Review of the Reliability and Validity of the Apgar Score

Perinatal outcomes of socially disadvantaged women in Australia: A population-based retrospective cohort study

OBJECTIVE

To examine the perinatal outcomes of women who experience social disadvantage using population-based perinatal data collected between 1999 and 2016.

DESIGN

Population-based, retrospective cohort study.

SETTING

Victoria, Australia.

POPULATION OR SAMPLE

A total of 1 188 872 singleton births were included.

METHODS

Cohort study using routinely collected perinatal data. Multiple logistic regression was performed to determine associations between social disadvantage and adverse maternal and neonatal outcomes with confidence limits set at 99%. Time-trend analysis for perinatal outcomes was performed in relation to area-level disadvantage measures.

MAIN OUTCOME MEASURES

Incidence of maternal admission to intensive care unit (ICU), postpartum haemorrhage (PPH) and caesarean section, perinatal mortality, preterm birth, low birthweight (LBW), and admission to special care nursery/neonatal intensive care unit (SCN/NICU).

RESULTS

Social disadvantage was associated with higher odds of adverse perinatal outcomes. Disadvantaged women were more likely to be admitted to ICU, have a PPH or experience perinatal mortality (stillbirth or neonatal death) and their neonates were more likely to be admitted to SCN/NICU, be born preterm and be LBW. A persistent social gradient existed across time for the most disadvantaged women for all outcomes except caesarean section.

CONCLUSIONS

Social disadvantage has a marked negative impact on perinatal outcomes. This aligns with national and international evidence regarding the impact of disadvantage. Strategies that improve access to, and reduce fragmentation in, maternity care in addition to initiatives that address the social determinants of health may contribute to improving perinatal outcomes for socially disadvantaged women.

Accuracy and Interrater Agreement of Registered Nurses' Assignment of Apgar Scores to Standardized Clinical Vignettes

The purpose of our study was to test whether registered nurses assign the correct Apgar score when provided all pertinent data, whether they assign an Apgar score even if all pertinent data are not provided, and to evaluate the Apgar score's interrater agreement. We conducted a REDCap survey and provided nurses with color photograph/vignette combinations of neonates, some of which lacked pertinent data points needed to correctly assign Apgar scores. Over 90% of study participants assigned Apgar scores even if data points for heart rate or respiratory effort were omitted. Participants' correct assignment of the component score for respiratory effort was affected by the description of the respiratory effort and whether neonatal heart rate was known. Interrater agreement was generally low to moderate. Our findings are consistent with earlier findings and support the conclusion that the Apgar score requires significant revision or needs to be retired and replaced.

Maternal and Fetal Risk Factors for Neonatal Hypoxic-Ischemic Encephalopathy: A Retrospective Study

Background

Neonatal hypoxic-ischemic encephalopathy (HIE) leads to different degree of neurological sequelae. The incidence of HIE is relatively high, and the risk factors associated with HIE are still controversial. It is necessary to identify the risk factors associated with HIE.

Methods

A total of 258 neonates (110 HIE patients and 148 controls) were enrolled in this study. The characteristics of pregnant women and fetuses during pregnancy and delivery were compared between HIE patients and controls, and the risk factors of HIE were analyzed.

Results

The proportions of premature infants, low-birth-weight infants and the levels of 1-minute Apgar score, 5-minute Apgar score in HIE group were significantly lower than those in control group, while the proportion of amniotic fluid contamination in the HIE group was significantly higher than those of the controls. When HIE was taken as the end point of 1-minute Apgar score, and 5-minute Apgar score, the cut-off value of 1-minute Apgar score was 3, and 5-minute Apgar score was 7 by receiver operating characteristic (ROC) curve analysis. The results of multivariate logistic regression analysis showed that low birth weight (<2.5 kg) (OR 1.780, 95% CI: 0.124-25.463, P=0.016), amniotic fluid contamination (OR 3.223, 95% CI: 1.049-9.901, P=0.041), low 1-minute Apgar score (≤3) (OR 92.425, 95% CI: 15.522-550.343, P<0.001), and low 5-minute Apgar score (≤7) (OR 12.641, 95% CI: 2.894-55.227, P=0.001) may increase risk of HIE. In addition, amniotic fluid contamination, low 1-minute Apgar score (≤3), and low 5-minute Apgar score (≤7) may increase risk of HIE among newborns born to women without previous childbearing history, but not in newborns born to women with previous childbearing history.

Conclusion

Low birth weight (<2.5 kg), amniotic fluid contamination, low 1-minute Apgar score (≤3), and 5-minute Apgar score (≤7) may increase risk of HIE.

