Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score: A Pilot Study

Understanding stakeholder perspectives on Apgar score, cyanosis and identifying jaundice in ethnic minority neonates

OBJECTIVES

To explore neonatal assessments that include an element of evaluating skin colour in neonates of black, Asian and minority ethnicities, focusing on the Apgar score, presence of cyanosis and presence of jaundice.

DESIGN

We employed focused ethnography involving diverse healthcare professionals (HCPs) and parents or caregivers with Black, Asian, or ethnic minority children born in the last five years. Zoom interviews were performed following a semi-structured interview guide. Ethnographic data analysis was conducted using NVivo software.

RESULTS

There was a lack of consistency in how HCPs applied the Apgar scores, which also varied from textbook guidelines. The use of pink as a skin colour descriptor for ethnic minority neonates created a divide among both parents and HCPs. HCPs relied more heavily on other elements of the Apgar score or infant breathing and crying at birth to gauge infant wellness. When identifying cyanosis, HCPs depend on specific body locations for accurate assessment of oxygenation, but the limitations of visual assessment are acknowledged. For jaundice, most HCPs recognised the difficulty in identifying the colour yellow in infants with darker skin tones. HCPs focussed on yellowing of the sclera and gums and other well-being assessments to detect jaundice. Some interviewed parents noticed jaundice in their infants before HCPs but felt they were not listened to when raising concerns. HCPs acknowledged the need for additional training to effectively assess the health of ethnic minority infants.

CONCLUSION

This study highlights disparities in neonatal health assessment from the perspectives of healthcare professionals and parents from diverse backgrounds. Varied practices in determining the Apgar score and recognising cyanosis and jaundice signal the need for standardised protocols, appropriate educational materials, and targeted training. Addressing these challenges is vital for equitable care, emphasising comprehensive training and bias mitigation efforts in maternal and neonatal healthcare.

Systematic review of Apgar scores & cyanosis in Black, Asian, and ethnic minority infants

BACKGROUND

Apgar score and cyanosis assessment may disadvantage darker-skinned babies. This review explored cyanosis and Apgar score assessments in Black, Asian, or minority ethnic neonates compared to White neonates.

MATERIAL AND METHODS

Four databases were searched. Studies of any methodology were included. A narrative synthesis was undertaken.

RESULTS

Ten studies were included. Three studies involving over 39 million neonates showed Apgar score ≤3 was predictive of neonatal mortality across all ethnicities. Black babies with Apgar score ≤3 had lower mortality rates before 28 days, however, variations in scoring practices were also observed. Three further studies (n = 39,290,014) associated low Apgar scores with poorer mental development up to 22 months, especially in mixed ethnicity and Black infants. One study reported inadequate training in assessing ethnic minority neonates. Cyanosis was the focus of three included studies (n = 455) revealing poor visual assessment of cyanosis across ethnicities. With pulse oximetry occult hypoxemia occurred slightly more frequently in Black neonates. Tongue color indicated oxygen requirement at birth, regardless of ethnicity.

CONCLUSIONS

Apgar scores correlate well with neonatal mortality in all ethnicities, however scoring variations exist. Cyanosis assessment is challenging, with tongue and lips the best places to observe in the absence of pulse oximetry.

IMPACT

Assessment of the color component of the Apgar score and of cyanosis visually are not accurate in babies with darker skin. Small racial differences may exist for pulse oximetry in neonates, but it is more reliable than visual assessment.

A critical appraisal of tools for delivery room assessment of the newborn infant

Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.

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.

The Apgar score in clinical research: for what, how and by whom it is used

OBJECTIVES

To review how the Apgar score is used in published clinical research as well as who uses it, and how this may have changed between 1989-90 and 2018-19.

METHODS

Pubmed search for English publications using MeSH Terms "apgar score" OR "apgar" AND "score" AND "humans" for epochs 1989-90 & 2018-19. The location and specialty of first author, primary purpose and how the Apgar score was used was recorded.

RESULTS

There was a 61% increase in number of publications in 2018-19 compared to 1989-90, from all regions except North America. The most common purpose for using the Apgar was to assess newborn status after pregnancy/delivery interventions. There were 50 different definitions of a significant score. Definition of significance was influenced by specialty in 2018-19 and by study purpose in both epochs.

CONCLUSIONS

Most studies using the Apgar score are focused on the mother. There is no consistent definition of a significant score. Development of any future newborn assessment tools should account for the multiple purposes for which the Apgar score is used.

Review of the Reliability and Validity of the Apgar Score

BACKGROUND

The Apgar score is the most common score used to quantify neonatal status after birth. It is routinely used in clinical practice and research. However, since its introduction there have been significant changes in peripartum and neonatal management, our understanding of neonatal physiology, and changes in data analysis capabilities.

PURPOSE

To assess the Apgar score's reliability and validity in the context of today's clinical and research environments.

