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Virginia Apgar – Scientist of the Day
Virginia Apgar, an American anesthesiologist, was born June 7, 1909.
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A baby born blue and silent. Doctors frozen in panic. Then one woman said five words that would save 50 million lives."Let's score the baby."It was 1952, inside a New York City delivery room, and Dr. Virginia Apgar had just changed medicine forever—though no one knew it yet.Apgar had dreamed of becoming a surgeon. She had the skill, the drive, and the brilliant mind for it. But in the 1940s, hospital doors stayed locked for women who wanted to hold scalpels. After being told point-blank that no hospital would hire a female surgeon, she made a choice: if they wouldn't let her into the operating room, she'd find another way to save lives.She turned to anesthesiology—and ended up exactly where she was meant to be.Working in Columbia-Presbyterian's maternity ward, Apgar witnessed something that haunted her: newborns dying within minutes of birth, while doctors stood helpless, unsure which babies needed urgent care and which would recover on their own. There was no system. No standard. Just chaos and heartbreak.So one morning over breakfast, she grabbed a napkin and designed a test. Five simple measurements: heart rate, breathing, muscle tone, reflex response, and skin color. Zero to ten points. Two minutes to assess. One score that could mean the difference between life and death.She called it the Apgar Score.Within a decade, nearly every hospital in America was using it. Infant mortality plummeted. Babies who would have been left to die were suddenly being resuscitated. Doctors finally had a universal language for newborn care—and it came from a woman they'd told couldn't be a surgeon.But Apgar didn't stop there. She earned a master's in public health at 50, joined the March of Dimes, and spent the rest of her life fighting for mothers and babies worldwide. She became one of the most powerful voices in maternal and infant health—the job they said she'd never have.When someone asked how she thrived in a world that didn't want her, she smiled and said: "Women are like tea bags—you don't know how strong they are until they're in hot water."Dr. Virginia Apgar died in 1974, but her legacy breathes in every delivery room on Earth. Every two seconds, somewhere in the world, a newborn takes their first breath while someone calls out a score.A score that honors the woman who refused to accept "no"—and who turned rejection into a gift that keeps on giving, one breath at a time.
Women are like tea bags — they don’t know how strong they are until they’re in hot water.
Dr. Virginia Apgar, American physician and inventor of the Apgar score
The Inspiring Legacy of Women Physicians
September is Women in Medicine Month. Women doctors are leaders in humanitarian care, government service, social media, and innovative ways to provide care. You may already have noticed a change in the health care you receive, if not, you will.
updated July 15, 2024 Why celebrate women physicians? In 1860 the United States had 200 women physicians. By 1900, there were 7000. The number of female physicians has increased from 35,626 in 1975 to 404, 000 in 2023. Women physicians comprise 37% of actively practicing physicians in the United States. Women physicians-not the minority now In 2018, for the first time since Elizabeth…
*sang like epcot
Apgar
BIO:
Anyone else have that weird mental image of doctors holding a newborn baby by their feet and spanking them to test whether they’re healthy or not? Not sure where that mental image came from? Yeah, me too... except now I know maybe it has something to do with this woman-- Virginia Apgar.
Virginia Apgar was an obstetrician and anesthesiologist who noticed a major problem with the number of babies born with birth defects, or passing away shortly after birth. As an anesthesiologist, she unfortunately knew that a lot of those stillbirths were an effect of giving the mother anesthesia during labor.
She understood that the first few minutes in a baby’s life are crucial for assessing whether or not they require special medical attention. But she also noticed that there was no uniform way for assessing a baby’s health immediately after birth-- no uniform understanding of what a healthy baby looked and sounded like. So, in 1952 she created the Apgar Score, which rated a newborn on the following criteria: heart rate, respiratory effort, muscle tone, reflex response, and color. They were simple criteria that could be assessed in a matter of minutes, meaning the baby could quickly receive any special medical attention it needed.
The Apgar Score is still used today-- however, many medical professionals think that APGAR is just a handy acronym, not a person. (Appearance, Pulse, Grimace, Activity, Reflex.) Now you know the woman behind the method!
