APGAR Score

On a trip recently to the National Women’s Hall of Fame in Seneca Falls, I came across something surprising to me and maybe to some of you! Most of you have heard of the term “Apgar Score”, but what is it and where did it come from?

The APGAR score was developed in 1952 to help assess an infant at 1 minute and 5 minutes of age. The babe is given a score of 0, 1 or 2 on the 5 categories: Appearance (Skin Color/Complexion), Pulse rate, Grimace (Reflex Irritability), Activity (Muscle Tone) and Respiration (Breathing). Technically, a baby can get a perfect 10 (although sometimes there is a tendency of giving a 9 instead for superstition says a perfect 10 is asking for trouble).

Apgar scores are usually said out loud during those first vital minutes of life but usually the parents are, for some reason, distracted by their new beautiful baby or something, and the score goes unheard. When I am present as a doula, I always make sure I get those scores to later give to the parents because they are good to know. Be sure and ask what your babies scores are! I would assume (although not always best practice to assume things) that the babies care provider is given that information and I believe I have seen it charted in the computer at all the births so might be on the labor and delivery records from your care giver. Either way, just ask.

What I found interesting at the National Women’s Hall of Fame was that the APGAR score is not only a backronym (a backward acronym) to help remember what the 5 criteria, but was also the name of the women who created it.  Dr. Virginia Apgar was interested in birth defects and preventing them.  Because gestational age is directly related to an infant’s Apgar score, Apgar was one of the first at the March of Dimes to bring attention to the problem of premature birth, now one of the March of Dimes top priorities.

Apgar scores are being used now as a potential predictor in future learning disabilities.  That is one reason it is good to know what your child’s Apgar scores were, if situations arise later in life.

So shout out to you, Dr. Apgar, for helping us understand the immediate and future health of our children a bit better!

 

Epidural Plus Fever During Labor Put Baby at Risk

From: http://www.medpagetoday.com/Anesthesiology/Anesthesiology/30914

Epidural Plus Fever During Labor Put Baby at Risk

By Crystal Phend, Senior Staff Writer, MedPage TodayPublished: January 30, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

  • A temperature spike during labor with epidural analgesia may indicate serious risks for the baby in an otherwise low-risk delivery.
  • Point out that the risks of hypotonia, assisted ventilation, low Apgar scores, and early-onset seizures weren’t associated with epidural catheters when fever above 99.5°F didn’t occur.

A temperature spike during labor with epidural analgesia may indicate serious risks for the baby in an otherwise low-risk delivery, researchers found.

Infants whose mother ran a fever over 101°F while receiving an epidural were two- to six-fold more likely to be weak, need ventilation, have low Apgar scores, and experience early-onset seizures, reported Elizabeth A. Greenwell, ScD, and colleagues from various institutions affiliated with Harvard University in Boston. Greenwell is now at the University of Colorado Denver School of Public Health.

The same risks weren’t observed with epidural catheter use when fever above 99.5°F didn’t occur, the group pointed out in the February issue of Pediatrics.

“Although epidural analgesia is generally considered a safe and effective method of pain relief during labor, both randomized trials and observational studies consistently demonstrate an association between epidural and maternal fever during labor,” they noted.

Some evidence suggests epidurals induce an inflammatory response and boost cytokines levels that inflict neurologic damage.

Regardless of the cause of fever, these results from pregnancies not complicated by infection suggest that even a moderately elevated temperature could hurt the baby, perhaps because fetal core temperature runs at least 1°F higher than that measured in the mother, Greenwell’s group explained.

“Although many of the specific outcomes we found associated with elevated maternal temperature may be transient, it is possible that particularly the increase in early-onset neonatal seizures could have implications for longer-term health of the infant,” they acknowledged.

Whether trying to cool down a woman during labor once the fever is detected would reduce risk for the baby isn’t clear, the group cautioned.

They studied outcomes for all women giving birth to their first child at term at Boston’s Brigham and Women’s Hospital in 2000. The patients did not have documented sepsis, meningitis, or major congenital anomaly.

Just 13% of these 3,209 low-risk women opted against an epidural during labor.

Fever of more than 100.4°F developed during labor in 19% of epidural users compared with just 2% of those who went without (P<0.0001).

Lower grade temperatures were also more common with epidural use. Overall, 45% of women who received an epidural had a temperature of at least 99.5°F during admission for delivery compared with 13.2% among women without an epidural.

Undergoing an epidural without developing a temperature didn’t appear to have any affect on infant outcomes measured.