METHOD

PubMed was searched using the term "Apgar." Just over 22,000 titles were identified. Full-text articles were obtained if they addressed the Apgar score's use, reliability, and validity, or if the score was a primary outcome measure. This was followed by a hand search using the same criteria. The 505 identified articles build the basis for this discussion of the Apgar score's reliability and validity.

FINDINGS

Multiple positive and negative aspects of the Apgar score's reliability and validity were identified. Some facets needed to evaluate reliability and validity do not seem to have been addressed in the literature. Overall, the identified concerns can introduce bias into outcomes obtained via the use of the Apgar score in both clinical practice and research.

IMPLICATIONS FOR PRACTICE

The Apgar score is no longer used to determine neonatal management in the delivery room.

IMPLICATIONS FOR RESEARCH

The use of the Apgar score in research may introduce bias into outcomes. As discussed in the Video Abstract, researchers need to address and improve the score's weaknesses or consider developing a new tool better suited to today's research needs.

VIDEO ABSTRACT AVAILABLE AT

https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=45.

Interactions between 14 Elements in the Human Placenta, Fetal Membrane and Umbilical Cord

The aim of the study was to investigate relationships between the concentrations of macroelements (Ca), microelements (Cr, Cu, Fe, Mn, Mo, Ni, Sn, Sr, V, Zn) and heavy metals (Ag, Cd, Pb) in the placenta, fetal membrane and umbilical cord. ‪Furthermore, we examined relationships between the concentrations of these metals in the studied afterbirths and maternal age, gestational age, placenta parameters (breadth, length, weight) and newborn parameters (length, weight and Apgar score). This study confirms previously reported Zn-Cd, Pb-Cd and Ni-Pb interactions in the placenta. New types of interactions in the placenta, fetal membrane and umbilical cord were also noted. Analysis of the correlations between metal elements in the afterbirths (placenta, fetal membrane and umbilical cord) and biological parameters showed the following relationships: maternal age and Mn (in the fetal membrane); gestational age and Cr, Fe, Zn (in the fetal membrane), Ag and Cu (in the umbilical cord); newborn’s length and Sr (in the placenta), Ag (in the umbilical cord); newborn’s weight and Sr (in the placenta), Cu (in the fetal membrane), Ag (in the umbilical cord); Apgar score and Ca, Cr and Ni (in the umbilical cord); placenta’s length and Cr and Sn (in the fetal membrane), Cu (in the umbilical cord); placenta’s width and Mo, Pb (in the placenta) and placenta weight and Sr (in the placenta), Ag, Fe, Mn (in the fetal membrane). The results show the influence of metals on the placenta, mother and newborn parameters, and the same point indicates the essential trace elements during the course of pregnancy.

Pregnant Inuit Women's Exposure to Metals and Association with Fetal Growth Outcomes: ACCEPT 2010⁻2015

Environmental contaminants such as heavy metals are transported to the Arctic regions via atmospheric and ocean currents and enter the Arctic food web. Exposure is an important risk factor for health and can lead to increased risk of a variety of diseases. This study investigated the association between pregnant women's levels of heavy and essential metals and the birth outcomes of the newborn child. This cross-sectional study is part of the ACCEPT birth cohort (Adaption to Climate Change, Environmental Pollution, and dietary Transition) and included 509 pregnant Inuit women ≥18 years of age. Data were collected in five Greenlandic regions during 2010⁻2015. Population characteristics and birth outcomes were obtained from medical records and midwives, respectively, and blood samples were analyzed for 13 metals. Statistical analysis included one-way ANOVA, Spearman's rho, and multiple linear and logistic regression analyses. The proportion of current smokers was 35.8%. The levels of cadmium, chromium, and nickel were higher compared to reported normal ranges. Significant regional differences were observed for several metals, smoking, and parity. Cadmium and copper were significantly inversely related to birth outcomes. Heavy metals in maternal blood can adversely influence fetal development and growth in a dose⁻response relationship. Diet and lifestyle factors are important sources of toxic heavy metals and deviant levels of essential metals. The high frequency of smokers in early pregnancy is of concern, and prenatal exposure to heavy metals and other environmental contaminants in the Greenlandic Inuit needs further research.

Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability

OBJECTIVE

To test the non-inferiority of an alternative to the Apgar score.

STUDY DESIGN

The Neonatal Resuscitation and Adaptation Score (NRAS) was recorded in parallel to the Apgar score by a resuscitation team at deliveries. Correlation between the systems was assessed, as well as the predictive ability of NRAS and Apgar scores for mortality or short-term morbidities.

RESULTS

A total of 340 infants were in the study group. The two scores correlated strongly (r = 0.87 and 0.83 at 1 and 5 min, respectively). Those needing ventilation at 48 h of life had a 5-min NRAS < 7 in 23/26 vs Apgar < 7 (23/36, p = 0.001). A low (0-3) 1-min NRAS score was more predictive of death, 53% vs 17%, p = 0.0065.

CONCLUSIONS

NRAS correlates with Apgar status assessment, and identifies newborns who die or may require further care better than the Apgar score.