Despite working in anesthesiology, a male dominated field, and encountering a good amount of hurdles due to her gender, Apgar was never comfortable identifying with the feminist movement. “Women are liberated from the time they leave the womb,” she said. However, she privately expressed frustration with the gender pay gap in her fields.
Oh, and about spanking babies upside down to get them to cry... that’s an outdated practice. Now, if a baby doesn’t cry immediately at birth (the G in APGAR), nurses will do something a bit more gentle, like rub them with a rough towel or tap their feet to get them to react.
READ MORE:
National Institute of Health: Changing the Face of Medicine
Anasthesia and Analgesia: How the Apgar Score Came to Be
Medical News Today: Changing perceptions of newborn care
CORRECTION:
The graphic incorrectly states that Apgar founded March of Dimes. March of Dimes was founded by President Franklin D. Roosevelt, and Apgar became Vice President of Medical Affairs and the lead publicist when the organization’s mission shifted from polio to birth defects.
Comparison of Neonatal Apgar Score & Umbilical Artery Blood Gas Parameters Among parturients Undergoing Elective Caesarean Section Under Spinal, Epidural & General Anaesthesia: A Prospective Randomized Observational Study-Juniper Publishers
Abstract
Introduction: Frequency of lower segment caesarean section (LSCS) is increasing today. All anaesthetic techniques used for LSCS may have certain advantages & disadvantages that affect short and long term neonatal outcome. This study aimed to compare effect of spinal, epidural and general anaesthesia on neonatal outcome in terms of Apgar score and umbilical arterial (UA) blood gas parameters.
Method: Total 90 parturients belonging to age group of 20-30 yrs of ASA grade I and II who were scheduled to undergo elective LSCS were randomly allocated by chit method into three groups (n=30). Group SA received spinal anaesthesia, Group EA received epidural anaesthesia and Group GA received general anaesthesia. Duration between induction to skin incision (I-SI), skin incision to delivery (SI-D) and uterine incision to delivery (UI-D) were noted. Intraoperative vitals like HR, SBP, DBP, RR, SPO2 and ETCO2 at various time intervals were recorded. Neonatal UA blood gas parameters (pH, PO2, PCO2, HCO3, BE) and Apgar score (at 1 and 5 minutes) were assessed after delivery of baby.
Result: Demographic profiles of parturients were comparable. Intraoperative episode of hypotension found more in group SA than group EA and GA. Mean Apgar score at 1 min, mean UA blood pH and PO2 were significantly low and mean UA blood PCO2 was significantly high in group SA and GA as compared to group EA (p<0.05) but difference in Apgar score at 1 min, mean UA blood pH, PO2 and PCO2 were statistically insignificant between Group SA and GA. (p>0.05) Mean Apgar score at 5 min, mean UA HCO3 and BE values were statistically insignificant and comparable among groups. (p>0.05).
Conclusion: All three anaesthetic techniques were safe for neonates in elective LSCS, but epidural anaesthesia was associated with better short term neonatal outcome as compared to spinal and general anaesthesia for elective LSCS.
Keywords: Spinal; Epidural; General anaesthesia; Apgar score; UA blood gas analysis
Abbreviations: LSCS: Lower Segment Caesarean Section; UA: Umbilical Arterial; I-SI: Induction to Skin Incision; SI-D: Skin Incision to Delivery; UI-D: Uterine Incision to Delivery
Introduction
Lower segment caesarean section (LSCS) is a life-saving procedure for the parturient and her baby. The frequency of caesarean section continues to rise steadily worldwide [1]. Today, caesarean delivery accounts for more than 30% of all births [2]. In India the incidence of LSCS is increased from 3% to10% between 1992-93 and 2005-06 [3]. Anaesthesia to a parturient affects both mother and fetus, so anaesthesiologist has to look over both individuals. The type of anaesthesia administered for LSCS is an important determinant of the short term and long term maternal and neonatal outcome. Each anaesthesia method for elective LSCS has their own advantages and disadvantages to both mother and neonate. Anaesthesiologist must choose the type of anaesthesia that is safe for mother, have least depressant effect on neonate and provides optimal working conditions for the obstetricians [4]. The spinal anaesthesia is commonly used method for LSCS, because of simple and quick technique, requires low volume of drugs for induction, less or no systemic effects to the baby, low risk of maternal pulmonary aspiration and an awake mother at the time of delivery but associated with high risks of an extensive block, fixed duration of anaesthesia, post-dural puncture headache and high incidence of maternal hypotension followed by decrease uterine blood flow in placenta, thus impair fetal acid base status even in an existence of a normal placental store [5-8].
