A Proposal for a New Method of Evaluation of the Newborn Infant

Abstract

Resuscitation of infants at birth has been the subject of many articles. Seldom have there been such imaginative ideas, such enthusiasms, and dislikes, and such unscientific observations and study about one clinical picture. There are outstanding exceptions to these statements, but the poor quality and lack of precise data of the majority of papers concerned with infant resuscitation are interesting. There are several excellent review articles1,2 but the main emphasis in the past has been on treatment of the asphyxiated or apneic newborn infant. The purpose of this paper is the reestablishment of simple, clear classification or “grading” of newborn infants which can be used as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of resuscitation. The principle of giving a “score” to a patient as a sum total of several objective findings is not new and has been used recently in judging the treatment of drug addiction.3 The endpoints which have been used previously in the field of resuscitation are “breathing time” defined as the time from delivery of the head to the first respiration, and “crying time” the time until the establishment of a satisfactory cry.4 Other workers have used the terms mild, moderate and severe depression5 to signify the state of the infant. There are valid objections to these systems. When mothers receive an excessive amount of depressant drugs in the antepartum period, it is a common occurence that the infants breathe once, then become apneic for many minutes. Evaluation of the breathing time is difficult. A satisfactory cry is sometimes not established even when the infant leaves the delivery room, and in some patients with cerebral injury, the baby dies without ever having uttered a satisfactory cry. Mild, moderate and severe depression of the infant leaves a fair margin for individual interpreta tion. A list was made of all the objective signs which pertained in any way to the condition of the infant at birth. Of these, five signs which could be determined easily and without interfering with the care of the infant were considered useful. A rating of zero, one or two, was given to each sign depending on whether it was absent or present. A score of ten indicated a baby in the best possible condition. The time for judging the five objective signs was varied until the most practicable and useful time was found. This is sixty seconds after the complete birth of the baby. Insofar as possible, the rating was done by two observers only, but as the series progressed, the score as determined by the anesthesia resident present at the delivery was found to be sufficiently accurate. These ratings have been included in the present series. The signs used are as follows: Heart Rate-This was found to be the most important diagnostic and prognostic of the five signs. A heart rate of 100–140 was considered good and given a score of two, a rate of under 100 received a score of one, and if no heart beat could be seen, felt or heard the score was zero. If one attends the baby alone, it is easy to learn to look briefly at the epigastrium or precordium for visible heart beat, while palpation of the cord about two inches from the umbilicus is the most satisfactory method for determining the heart rate quickly, and avoids the area of clamping or tying of the cord. It is of great assistance to the person caring for the baby to have an assistant demonstrate by motion of a finger of one hand the heart rate as palpated by the other hand. In only three cases was a heart rate of over 140 detected, accompanied by arrhythmia in two of these infants. I was puzzled as to the proper way to rate this in these patients, but they were given a full score of two points. The tachycardia and arrhythmias were apparently related to an overdosage of a vasopressor drug during spinal anesthesia for cesarean section. Respiratory Effort-An infant who was apneic at 60 seconds after birth received a score of zero, while one who breathed and cried lustily received a two rating. All other types of respiratory effort, such as irregular, shallow ventilation were scored one. An infant who had gasped once at thirty or forty-five seconds after birth, and who then became apneic, received a zero score, since he was apneic at the time decided upon for evaluation. Reflex Irritability-This term refers to response to some form of stimulation. The usual testing method was suctioning the oropharynx and nares with a soft rubber catheter which called forth a response of facial grimaces, sneezing or coughing. Although spontaneous micturition and defecation are not a response to an applied stimulus, they were considered to be favorable signs if they occurred. Muscle Tone-This was an easy sign to judge, for a com pletely flaccid infant received a zero score, and one with good tone, and spontaneously flexed arms and legs which resisted extension were rated two points. We are unable to