Help with Apgar Scoring

  1. I have worked Labor and Delivery for @ 6 years. Our department has all LDRP's and all nurses function in labor, delivery, pp and newborn care. I recently had a new grad midwife question my Apgar score on a delivery. I scored 8 and 9 apgars counting off for color. The midwife says that you can't give a 0 for color if you give a 2 for heart rate and respirations.
    I count 1 for color if the infant is pink centrally w/acrocyanosis and I count a 0 for color if there is any central cyanosis (circum-oral included). I have practiced this way for my entire career and have never had anyone question my scoring. Every APGAR chart I find is unspecific, it say 0 for apperance if the infant is blue/pale, and 1 for color if pink with blue hands and feet.
    My rationale is if there is any central cyanosis, it doesn't fall under the 1 category? Am I wrong? I am willing to change my practice if I can find documentation to back it. Any help will be appreciated.
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  2. 15 Comments

  3. by   ElvishDNP
    NRP has always preached to us that if a baby is pink, and vigorous that you can assume the HR is >100. However, I have seen many babies come into this world very pale/blue but RR>30 and HR >100. These are usually the ones that are alert but haven't cried yet, in my experience. Once they cry they pink right up and bam! another 1-2 apgar points.

    You score what you see. If she were doing the apgars, she would score what she sees. I don't see as how you're doing anything wrong. JMO.
  4. by   DEB52
    That's the way I did apgars.
  5. by   Spidey's mom
    Your midwife doesn't make sense.

    You score what you see. You did the right thing.

    steph
  6. by   lovemyjob
    Sounds like a certain midwife is trying to make numbers look better!!

    It is not uncommon for a kid to have a HR >100 and be screaming but still be blue as a goose. It has to do with transition of blood flow more so than RR and HR.

    I have been told by many-a-docs that a 10/10 apgar is impossible, that fetal transition does not happen that fast.

    You go right ahead and chart what you see..... it is YOUR call!!!
  7. by   SmilingBluEyes
    What the others said. Score what YOU see. And chart it that way.
  8. by   33-weeker
    Our charting system says 'centrally pink with blue extremities' = 1. Acrocyanosis is a normal newborn finding. I don't count off for that.
  9. by   crissrn27
    I have had OBs get really mad at my APGARs, especially with a bad baby. A couple have told me that this is their "report card" of how well the labor/delivery went, and who doesn't want to do well on their report card?

    I read a study that said the delivering person should never give the baby Apgars, because they are always higher than they should be. I will try to find it and post it here.

    I give out more 10s than a lot of the nurses I work with, but it has been very rare that I have given, or seen 10/10s. Most babies just don't transition that fast. I usually give 8 for 1 minute, counting off either 2 for color (I count central cyanosis as 2) or 1 off for color and 1 off for tone. Now, if this isn't the case I give what I see. I have given 9/10 and 10/10, but I don't think it happens often. Then again, some of the nurses I work with "knee-jerk it" and give 8/9 for all health babies.
  10. by   strn96
    I agree, chart what you see. I've never actually given a 10/10. Never had a baby that I thought deserved it. I have given a few 9/10s, and quite a few 9/9s. It is frustrating when the doctor/midwife tries to argue Apgars. After all, you're the one that's right there with the baby while they're busy attending to mom. And yes, babies can have a HR>100 and still deserve a 0 for color.
  11. by   lovemyjob
    To those who dont count acrocyanosis, although it may be a normal finding, it is still (according to NRP, the standard reference for APGAR scoring) counted as a 1. Central cyanosis at 1 min is not really such an abnormal finding either. Some kids may take longer than one minute to transition....

    I assume if NRP says to count acro as a 1, then acro should be a 1. How is this less important than scoring 2 for the HR when it is not above 100? If we do apgar scoring "cafateria style," it takes away from the validity of the scoring.
  12. by   Spidey's mom
    I don't give points for anything . . . I start with 10 and take away points. It is easier for my math-phobic brain.

    So, if a baby comes out with central cyanosis . .. .10 - 2 = 8.

    Acro - 10 - 1 = 9

    Etc.

    steph
  13. by   MemphisOBRNC
    I recently attended a delivery in which the baby had a heart rate >100 at 1 minute (2) and that was all. Just as the ambu bag was put on the face, it started screaming (2), pinked up (1), had good tone (2) and reflexes (2) plus the heart rate still > 100 (2). I charted 2/9 Apgars.

    The pediatrician report to Risk Management that the 'nurses don't know how to assign Apgars'. I was asked about it and printed out the information for the Risk Manager who doesn't 'do' OB. She understood. I saw the Dr. the next day and told her I was the one who had assigned the 2/9 Apgars and I was knew perfectly well how to do it. Long story short, she argued the fact. I expressed that I had done this for 22 years and knew what to look for in scoring a baby. She said if the baby had a heart rate >100 it HAD to have respirations. I told her it did not. She said 'maybe you just didn't see them'. I told her if I didn't see them, I sure wouldn't chart it! I was so mad my ears turned red!!! (I hate it when that happens!):angryfire :smackingf
  14. by   lovemyjob
    Memphis

    Isnt that SOOOO frustrating??

    I had a similar situation, however, I had no bag/mask and no O2 tubing for blowby. I listened and listened and listened while urgently telling the OB nurse that I needed the stuff stat. I had a good HR, but there were NO (I repeat NO) breath sounds. There was no chestrise and no breath sounds. For some reason, the baby was pinking up. But still no breath sounds. At one minute the baby was still a bit cyanotic so I gave a 2. The OB attending was at the bedside and said the baby must be fine, he was pinkind up. I offered him the stethescope and as soon as he put them in his ears the baby took a nice big breath and started breathing. He looked up at me and said "He has breath sounds." WAell, he also had chestrise, so what do you conclude from that?? I assume he didnt have breath sounds if he had NO chest rise!!! (plus I listened so I knopw my assumption was right!)

    He got into a huge argument with me when he was at the desk asking apgars. I told him it was my call, so discussion over.

    There is a reason the person doing the delivery doesnt assign apgars!!!

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