Epidural block for LSCS has increased in popularity due to its benefits like low incidence of maternal hypotension and neonatal respiratory depression, less or no postoperative pain and discomfort to mother. Though general anaesthesia is associated with good control of airway and ventilation, better maintenance of cardiovascular stability, but the drugs required for general anaesthesia are multiple and may produce systemic effects in the baby like low Apgar score and sedation, directly by placental transfer and indirectly by maternal physiological and biochemical changes. General anaesthesia is also associated with maternal risks of difficult intubation, pulmonary aspiration, delayed recovery, nausea and vomiting [9]. The incidence of maternal mortality may reach up to 10% under general anaesthesia [10]. Apgar score and umbilical artery pH known to provide best measures of neonatal outcome after LSCS under all three types of anaesthesia and both can be affected by alterations in the cord blood flow with the delivery process and different anaesthesia techniques [11]. Due to benefits and risks of the different anaesthetic techniques, it is important to choose safest anaesthesia for good maternal and neonatal outcomes irrespective of indications of caesarean section.
No ideal anaesthetic method for minimizing adverse neonatal outcome has yet been described in literatures. Uniform data available regarding comparative effects of types of anaesthesia on cord blood gases of neonates in healthy maternal population are limited. So the aim of present study was to determine the effect of spinal, epidural and general anaesthesia on neonatal outcome in terms of Apgar score and umbilical cord blood gas values in elective LSCS. So that we can standardize the anaesthesia technique for elective caesarean section that have least effect on neonatal outcome.
Method
This study was conducted in the Department of Anaesthesiology and Critical care, Pt. J.N.M. Medical College & Dr. B.R.A.M. Hospital Raipur, C.G, after approval from the institutional ethics committee. This prospective, randomized, open label observational study was done in total 90 parturient belonging to the age group of 20-30 yrs, ASA grade I & II, who were scheduled to undergo LSCS under spinal, epidural and general anaesthesia. The Parturients were randomly divided by chit method into three groups of 30 parturients in each group (n=30), Group SA received spinal anaesthesia; Group EA received epidural anaesthesia and Group GA received general anaesthesia. Before the study, a power of study was calculated by using software G Power 3.0.10, taking mean values from the study of Petropoulos G et al [12] and considering a probability level of 0.05 (α-error) and power of 0.80 (1-ß) yielded a sample size of 30 parturients for each group. Parturients complicated with following conditions were excluded from the study: Anaemia (<10gm/dl), severe PIH, placenta previa, abruptio placenta, oligohydramnios, gestational diabetes mellitus, morbidly obese (BMI > 40 kg/ m2), major cardiac abnormalities, congenital malformations, intrauterine growth retardation and fetal distress. Induction to delivery time >10 minutes, skin incision to delivery time >8 minutes and uterine incision to delivery time >3 minute were also excluded from the study.
