Apgar Scoring-Simulation pre-reading PDF

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Apgar Scoring Pre-reading Assignment ALERT The Apgar score alone should not be used to determine the need for resuscitation or to establish a diagnosis of asphyxia in a newborn.2,3 OVERVIEW The Apgar score is a rapid scoring system used in the immediate postdelivery period to assess a neonate's clinical status and response to resuscitation interventions. The purpose of the Apgar score is not to predict outcomes but to indicate how well the newborn is transitioning from uterine to extrauterine life and to guide the level of clinical interventions. The score is calculated for all newborns at 1 minute and 5 minutes; it is extended at 5-minute intervals for a newborn receiving active resuscitation measures until he or she has recovered or has been transferred to an intensive care unit, or time of death has been declared.5,6 The neonatal resuscitation protocol guidelines recommend repeating Apgar scoring every 5 minutes for up to 20 minutes if a score is below 7.2,3 Parts of the Apgar assessment may be done simultaneously to facilitate rapid scoring. The 1-minute Apgar score expresses the newborn's immediate physiologic condition as a response to the stress of labor and birth. The 5-minute score more accurately reflects the newborn's adaptation to extrauterine life or response to resuscitation efforts.6 Both scores may be affected by interventions, gestational age, maternal medications, and cardiopulmonary and neurologic conditions. Maternal factors that may affect the Apgar score include use of pain medication or magnesium sulfate during labor, use of illicit drugs during pregnancy, infection or septicemia, and other conditions. Because of these external factors, the Apgar score cannot accurately predict the risk for newborn morbidity, mortality, or cerebral palsy. The Apgar score is not used for decision making regarding resuscitation. Trained health care personnel should begin resuscitation measures immediately after delivery for depressed newborns and should not wait for a 1-minute Apgar score before intervening.2,3 The Apgar score rates five signs from 0 to 2 each: the newborn's color, heart rate, respirations, muscle tone, and response to stimulation (reflex irritability) (Table 1).2,6 A score of 10 is the highest score that can be attained.6 However, the newborn's family should be made aware that Apgar scores of 7 through 10 are considered normal and indicate that the newborn has appropriately transitioned to extrauterine life.3,6 Many newborns do not receive an Apgar score of 10 because most have some degree of peripheral cyanosis, and a score of 0 or 1 for that criterion is common.3 The Apgar score assigned during resuscitation interventions is not equivalent to a score assigned to a spontaneously breathing newborn. Many interventions used during resuscitation can influence the Apgar score but are not identified in the score. Although there is no consensus as

to how accurately to score a newborn undergoing resuscitation, a proposed expanded score is available to use during an acute resuscitation.2,3 An Apgar score below 3 at 5 minutes is considered very low; a low score at 5 minutes in term newborns may correlate with neonatal morbidity.3 Other newborn factors, including maturity level, anomalies, heart defects, and mechanical defects such as diaphragmatic hernia, also need to be considered. Although Apgar scoring has a role in newborn assessment, it should not be used to predict future development. PATIENT AND FAMILY EDUCATION   

Inform the family about the purpose of Apgar scoring and the normal range. Explain that the Apgar score may be completed while the newborn is in skin-to-skin contact if he or she is stable after birth. Encourage questions, and answer them as they arise.

ASSESSMENT AND PREPARATION Assessment 1. Perform hand hygiene before patient contact. 2. Verify the correct patient using two identifiers. Preparation 1. Gather supplies. PROCEDURE 1. Perform hand hygiene and don gloves. 2. Verify the correct patient using two identifiers. 3. Start the Apgar timer or have another team member document the time immediately after delivery of the newborn. Warm, dry, and stimulate the newborn if indicated and perform resuscitation measures as needed. Rationale: According to current neonatal resuscitation guidelines, warming and drying most newborns are essential steps in assisting with successful transition to extrauterine life.4 Special care should be implemented for very low-birth-weight or extremely premature newborns who have delicate skin and the potential for rapid heat loss. Do not delay resuscitation if it is needed before the 1-minute score.2,3 4. Complete the Apgar score as quickly as possible at 1 minute after birth:3 a. Assess and score respiratory effort:3,6

1. 0, Absent respiratory effort 2. 1, Weak effort (slow or irregular) requiring assistance 3. 2, Adequate with good cry b. Assess and score apical heart rate using a clean stethoscope or palpation of the umbilical cord: 1. 0, Absent heart rate 2. 1, Rate less than 100 bpm 3. 2, Rate greater than 100 bpm Rationale: The heart rate for the Apgar score can be obtained via auscultation with a stethoscope or palpation of the umbilical cord to provide the most accurate rate.1

5. 6.

7. 8. 9.

c. Assess and score color: 1. 0, Pallid or centrally cyanotic 2. 1, Pink with blue extremities (acrocyanosis) 3. 2, Pink all over d. Assess and score reflex irritability or response to stimulation such as back or foot rubbing: 1. 0, No response 2. 1, Grimace 3. 2, Good cry or active withdrawal e. Assess and score tone of extremities: 1. 0, Flaccid 2. 1, Some flexion 3. 2, Well-flexed/active motion Repeat the Apgar score at 5 minutes of life.2 If the 5-minute Apgar score is less than 7, repeat scoring at 5-minute intervals until the score is 7 or greater or until 20 minutes of life.2,3 Continue resuscitation measures as needed. Discard supplies, remove gloves, and perform hand hygiene. Document the procedure in the newborn's record.

MONITORING AND CARE 1. Continue to monitor the newborn closely, according to the organization's practice, for the first few hours of life. Rationale: During the transitional stage, the newborn's condition may change rapidly, so close monitoring during the first few hours is important. 2. Assess, treat, and reassess pain.

EXPECTED OUTCOMES  

Accurate Apgar score obtained Appropriate resuscitation performed as needed

UNEXPECTED OUTCOMES  

Inaccurate Apgar score obtained Failure to recognize need for interventions

DOCUMENTATION    

Apgar scores and interventions performed Condition of the newborn Family education Unexpected outcomes and related nursing interventions

REFERENCES 1. Alden, K.R. (2012). Chapter 24: Nursing care of the newborn and family. In D.L. Lowdermilk and others (Eds.), Maternity and women's health care (10th ed., pp. 553605). St. Louis: Mosby. 2. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). (2012). Chapter 8: Care of the newborn. In Guidelines for perinatal care (7th ed., pp. 265-319). Elk Grove Village, IL: AAP. (Level VII) 3. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. (2006, reaffirmed 2010). The Apgar score. Pediatrics, 117(4), 1444-1447. doi:10.1542/peds.2006-0325 (Level VII) 4. Kattwinkel, J. and others. (2010). Part 15: Neonatal resuscitation. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(18 Suppl. 3), S909-S919. doi:10.1161/CIRCULATIONAHA.110.971119 (Level VII) 5. Murray, S.S., McKinney, E.S. (2014). Chapter 13: Nursing care during labor and birth. In Foundations of maternal-newborn and women's health nursing (6th ed., pp. 220-252). St. Louis: Saunders. 6. Pappas, B.E., Robey, D.L. (2015). Chapter 5: Neonatal delivery room resuscitation. In M.T. Verklan, M. Walden (Eds.), Core curriculum for neonatal intensive care nursing (5th ed., pp. 77-94). St. Louis: Saunders....