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ORIGINAL RESEARCH REPORT

Hypoxic‑ischemic encephalopathy and the Apgar scoring

system: The experience in a resource‑limited setting
Ibrahim Aliyu, Teslim O. Lawal1, Ben Onankpa2

Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, 1Department of Paediatrics, Federal Medical Centre,
Birnin Kebbi, 2Department of Paediatrics, Usman Danfodiyo University, Sokoto, Nigeria

Address for correspondence:
Dr. Ibrahim Aliyu,
Department of Paediatrics, Aminu
Kano Teaching Hospital/Bayero
University Kano, Kano, Nigeria.
E‑mail: ibrahimaliyu2006@yahoo.
com
ABSTRACT
Introduction: Virginia Apgar developed the Apgar scoring which has shown relevance in
assessing the general well‑being of the newborn at delivery and also determining the response
and effectiveness of resuscitation. This includes the 1st, 5th, and even the 10th and 20th min scores.
However, the first and fifth scores have been severally used in defining perinatal asphyxia.
This study, therefore, seeks to assess the performance of Apgar scoring in a resource‑limited
setting in determining hypoxic‑ischemic encephalopathy (HIE). Materials and Methods: This
was a retrospective study. The medical records of 142 admitted newborns with a diagnosis
of perinatal asphyxia were reviewed over a 1‑year period. Results: There were 86 males and
56 females with perinatal asphyxia and a male‑to‑female ratio of 1.5:1. Most cases had a 1 min
Apgar score in the range of 4–5 (62.0%), whereas using the 5th min Apgar score, majority of
the cases had scores of 6 and more. Sixty‑five cases (45.8%) had HIE, whereas Stage 1 HIE
was the most recorded form of encephalopathy. The 1st min Apgar scoring showed that most
cases with a score of 4–5 had Stage 1 HIE, whereas all the nine cases with Stage 3 HIE had a
score of 0–3 (Fisher’s exact test = 132.074; P = 0.00); furthermore, most cases with Stage 1 HIE
had a 5 min score of 6 and above, but all the cases with Stage 3 HIE had a score between 4
and 5 (Fisher’s exact test = 49.024; P = 0.00). Conclusion: The Apgar score still remains an
important tool in neonatal resuscitation and monitoring; asphyxiated neonates need to be
actively and effectively resuscitated.
Key words: Apgar score, birth asphyxia, hypoxic‑ischemic encephalopathy, resource‑limited
setting

INTRODUCTION afterward, resuscitation should be called off.[5] Till date,

The Apgar score was developed by Virginia Apgar in
the year 1952[1,2] to assess the well‑being of newborn at
birth; therefore, identifying those who need attention
and immediate resuscitation. It consists basically of
observation of five physical parameters with a score of
0–2 assigned to each.[3] These scores are determined in the
1st and 5th min of life. However, it has been modified over
the years with the 10th min and 20th min Apgar scorings
included.[4] To avoid ambiguity, several regulatory bodies
such as the International Liaison Committee on Resuscitation
recommends that the duration of Apgar scoring should be
limited to the 10th min in the absence of any sign of life;
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controversy still persists on the scope of its utilization,
while some researchers believe that it could predict
long time neurologic outcome,[6,7] others hold contrary
opinion.[8‑10] Furthermore, the isolated use of the Apgar
score for defining perinatal asphyxia has been discontinued
over the years in developed countries. Therefore, the
American Academy of Pediatrics and the American College
of Obstetrics and Gynecology definition stipulate that other
evidences of hypoxemia such as acidemia, encephalopathy,
and multiorgan dysfunction should be present before the
diagnosis could be made.[11] Some of these guidelines are
often difficult to implement in some resource‑constraint
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DOI: How to cite this article: Aliyu I, Lawal TO, Onankpa B.

10.4103/jcls.jcls_102_17
Hypoxic-ischemic encephalopathy and the Apgar scoring system: The
experience in a resource-limited setting. J Clin Sci 2018;15:18-21.