Pre-anaesthetic evaluation was carried out and written informed consent was obtained either from the parturient or from her relatives to carry out the procedure and enrolled her in this study after explanation. In operation theatre multipara monitor (Philips MP 30) was applied to monitor non-invasive blood pressure, ECG, SPO2 and ETCO2. Intravenous line was maintained by inserting 18 G i.v. cannula in vein of dorsum of hand. Premedication was given with inj. Ranitidine 50 mg i.v. and inj. metoclopramide 10 mg i.v. 30 min before induction to all the parturient. Parturients were induced with particular anaesthesia according to groups assigned. In group SA, with all aseptic precautions subarachnoid space was approached at L3- L4 or L4-L5 interspace with 26 G Quincke spinal needle in sitting position. Inj. Bupivacaine 0.5% (heavy) 2 ml was injected and parturient was placed in supine position immediately. A tilt of 10-15 degree was given to achieve appropriate block height. Block height was checked by spirit swab for temperature sensation. Parturients in group EA were placed in sitting position and with all aseptic precautions epidural space was approached and identified by loss of resistance method at L3-L4 or L4-L5 interspace, epidural catheter was inserted, left in situ and fixed. Inj. After injection of test dose of Lignocaine with adrenaline 2%, 3ml, Inj. Bupivacaine 0.5%, 12 ml were given. Block height was checked by spirit swab for temperature sensation. In group GA, parturients were induced with i.v. Thiopentone sodium 5-7 mg/ kg after 3 min preoxygenation with 100% O2. Inj. Succinylcholine 1.5 mg/kg i.v. was given to facilitate tracheal intubation. Trachea was intubated with 7-7.5 mm cuffed endotracheal tube. After checking bilateral air entry, tube was fixed.
Depth of anaesthesia was maintained with O2:N2O 50%:50%, isoflurane and muscle relaxant i.v. Atracurium 0.5 mg/kg bolus followed by maintenance dose 0.1 mg/kg. At the end of surgery, when parturient resumed some breathing effort, residual effects was reversed with i.v. Neostigmine 0.05 mg/ kg and i.v. Glycopyrrolate 0.01 mg/kg. When the patients were fully awake then the endotracheal tube was removed with oral suction. Hypotension defined as fall in baseline SBP >20% was corrected with intravenous crystalloid fluid, if persist then i.v. Mephentermine 6 mg incremental dose was given. Bradycardia (HR <60) was corrected with i.v. Atropine 0.6 mg. ECG, Heart rate, Systolic blood pressure, Diastolic blood pressure, Mean blood pressure, Respiratory rate, Oxygen saturation and End tidal CO2 were recorded throughout the procedure and note at the time of induction and at every 2 minute after induction till delivery of baby. Induction to skin incision, skin incision to delivery and uterine incision to delivery time were also noted. Umbilical artery blood sample was taken from a double clamped segment of umbilical cord and umblical arterial blood gas analysis was immediately done using COBAS 121 ABG machine. Apgar score of neonate at 01 and 05 minutes after delivery of the neonate were assessed. Statistical analysis was done using Graph pad prism 7 software. Data were analyzed by One way ANOVA test and Tukey’s multiple comparison test. Tukey’s multiple comparison tests was used for multiple pair wise group comparison. The results were analyzed by various statistical techniques like percentage, mean and standard deviation. p- Value <0.05 considered significant finding.
Results
The maternal and neonatal demographic profiles, induction to skin incision time, skin incision to delivery time and uterine incision to delivery time were statistically comparable among three groups (p>0.05) (Table 1). Highly significant fall in maternal HR from baseline was seen just after induction, at 2 min, 4 min and 6 min in group SA and group EA than group GA (p<0.001) but bradycardia was not seen in any parturients and none of the parturient required atropine (Figure 1). Highly significant fall in SBP and DBP from baseline was seen at 4 min and 6 min in group SA than group EA and group GA. (p<0.0001) The difference in mean SBP and DBP was statistically insignificant between group EA and group GA. (p>0.05) (Figures 2&3) 3 patients in group SA had episode of hypotension that was not severe and did not require vasopressure. None of the patient in group EA and group GA had experienced episode of hypotension. Respiratory parameters RR, SPO2 and ETCO2 were comparable in all three groups. Mean Apgar score of neonates at 1 minute was significantly low in both group SA and group GA as compared to group EA. This difference was statistically highly significant between group GA and EA but only significant between group SA and EA. Difference in mean Apgar score at 1 min between groups SA & GA was insignificant. (p>0.05) Mean Apgar score at 5 minute was statistically insignificant among groups. (p>0.05) Mean UA pH and pO2 were significantly low while mean UA pCO2 was significantly high in group SA and GA as compared to group EA. (p<0.05) Difference in UA pH, pO2 and pCO2 values were statistically insignificant between SA & GA groups. (p>0.05) The difference in mean UA HCO3 and BE was statistically insignificant among groups (p>0.05) (Table 2).