But the higher a woman’s temperature while delivering with an epidural, the higher the risk to the baby. Comparing maternal temperature of 99.5°F or lower to one over 101°F, the results were:

  • Transitional hypotonia prevalence rose from 11% to 25% (P<0.001)
  • Hypotonia lasting more than a quarter of an hour rose from less than 1% to 3% (P=0.0005)
  • Requirement for substantial resuscitation efforts at birth rose from 4.4% to 12.2% (P<0.0001)
  • Apgar scores under 7 at one minute after birth rose from 6.4% 13.5% (P<0.0001)
  • Apgar scores under 7 at five minutes after birth rose from 0.3% to 2.1% (P=0.0007)

After adjustment for maternal age, baby’s birth weight, duration of labor, and method of delivery, these risks were all significant at a fever of more than 101°F.

A temperature of 99.6° to 100.4°F also significantly predicted more transitional hypotonia and poor Apgar scores at one minute. A temperature of 100.5° to 101°F also predicted poor Apgar scores at one minute along with hypotonia lasting more than 15 minutes.

Only eight infants developed early-onset seizures, but four had been exposed to a maternal temperature over 100.4°F during delivery. Compared with women whose temperature never went over 99.5°F, that represented a 6.5-fold higher risk.

The researchers cautioned that few women in the low-risk population developed a fever in the absence of epidural use, which precluded analysis of whether fever was more dangerous in the setting of an epidural.

Bias from a pediatrician being in the room more frequently when women develop fever during labor likely wasn’t responsible for the difference in outcomes, because the results were similar for women running temperatures of 99.6° to 100.4°F for which pediatricians wouldn’t be called in, the group noted.

Undetected maternal or infant infection was plausible but unlikely to be responsible for the findings either, they added.

The study was supported in part by an award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The researchers reported having no conflicts of interest.

Transition unto Transformation

My family is currently experiencing what I believe to be the throws of transition… So it got me thinking about birth (of course), because what we’re doing is birthing a new day for our household. For a couple of years now we have been juggling the idea of actually settling into Rochester, finding that ‘permanent job,’ buying the house in the country, rounding off our family with this ‘last’ little one. Finding our groove. Basically ~ early labor.

Exactly a year ago we hit active labor hard and heavy ~ my husband landed a great job in a career of his choice, we gave birth to baby number five, and we sold our wonderful home in the city and moved out to a beautiful (but totally different!) country location. What a year. Non-stop action for twelve straight months. One might think that was it… labor pains done, on to greener pasture.

Along comes transition. Ahh – what a word. According to Wikipedia, ” ‘trans’ is a Latin noun or prefix, meaning “across”, “beyond” or “on the opposite side [of].” Transition is that incredibly real and somewhat treacherous part of the journey to the other side. Typically short-lived, it is the embodiment of pain, challenge, questioning and fear. What is happening? Why did we do this? I want to go home! Make it go away.

This is exactly where my family finds itself right now… worn out from active labor and in the midst of major transition. We’re trying desperately to settle in and claim this new way of living – to find the rhythm of our labor as it moves fast and furious through our home. Gardens, flower beds, new work schedules, commutes to the city, new neighbors, pool maintenance, a busy toddler, bugs, snakes, chicken coops, clothes lines, wood burning furnaces, school work, major lawn mowing, children that grow like weeds, new doctors – dentists – hair dressers – stores – sports groups – clubs and more. The list goes on and on. Transition ~ crossing over ~ can be painful and it’s hard work. But wait a minute…

A word about transition – it is most definitely not without its’ merits. Transition is undoubtedly the most painful and frightening part of labor… the time when you wonder if you can possibly make it through. Many women contemplate the use of pain medications during transition (I’m currently considering chocolate by the truck load), they doubt their ability and strength (My husband is trying to figure out who this person is that he’s married to and what happened to his wife) and they need access to unlimited support and reassurance (I’m about to call in the ‘mother ship’ for reinforcements). But this is also a time for ‘crossing over’ in our lives as women ~ finding a new strength and passion inside ourselves that we might not know exists. Drawing courage from deep within, leaning on the strengths in your life and moving forward with perseverance. You will be a different person for the experience ~ completely transformed.

Let transition work for you.

Now second stage… pushing! That is what I’m hanging on for. Work ~ with reward. Children running the countryside in bare feet, vegetables peeking their heads up out of the rich soil of my new garden, chickens laying eggs for little hands to collect, laundry blowing in the breeze, hot and lazy days of summer to jump in the swimming pool, a warm and cozy home heated with our own fire when the days once again turn cool, routine. Second stage just feels different, and the gifts are visible and within arm’s reach!