complete the process. If the doctors were required to make at least one additional assessment before sending out the infant, they might detect a problem that was not apparent at birth or at five minutes.
 
This might have helped in the case of Baby Martha, who had Apgar scores of 8 and 10 at birth and at five minutes of life, respectively. Because of this near perfect score, the pediatric resident placed her in the well-baby nursery. Upon the baby's arrival, the intake nurse noted that her fingers were a little bit on the bluish side. She reported this to the same resident, and he opted to keep the baby in the nursery because the Apgar scores "were so good".
 
Three hours later the child became severely cyanotic (bluish color due to lack of oxygen) with her heart rate in the high 160s. The resident wrote in his progress note that he decided to continue "observation" and took no action. A few hours later, the baby stopped breathing. There was a rush to bring the infant to the neonatal intensive care and hook her to a ventilator. The unit staff resuscitated the child, but by then it was too late to prevent the severe brain damage that occurred.
 
Although negligence to that extent is thankfully somewhat unusual in my experience, the problems began with reliance on an assessment tool that is self-limiting. This being the standard of care, one cannot fault the physician for deciding to bring the child to the well-baby nursery. The fault was in the decision to do nothing in the face of the presenting cyanosis. Nonetheless, a change in the standard, with implementation of the Apgar scoring to be repeated three or four additional times for one hour, might help to reduce the incidence of babies being in the well-baby nursery when they should be in neonatal intensive care. If this became a widespread consumer demand, the medical, nursing, and hospital management professions would likely give in.
 
All new parents whose babies go to the regular nursery should ask, "What assurance can you give me that my child does not need closer observation?"
 
If the answer is "We last examined your child thirty minutes ago at five minutes of life and it was fine then," that is unacceptable. The answer should be "I'll examine your child again now and I will follow up in an hour to make sure." If that is not the answer you receive, ask the nurse in the nursery to examine your child again to make you feel more comfortable that all is well. Then when they bring the baby to you for the first feeding, carefully check your baby's lips, fingernails, and toenails for any bluishness. Also note the strength of your baby's sucking. If you have even the slightest doubt, insist that the nurse call the attending pediatrician. The doctor then owes you a duty to come and examine your baby-even if it is just for reassurance. This goes back to the underlying theme of this entire book - never place your total trust in the system.

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