Discussion
As with increasing incidence of LSCS in India, the role of anaesthesiologist is also increased. Since beginning spinal anaesthesia has been used for LSCS but it is associated with maternal hypotension which impairs uteroplacental flow. In our study heart rate was decreased from baseline in both spinal and epidural anaesthesia group but bradycardia (HR <60 per min) was not seen in any parturients. Heart rate was significantly raising in general anaesthesia group after induction which was due to sympathetic stimulation during laryngoscopy. Abdallah MW et al [13] also observed tachycardia after induction in general anaesthesia group. Incidence of hypotension was 10% (3 of 30 parturients) in spinal anaesthesia group in our study, but none of them required vasopressure. We observed no episode of hypotension in epidural and general anaesthesia groups. Similar result was observed by Tonni G et al, Mekonnen S et al and Saygi A et al [14-16]. Frequency of hypotension observed in studies of Kolatat T et al [17] (56.8% in spinal anaesthesia & 51.3 % in epidural anaesthesia) and Sener EB et al [18] (51% in epidural anaesthesia) were more as compared to our study.
This could be due to drugs used by them i.e. Kolatat T et al [17] used 1.2 ml 5% Lignocaine for spinal block and 20 ml of 2% Lignocaine with Adrenaline for epidural block and Sener E B et al [18] used 20 ml of 0.325% Bupivacaine, were different from our study. In our study 1 min Apgar scores were low in spinal and general anaesthesia as compared to epidural anaesthesia, but 5 min Apgar scores were statistically comparable among groups. Gori F et al, Rasooli S et al and Saygi A et al [1,19,16] also found similar results in their studies. Hypotension in spinal anaesthesia and depressant effect of drugs used for induction of general anaesthesia might be responsible for low 1 min Apgar score. But these effects are short term and do not affect 5 min Apgar score. Mean UA pH was significantly low in spinal and general anaesthesia as compared to epidural anaesthesia but UA pH<7.15 (acidemia) was not observed in our study. We also found no significant difference in mean UA pH between spinal and general anaesthesia. Similar findings were observed by Kolatat T et al, Sener EB et al, Tonni G et al, Strouch ZY et al and Rasooli S et al [14,17-20]. In our study UA PO2 was significantly low and PCO2 was significantly high in spinal and general anaesthesia as compared to epidural anaesthesia, while no significant difference was found in UA HCO3 and BE values among groups and all these parameters were within normal limits.
Kolatat T et al, Petropoulos G et al, Tonni G et al, Abdallah MW et al and Rasooli S et al [17,12,13,14,19] observed similar findings regarding UA PCO2, HCO3 and BE. Kolatat T et al [17], Petropoulos G et al [12] and Tonni G et al [14] found high UA PO2 in general anaesthesia group and their results were different from our study. They explained it, that high maternal inspired O2 concentration in general anaesthesia result to high UA PO2 in neonates. Long intervals including induction to delivery time >10 minutes, skin incision to delivery time >8 minutes and uterine incision to delivery time >3 minutes adversely affects neonatal outcome by decreasing uteroplacental blood flow, but these intervals are within normal limits in our study. Limitation of our study was small sample size and also we have not done maternal arterial blood gas analysis which might be the reason for the neonatal acid base imbalance. Further study with large sample size including both maternal and neonatal arterial blood gas analysis should be done to evaluate the effects of anaesthesia techniques on neonatal outcome.
Conclusion
We concluded that spinal anaesthesia, epidural anaesthesia and general anaesthesia are safe for both mother and neonates as maternal blood pressure, Apgar score and umbilical arterial blood gas values are not significantly affected. However among three anaesthetic techniques, epidural anaesthesia was associated with better short term neonatal outcome and could be a preferred anaesthetic choice for elective lower segment caesarean section.
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