The mother of the Apgar score

Virginia Apgar MD devised the simple observational test that bears her name after watching doctors swiftly give up on struggling newborn babies, leaving them to die, Atul Gawande writes in his book, Better. At the time, a few years after World War II, one in 30 births in the United States ended in the infant’s death.

Virginia Apgar

Dr. Virginia Apgar

The Apgar score, introduced in 1953, is a 10-point scale for assessing how a newborn baby is doing — first with the birth process, and then with adjusting to the world. It is given in hospitals one minute after birth, and again at five minutes. A robust baby might garner 10 points, but a baby with an Apgar score of four or less draws serious concern and, likely, vigorous intervention.

Dr. Apgar’s scoring system transformed delivery, Gawande writes. “Even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered,” he writes.

The daughter of a Westfield, N.J., insurance executive, Dr. Apgar graduated from Mount Holyoke College in 1929, and began medical school at Columbia University’s College of Physicians and Surgeons, where eight of her classmates were women and 81 were men. She began a surgical residency but, in the depths of the Great Depression, decided it might be difficult, especially as a woman, to make a living as a surgeon.

Dr. Apgar enrolled first in a course for nurse-anesthetists and then in Dr. Ralph Waters’ seminal residency program in anesthesiology at the University of Wisconsin in Madison, followed by a stint with Emery Rovenstine at Bellevue Hospital in New York — strong training for the day.

She founded the anesthesiology program at Columbia’s College of Physicians and Surgeons. However, when the program became a department, Dr. Apgar was passed over for the job as chairman, in favor of a man. She did become a full professor, though — in itself an accomplishment at the time — and was a pioneer in obstetrical anesthesiology.

Dr. Apgar saw a number of birth defects during the thousands of births she attended, and in 1958 she went back to school in public health at Johns Hopkins’ medical school in Baltimore. In 1959, Dr. Apgar joined the March of Dimes in its campaign to eliminate birth defects.

Dr. Apgar never married. Her entire life, she was famous for intelligence, energy, empathy and a great sense of humor. She was still working on behalf of the most vulnerable babies when she died in 1974, at the age of 65, of liver failure.

Gawande’s chapter about Dr. Apgar, “The Score,” also ran in the New Yorker.

The basics of birth safety

What do women need when birth becomes difficult? The Averting Maternal Death and Disability program has identified a handful of intervention capabilities that should be in place for emergencies wherever babies are born.

These "signal functions" include having personnel on hand who are trained to administer drugs by injection -- antibiotics, anticonvulsants and "oxytocics," which can start or speed labor -- manually remove the placenta and other "products of conception" not leaving the body spontaneously, and perform assisted vaginal delivery -- with forceps, for example.

AMDD, a major initiative of the Mailman School of Public Health at Columbia University in New York City,  has worked with UNICEF and other partners for 20 years to bring down maternal-mortality rates in the developing world.

Its directive, issued in 1997, cites two additional interventions that might be necessary to save lives -- Caesarean section and blood tranfusion. These two go beyond the basics of a birth center -- in some parts of the world they are strictly wish-list items -- but they can often make the difference between life and death, as they did in our case.

AMDD doesn't include anesthesiology in its signal functions, although surgery is difficult without it.

We in the United States might view these interventions as humdrum, or even as irksome or worse if they become part of our own birth story, but behind the development of each one of them are amazing tales.