Apgar lecturing on resuscitation of newborns. Her visual aid is a poster showing the key points of the Apgar score, using the "APGAR" mnemonic, and accompanied by a frequently-used photo of Apgar in surgical gown, testing the reflexes of a newborn, which she holds suspended by its heels.

Revealing Data: Reflections on the APGAR Score

By Kelly West ~

When I consider that I was once a sickly, premature baby brought into this world while my mother was on the verge of death, it seems incredible that we both survived. While physicians were trying to stop my mother’s blood loss, they were also evaluating newborn me, with a tool that I can partially thank for the miracle of my life: the APGAR score. Developed by the American physician, Virginia Apgar, the APGAR score helped save my life by alerting physicians to my need for immediate medical care. I was whisked away to the neonatal intensive care unit (NICU) while my mother was treated for her postpartum hemorrhaging. The day my mother held me in her arms for the first time, weeks after we both recovered, may not have been possible without the APGAR score or its creator.

Born in Westfield, New Jersey, in 1909, Apgar’s early interest in science and medicine is believed to be inspired by her father, an amateur inventor. By high school, she was determined to pursue a medical career. After graduating from Mount Holyoke College in 1929, Apgar began her medical training at Columbia University’s College of Physicians and Surgeons, where she worked for decades within the field of anesthesiology which she helped to found. In the 1950s, she developed a scoring system that would help save lives for generations—including my own.

Apgar holds a newborn baby upside-down to test its reflexes, as part of an Apgar evaluation, at Columbia-Presbyterian Medical Center. Reflex irritability--in response to tickling the nostrils or gently slapping the feet--is one of the five Apgar score criteria.
Virginia Apgar Demonstrating Apgar Score, 1959
Reproduced with permission of the March of Dimes
Courtesy of Mount Holyoke College
Profiles In Science

The APGAR score, although seemingly simple, has had a huge impact on the way physicians care for newborns. Its name works as both an acknowledgement to its creator and as an acronym to describe components of the score: appearance, pulse, grimace, activity, and respiration. Though infant mortality rates in general had been steadily declining since the 1900s, mortality rates specifically for newborns (also called neonates) were still high. Apgar, an anesthesiologist, was particularly concerned with finding a way to reduce instances of neonatal respiratory difficulty because she was aware that anesthetic agents, often depressants, affected the baby as well as the mother. By creating an organized method to evaluate neonates by, the APGAR score helped physicians and nurses rapidly assess the need for resuscitation efforts. A score of 6 or below could mean a newborn needed medical intervention such as breathing stimulation, temperature normalization, or even chest compressions. The APGAR score introduced the concept of viewing newborns as patients with their own specific needs and assessment protocols—an idea that wasn’t universally accepted before the creation of the score. This change in perspective opened a new world of data collection and research, which paved the way for neonatal healthcare advancements.

Resuscitation Laboratories manufactured standard scoring forms for recording Apgar scores, and clipboards with built-in timers, for hospital use.
Apgar Scoring Form and Clipboard, 1970
Courtesy of Mount Holyoke College.
Profiles in Science

As Apgar was expanding the field of neonatology with her assessment tool, other physicians were developing technologies and research-based protocols that also improved neonatal health. The Hess incubator, designed in the early 1900s by Chicago pediatrician Julius H. Hess, M.D., was gaining more widespread use as means to provide temperature and humidity control to newborn patients—variables Apgar also recognized as critical for increasing neonate survival chances. At the same time, Dr. Louis Gluck’s research on infection risk in neonates prompted him to develop new handwashing protocols and push for a redesign of special care nurseries. Based on Gluck’s research, the first American NICU opened in 1960 at Yale New Haven Hospital.

An engraving of a closed box with adjustable ventilation and electric heating
Bag for Carrying Prematurely Born Infants in Infant Feeding: A Handbook for the Practitioner, 1923 by Julius Hess
National Library of Medicine #49420700R

The scale of data collection and evaluation continued to increase as time went on. In 1966, the National Collaborative Perinatal Project completed a 12-institute study involving more than 17,000 children. The study focused on the relationship between APGAR scores and longer-term disability in children. Results of the study confirmed that APGAR scores were a crucial component in determining if a newborn was at high risk of death or disability and needed immediate intervention. Although no other U.S.-based study of pregnancy and childhood conducted before or after has matched the size, breadth, and depth of the National Collaborative Perinatal Project data, other studies have examined the APGAR score from different angles. A 2003 study by Doyle et al examined the validity of APGAR score predictability through the lens of race and ethnicity, determining that the score is a strong predictor of survival within ethnic groups.  A 2013 Danish study investigated whether high APGAR scores were a risk factor for atopic dermatitis. Even more recently, a 2022 study by Tavares et al examined factors associated with death and survival in newborns with low APGAR scores at a NICU in northern Brazil. This shows how useful the score still is today, and how the scope of APGAR score usage is constantly being refined over time.

Apgar lecturing on resuscitation of newborns. Her visual aid is a poster showing the key points of the Apgar score, using the "APGAR" mnemonic, and accompanied by a frequently-used photo of Apgar in surgical gown, testing the reflexes of a newborn, which she holds suspended by its heels.
Virginia Apgar Lecturing on Resuscitation, 1964
Courtesy of Mount Holyoke College
Profiles In Science

The continued legacy of the APGAR score cannot be overstated. Not only did this singular assessment tool lead to international research and large-scale studies, but it also helped save the lives of countless newborns. The data points collected in APGAR score studies represent real people, with their own stories, hopes, and dreams. Most people in the West today have encountered the APGAR score at some point in their lives, likely as their first physical examination—even if they don’t remember it. I’m in awe that such a simple tool supported my survival in 1996 and will continue to contribute to the survival of newborns for years to come.

Virginia Apgar is featured in the NLM exhibition Rise, Serve, Lead! which features a database of over 300 biographies of women who have made a difference through their medical practice and research, work as activists, service as administrators, and mentorship to the next generation of physicians. You can learn more about her and see digitized images and documents from her papers in NLM’s Profiles in Science.

A young Black woman posed casually outdoors.Kelly West is an Associate Fellow at the National Library of Medicine. She received her MLIS from Louisiana State University in May 2022. As an NLM fellow, Kelly engaged with curricula spanning collection development, grant management, policy, and research. She also participated in independent projects ranging from survey research to usability testing. After the fellowship, Kelly hopes to continue doing work related to data management, research, and/or health literacy.

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