Adequate Prenatal Care: An Integrative Review

INTRODUCTION

Prenatal care (PNC) is a core element of preventive care and is vital in identifying and managing conditions that can put the pregnant person and the fetus at risk. National and international guidelines differ in what is considered adequate or quality PNC. Indices of care adequacy rely only on number of attended PNC visits without regard to factors that affect a patient's ability to obtain care or the quality of the care received. This integrative review explored stakeholders' perceptions of adequate and quality PNC.

METHODS

Three electronic databases, CINAHL, PubMed, and Web of Science, were searched to identify original research articles published between 2012 and April 2022. Studies conducted in the United States, published in a peer-reviewed journal, and having a primary focus on the components of adequate or quality PNC were included. The quality of included studies was assessed via the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

Thirteen articles met inclusion criteria. The concepts of adequate or quality PNC were not well defined in the literature. Studies revealed a variety of approaches to assessing individual components of PNC with at times conflicting results of what adequate or quality PNC is. Viewpoints regarding adequacy or quality of PNC were limited by the perceptions and interpretations of individual stakeholders, who included researchers, public health officials, insurers, health care providers, and patients.

DISCUSSION

Ideas of how to redesign PNC were affected by study setting and stakeholders, as well as the emergence and integration of telehealth into PNC delivery. This review is a first step in identifying the gap in the research literature regarding how these concepts are defined and measured. Future research is needed to identify the relevant components of PNC that are necessary to reach consensus definitions of both adequacy and quality of PNC.

Placental plastics in young women from general population correlate with reduced foetal growth in IUGR pregnancies

Constant exposure to plastics particulates has raised concerns against human health, particularly when it comes to birth outcomes. The present study explores the first appraisal of plastic particles in fresh human placenta and its association with foetal growth in neonates. Specifically, 43 pregnant women from general population were selected and their placentas were analyzed by digital microscopy and Raman microspectroscopy for microplastics (MPs <5 mm). We used regression analysis to estimate associations between MPs count in placenta and neonatal anthropometric measurements. MPs were found in all (13 out of 13) intrauterine growth restriction (IUGR) pregnancies and their average abundance ranged from 2 to 38 particles per placenta, but were less than limit of detection (LOD) in normal pregnancies except three out of 30 subjects. This study is one of very few that detected MPs in human placenta in which particles <10 μm were the most abundant in both IUGR and normal pregnancies, accounting for up to 64%. Fragments clearly prevailed at normal pregnancies and fragments together with fibers predominated at IUGR placentas. Despite four different polymers forming the MPs being identified, the majority of MPs comprised of PE (polyethylene) and PS (polystyrene). Inverse associations between MPs exposure and birth outcomes were observed in terms of birth weight (r = - 0.82, p < 0.001), length (r = - 0.56, p < 0.001), head circumference (r = - 0.50, p = 0.001), and 1-min Apgar score (r = - 0.75, p < 0.001) among those with IUGR, compared to those that were nominated as normal pregnancies. While it seems plastic particles may affect placental-foetal interrelationship, the pattern of associations between their content in placenta and birth outcomes, however, shows evidence of a nonlinear or nonmonotonic dose response possibly through perturbation of gas and nutrients exchange which is worth future investigation.

Validity of Apgar Score as an Indicator of Neonatal SARS-CoV-2 Infection: A Scoping Review

The coronavirus disease 2019 (COVID-19) pandemic has had profound impacts on healthcare systems worldwide, particularly regarding the care of pregnant women and their neonates. The use of the Apgar score—a discrete numerical index used to evaluate neonatal condition immediately following delivery that has been used ubiquitously as a clinical indicator of neonatal condition and widely reported in the literature for decades—has continued during the pandemic. Although health systems adopted protocols that addressed pregnant women and their neonates during the pandemic, limited research has assessed the validity of Apgar scores for determining neonatal conditions in the context of COVID-19. Therefore, this scoping review was conducted on the first 2 years of the pandemic and included mothers with reverse transcription-polymerase chain reaction confirmed COVID-19 and their resulting positive or negative neonates. In total, 1,966 articles were assessed for eligibility, yielding 246 articles describing 663 neonates. Neonates who tested negative had median Apgar scores of 9 and 9 at 1 and 5 mins, respectively, while test-positive neonates had median Apgar scores of 8 and 9 at the same time points. The proportions of test-negative neonates with Apgar scores below 7 were 29 (4%) and 11 (2%) at 1 and 5 mins, which was not statistically significant (p = 0.327, χ² = 0.961). These proportions were even lower for positive neonates: 22 (3%) and 11 (2%) at 1 and 5 mins, respectively, which was not statistically significant (p = 1, χ² = 0). The low proportion of Apgar scores below 7 suggests that low Apgar scores are likely to be associated with severe maternal COVID-19 symptoms during delivery rather than neonatal COVID-19. Therefore, this study indicated that Apgar scores are poor indicators of neonatal COVID-19 status.