I first learned about the Apgar Score when I studied to become a midwife. (That was over 25 years ago and for my class project, I got pregnant with Anand and delivered him halfway through the course.)

APGAR stands for:

Activity

Pulse

Grimace

Appearance

Respiration

and is, in my humble opinion, a clumsy acronym for an elegant and incredibly powerful little tool.

I memorized it in class, never realizing how the tool, and the woman behind it – an anesthesiologist named Virginia Apgar – revolutionized the care of newborn babies in trouble, babies who might otherwise have been left to die.

What was it like back in the 30’s when she began practicing medicine?

It wasn’t easy to be a woman physician and it wasn’t safe to be a premature baby. In those days, a baby born with an obvious disability, or too small, or a little blue around the edges was simply put to one side and left to its fate. Doctors believed such infants were too sick to survive and didn’t even bother trying to revive them.

As the anesthetist, not the obstetrician (and a lowly woman in a man’s world), Dr Apgar also didn’t bother trying to change the doctors’ minds. She did something more strategic, more practical and ultimately, more effective: she designed a score sheet.

One minute after delivery, again at five minutes and a third time at ten minutes, the newborn was to be rated against an objective scale and for each parameter, the kid would get two points:

Moving all four limbs? 2

Heart rate over a hundred? 2

Crying? 2

Pink all over? 2

Taking strong, deep breaths? 2

10 points = perfect condition.

Less than 4 = a baby in trouble.

The interesting thing was the change the score sheet engendered in doctors who were once willing to give up on  struggling babies based on a vague clinical impression. Dr Apgar must have been an astute student of human nature.  She knew that part of the problem was the vagueness. So she quantified it and made it specific: nothing quite like a number. That alone ensured that the baby’s condition was carefully observed.

Then she added the brilliant stroke of scoring again at five minutes and a third time at ten. The implicit assumption is that everything could change in ten minutes. And the underlying knowledge: that doctors are competitive by nature. You can almost hear them thinking: “Four? No way is my baby going to stay at four! Lemme at this kid!”

The Apgar Score may seem simple but it was directly responsible for a host of sophisticated and complex new approaches to newborn infant care. With documented information on the condition of babies suddenly available, it became possible to study the effect of specific interventions like the use of oxygen, different types of anethesia, forceps – you name it.

As people working to improve the lives of children with disabilities, we are constantly trying things out and experimenting with new approaches and ideas. Reading about the logic behind Dr Apgar’s test (in a WONDERFUL book called “Better” by Atul Gawande) convinced me, as nothing ever has before, of the need for documentation. I always thought it was a bureaucratic requirement of funding agencies. I was wrong. It’s revolutionary.