ison of Results to Infant Following Mater- a1 Regional or General Anesthesia for Delivery J VIRGINIA APGAR, M.D., NEW Y3RK CITY L (From the Department of Anesthesiology, Columbia University College of Physicians ad Surgeons) WL recently, clinical impressions have us to believe that there was no dif- the condition of the infant at birth as o the anesthetic method chosen for the if an anesthesiologist experienced in ob- blems administered the anesthesia. other evidence1.21s indicating that one alation agents, cyclopropane, is ac- by certain undesirable changes in the it seemed indicated to examine more of our own experience at the infants have been in excellent condition, nt moderately depressed, and 6 per cent depressed, as judged by a scoring sys- This incidence apparently prevailed r the anesthesia WBS by a regional method, anesthetic method, or even if no anes- obstetric situations accompanied by a and premature delivery. ed to examine these situa- eath rates, scores, and time of sustained . By "regional anesthesia" is meant block, or spinal, caudal, or lumbar ock, with no supplementary anesthesia d. By "general anesthesia" is meant f nitrous oxide or cyclopropane anesthe- use of Pentothal or relaxants. sections chosen were entirely e the onset of labor, and with no ons such as bleeding or toxemia. cation in all cases was 50 mg. of 0.4 mg. of scopolamine intramuscu- sections with cyclopropane there one infant death, as there was also in a group 66 sections with spinal anesthesia. No con- pted from the symposium and panel diecussion, "Peri- Mortality: Causes and Prevention." at the %qui- 1 Convention of the Medical Society of the State F- ew York, New York City, February 18,1957. TABLE I.-ELEWIVE CEUAREAN SECTIONS* ----- Scores - Anesthesia 0 to 4 5 to 10 Spinal 1 165 Cyclopropane 28 39 * Probability = <0.001. TABLE II.-BREECH DELIVERIEU Number of Number of Per Cent Anesthesia Deliveries Deaths of Deaths Regional -98 8 8.17 General 284 23 8.10 ~~~~ TABLE III.-BEEEcH DELIVERIEB* ---- Scores - Anesthesia 0 to 4 5 to 10 Regional 25 73 General 88 196 * Probability = > 0.30. clusions can be drawn from this small number. Likewise, since we have been recording time of sustained respiration in every case, there have been no elective sections with cyclopropane. From the scores, however, it can be seen that the infants following spinal anesthesia were signifi- cantly better than those following cyclopropane anesthesia (Table I). The score depends on the heart rate, respiratory effort, muscle tone, reflex irritability, and color one minute after the birth of the infant. The high death rate following breech deliveries has been disturbing us for years. It is impera- tive to know whether the impression that con- duction anesthesia should be chosen preferen- tially for breech deliveries is correct or incorrect. In 382 breech deliveries there was no difference in the death rate in the regional anesthesia and general anesthesia groups (Table 11). Likewise, there was no significant difference in scores (Table III) or in time of sustained respiration (Table rv>. Twenty-seven version and breech extractions were omitted because of the need for hber 15,1957 2955 VIRGINIA JPGAR 25 20- E 2 15- 8 IO 5- TABL~ IV.-TIME OF &JBTAINED RESPIRATION IN BBEEClI DELIVERIEB* -Time in Seconds--. Anesthesia 0 to 149 150 and Over Regional 43 6 General 126 15 - n5 - 76 33 31 II p ;; 04 IL 0, * Probability = > 0.30. TABLE V.-PEEMATUBE VAQINAL VEBTEX DELIVEaIEB 1.OOO TO 1,999 GM. Number of Number of Per Cent Anesthesia Deliveries Deaths of Deaths Regional 78 15 IO General 52 10 19 MSTRlBUTlON OF 97 DEATHS IN 6 BY SCORE SLOANE nowru KW 4 FIQ. 1 a relaxed uterus and deep general anesthesia. Premature infants born vaginally in the vertex position were studied. The infants below 1,OOO Gm. were omitted because of their excessively high death rate, and those over 2,000 Gm. were omitted because their condition appeared to be similar to the full-term infants. In 130 infants between 1,000 and 1,999 Gm. the death rates were identical whether regional or general anesthesia was employed (Table V). Comment The only significant result from this study is the superiority of infants born after elective cesarean section with spinal anesthesia. The average score of 166 infants following spinal anes- thesia was 8.4, while for 67 infanb following cyclopropane anesthesia it was 5.0. As seen in Fig. 1, the death rate of infants scored 5 is five times that of infants scored 8. It is impossible to compare emergency cesarean sections by these two methods of anesthesia, for in almost all cases cyclopropane anesthesia was chosen .for reasons of the necessity of speed. The main objection to spinal anesthesia voiced in some quarters is the high maternal death rate. Recently in another borough there were 12 maternal deaths following spinal anesthesia used for deliveryl6 and last year in a neighboring state there were 14 maternal deaths, 11 of which were accompanied by spinal anesthesia.6 In one case the wrong drug was administered, and in the other ten the complications were mishandled. In our experience, if spinal anesthasia i sidered with the same gravity 8s is g thesia, especially in a short, fat obstet no fatalities whatsoever should occur. has recently reported no anesthesia 27,178 consecutive spinal anesthesias for rics. In order to improve infant mortality to anesthesia problems, it is necessary the method individually for three patient, the person available to anesthesia, and the obstetrician. Conclusions As anesthesia and obstetrics are the Sloane Hospital for Women, the gional or general anesthesia in bree and for premature infants between 2,000 Gm. makes no difference in of the child, but in elective cesarean secti anesthesia is preferable to cyclopropane Sia. References 1. Smith, C. A,: Surg., Gynec. & Obat. 69: 2. Edwarda, W. B., and Ningaon, R. A.: A 3. Bundesen, H. N., Potter, E L.. Fehb 1 (Ahatr.) 57: 459 (1942). Bauer. F. C., and Plotzke, G V.: Progresa in tion of Needleaa Neonatal Deaths, P. 9. 0. Annual Report, Chicago Health Departm 4. Apgar, V: Current Reaearchea in 32: 260 (1953). 5. Goldmark. C.. Jr.: Pereonal communi0 6. Pollard, W. E.: Personal communication. 7. Marquis. A.: Bull. Women'a Hoap. De I (1957). 2956