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Aliyu, et al.: Hypoxic‑ischemic encephalopathy and the Apgar scoring system
settings, for instance, blood gas analysis. The pertinent
question then will be done we suspend the diagnosis
of perinatal asphyxia in such settings? The resounding
answer will be a no. The bottom line of perinatal asphyxia
is the presence of hypoxic‑ischemic encephalopathy (HIE).
Therefore, this study seeks to determine how efficient
and effective is the 1st and/or 5th min Apgar scoring in
defining and classifying birth asphyxia and also comparing
its score with the clinical manifestation of HIE using the
Sarnat‑Sarnat classification.[12]
MATERIALS AND METHODS
This was a retrospective study of inborn neonates
admitted into the Special Care Baby Unit of our health
facility with a diagnosis of birth asphyxia from January 1,
2012, to December 31, 2013. Their medical records were
reviewed, and information on bio‑data including sex,
weight, gestational age, and information on Apgar score
and clinical features diagnostic of HIE were extracted
and entered into the study pro forma. Newborns with
Apgar scores <7 at 1st min were included in the study;
furthermore, only those scored by health personnel well
trained in neonatal resuscitation were included in the
study. In our institution, pediatricians attend deliveries of
high‑risk pregnancies, cesarean sections, and complicated
labors; and they ascribe the Apgar score; however, the
obstetricians and trained obstetric nurses score in
noncomplicated deliveries. Files with incomplete records
and nondocumented Apgar scoring were excluded in the
data analysis. Infants <34 (completed) weeks’ gestation
were also excluded from the study.
The Apgar score is interpreted as normal (reassuring)
if the score is 7–10, 6 is a fairly low score, 4–5 is low,
whereas 0–3 is very/critical low in the term infant and
late‑preterm (near‑term) infant.[13,14] Perinatal asphyxia
had been previously defined based on the Apgar scoring
alone. therefore, the 5th min Apgar score of <7[15] and
the 1st min Apgar score of <7[16] have been variedly used
to define perinatal asphyxia. The severity of perinatal
asphyxia was classified as mild, if the Apgar score is 6,
moderate perinatal asphyxia is Apgar score of 4–5, whereas
a score of 0–3 is severe perinatal asphyxia.[16] We, therefore,
compared how effective was the 1st or the 5th min Apgar
in determining newborns who subsequently develop HIE.
HIE was classified using the Sarnat and Sarnat criteria.[12]
Data analysis
Data obtained were entered in a computer and were
analyzed using Statistical Package for the Social Sciences
version 16 (SPSS Inc., Chicago, Illinois, USA). Quantitative
variable was summarized as a mean and standard
deviation, whereas qualitative variables were summarized
in percentages. The Fisher’s exact test and one‑sample
Chi‑square binomial tests were adopted as the tests
JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 1, January-March 2018
of significance and P < 0.05 was adjudged statistically
significant.
RESULTS
There were 1600 recorded deliveries and 142 neonates
fulfilled the criteria for inclusion in the study; 86 males
and 56 females with a male‑to‑female ratio of 1.5:1. There
were 30 (21.1%) preterms and 112 (78.9%) term infants.
The birth weight ranged from 1.9 kg to 4.00 kg with a
mean of 2.6 + 0.5 Kg. They were all appropriate for their
gestational age.
Table 1 described the 1st and 5th min Apgar scores and the
frequency of HIE of the cases. It showed that most of the
cases had a 1 min Apgar score in the range of 4–5 (62.0%);
using the 5th min Apgar score, majority of the cases had
scores of 6 and more. Sixty‑five (45.8%) of the subjects
had HIE; Stage 1 HIE was the most recorded form of
encephalopathy.
Table 2 compared the Apgar scores of the 1st and 5th min
with the clinical stages of HIE: the 1st min Apgar scores
showed that 22 of the newborns with a score of 4–5 had
Stage 1 HIE, whereas all the nine cases with Stage 3 HIE
had a score of 0–3 (Fisher’s exact test = 132.074; P = 0.00);
furthermore, most cases with Stage 1 HIE had a 5th min
score of 6 and above; however, none had a score of 0–3,
but all the cases with Stage 3 HIE had a score between 4
and 5 (Fisher’s exact test = 49.024; P = 0.00).
DISCUSSION
The Apgar scoring has been applied variedly in different
settings. While some use the 1st min Apgar score in defining
perinatal asphyxia,[12] majority use the 5th min Apgar
score.[17,18] Therefore, this may account for the varied
prevalence, and severity of perinatal asphyxia reported in
several studies.[19‑21]
In the 1st min Apgar score, about 62.0% of the subjects
were moderately asphyxiated with only 9.9% being mildly
asphyxiated; this improved significantly (P = 0.001)
with no documented score of 0–3 at the 5th min Apgar
score and the score of 6–7 increased to 26.8% signifying
the relevance of Apgar scoring in monitoring of
resuscitation.[22,23]
Our findings showed that a low 1st and 5th min Apgar score
was associated with the clinical features of HIE in 45.8% of
the cases, whereas the rest had no clinical manifestations
of HIE. Therefore, newborns who had critically low 1st min
Apgar scores were more likely to develop severe forms
of HIE (Stages 2 and 3); however, most of those whose
1st min Apgar scores were in the moderate range (4–5)
and the 5th min scores of 4–5 and 6, respectively, mostly
had Stage 1 HIE.
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Aliyu, et al.: Hypoxic‑ischemic encephalopathy and the Apgar scoring system

Table 1: The Apgar scores distribution and system in their routine delivery and newborn assessment
hypoxic‑ischemic encephalopathy staging among protocol. With constant practice, training, and retraining,
the study group consistency in scoring may be achieved.[25] Even in tertiary
Frequency (%) P centers, there are also concerns of interobserver variability
1 min Apgar in Apgar scoring;    O’Donnell et al.[26] reported significant
0‑3 40 (28.2) 0.001* interobserver differences in the Apgar scores of up to 2.4
4‑5 88 (62.0) points among staffs involved in newborn resuscitation;
6 14 (9.9) however, retraining and use of simulations can significantly
Total 142 (100) improve the reliability of the Apgar score. Nadler et al.[27]
5 min Apgar reported a significant correlation between reported Apgar
0‑3 0 0.001** scores by clinicians participating in simulation exercise and
4‑5 104 (73.2)
that of experts who designed the program.
>6 38 (26.8)
Total 142 (100)
HIE CONCLUSION
Stage 1 33 (47.9) 0.001***
Stage 2 23 (39.4) The Apgar score still remains an important tool in newborn
Stage 3 9 (12.7) assessment and monitoring the progress of resuscitation
Total 65 (100) in a resource‑poor setting. Both the first and 5th min Apgar
*One sample Chi‑square test, **One‑sample binomial test, *** One sample scores showed a good correlation with clinical features of
Chi‑square test. HIE=Hypoxic‑ischemic encephalopathy
severe forms of HIE.

Table 2: Comparing the Apgar scores with the Financial support and sponsorship
hypoxic‑ischemic encephalopathy staging status Nil.
HIE staging
Conflicts of interest
1 2 3 No HIE Total
There are no conflicts of interest.
Apgar score (1 min)#
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