The Apgar Score

img_0757One of the pleasures of reading non-fiction is to come across some quirk of history you’ve never heard of before. It’s the sort of thing that leads to me starting conversations with ‘Hey, did you know …

In his 2007 book Better – A Surgeon’s Notes on Performance, Atul Gawande tells lots of these stories – including the story of the number given to almost every newborn baby in hospitals across the world.

The Apgar Score is given at one minute after birth and again at five minutes with a 0, 1 or 2 for skin tone, crying, breathing, heart rate, and moving all four limbs. First published ‘to revolutionary effect’ in 1953, it drove doctors towards producing better scores. Even if, Gawande writes ‘only because doctors are competitive’.

Many babies with a low score at one minute could, with simple interventions like warmth or oxygen, have an excellent score at five minutes. ‘The score began to alter how childbirth itself was managed.’ Better anaesthesia was shown to produce babies with better scores and better outcomes. Gradual improvement was effected and became easily measurable. Over decades, the score helped bring about the low rates of deaths in childbirth we see today.

It started with Virginia Apgar. Though she completed her surgical residency in 1937, she was persuaded to take up anaesthesiology and began to study obstetrical anaesthesia. Apgar loved the work but was, ‘appalled by the care that many newborns received. Babies who were born malformed or too small or just blue and not breathing well were placed out of sight and left to die.’ Without the authority to direct change, ‘she took a less direct but ultimately more powerful approach: she devised a score’.

Apgar was a talented violist, made her own instruments, and – at age 59 – took up flying single-engine aircraft. The US National Library of Medicine has a nice short biography.

The Apgar story shows how measurement can be critical to the business of improvement. Yet Gawande never presents improvement in purely technical terms; ethical questions over how to “do right” are central. He discusses the influence of money on healthcare, doctors in war zones and those who assist in capital punishment. He presents a complex, rounded picture of contemporary medicine and its challenges. Though now nearly ten years old Better seems to have scarcely dated, and will reward anyone interested in medicine, ethics, elegant writing or just wanting to know how to become better.

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