Homebirth midwives and rampant Apgar inflation

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We’ve all suspected it. We’ve all seen the homebirth photos of hideously blue babies given high Apgar scores by homebirth midwives. Now comes confirmation that Apgar inflation is rampant among homebirth midwives.

In a new paper, Justified skepticism about Apgar scoring in out-of-hospital birth settings published in The Journal of Perinatal Medicine, Grunebaum et al. looked at 13,830,531 singleton term deliveries delivered from 2007 to 2010 in a hospital, a birthing center, or at home by either a physician, a CNM, or another midwife, and who had a 5 min Apgar score documented.

They found:

Newborns delivered by other midwives or certified nurse midwives (CNMs) in a birthing center or at home had a significantly higher likelihood of a 5 min maximum Apgar score of 10 than those delivered in a hospital [52.63% in birthing centers, odds ratio (OR) 29.19, 95% confidence interval (CI): 28.29 – 30.06, and 52.44% at home, OR 28.95, 95% CI: 28.40 – 29.50; CNMs: 16.43% in birthing centers, OR 5.16, 95% CI: 4.99 – 5.34, and 36.9% at home births, OR 15.29, 95% CI: 14.85 – 15.73].

This is both surprising and important since the Apgar score is not discretionary. There are strict criteria for assigning Apgar scores, as the chart below demonstrates, and we would expect only a very few Apgar scores of 10 regardless of setting because normal neonatal physiology means that most babies will have blue extremities for a significant amount of time after birth.

Apgar scores

As the authors explain:

Our study shows an inexplicable bias of high 5 min Apgar scores of 10 in home or birthing center deliveries. Midwives delivering at home or in birthing centers assigned a significantly higher proportion of Apgar scores of 10 when compared to midwives or physicians delivering in the hospital. Studies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with skepticism by obstetricians and midwives, by pregnant women, and by policy makers.
The continued use of studies using higher mean or high cut-off 5 min Apgar scores, and a bias of high Apgar score, to advocate the safety of home births is inappropriate.

That’s a nice way of saying that homebirth midwives are either incapable of accurately assigning Apgars scores or deliberately inflating them.

Interestingly, a homebirth midwifery executive has also noted this inexplicable bias and ascribed a similar cause.

Melissa Cheyney, Liar-in-Chief of the Midwives Alliance of North America (MANA) in her role as Director of Research has invoked the incompetence of homebirth midwives in an effort to dismiss previous studies that have demonstrated an increased death rate at homebirth over comparable risk hospital birth. In Cheyney’s recent bizarre opinion piece in the Lamaze journal Birth: Issues in Perinatal Care alleging a “crusade” against homebirth, she writes:

There appear to be real differences between how physicians and home and birth center midwives perceive and report Apgar scores at the edges of the Apgar spectrum. Physicians are more likely to report fine gradations of either very low or very high Apgar scores, whereas home and birth center midwives are more likely to report Apgar scores of 0 or 10 more absolutely.”

In other words, Cheyney is insisting that homebirth midwives aren’t presiding over more deaths, they’re just stupid. Homebirth midwives deliver babies that are either better or deader than those delivered in hospitals because they are can’t accurately assign Apgar scores. But the reality is that there are no “fine gradations” of Apgar scores; there is no discretion in assigning Apgar scores of 0 or 10; and there are no differences in “perception” of neonatal death or a vigorous, completely pink newborn.

As poorly educated and poorly trained as I believe homebirth midwives to be, even I cannot imagine that they are mistakenly diagnosing babies as dead when they are not dead. And the only remotely plausible reason for more Apgar scores of 10 among a population that has a greater number of deaths than expected is rampant inflation of Apgar scores by homebirth midwives.

The bias of tendency of homebirth midwives to assign higher Apgar scores than warranted was anticipated by Virginia Apgar herself in recommending that the Apgar scores be determined by someone other than the person who delivers the baby:

Dr. Apgar herself anticipated the potential for bias in scoring when she stated: “ it is strongly advised that an observer, other than the person who delivers the infant, be the one to assign the score ” and “ … experience has demonstrated that the person delivering the infant should not be the one to assign the score. He or she is invariably emotionally involved with the outcome of the delivery and with the family, and cannot or unconsciously does not make an accurate decision as to the total score ” .

And indeed, the key difference between the assignment of Apgar scores at home and in the hospital is that at homebirth the midwives assign the Apgar score whereas the hospital nurse assigns the score in the hospital, eliminating the tendency to artificially inflate the score.

The authors conclude by calling into doubt the results of homebirth studies that use mean Apgar scores to “demonstrate” the safety of homebirth:

… [S]tudies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with sustained skepticism by obstetricians and midwives, by pregnant women, and by policy makers. The continued use of studies using higher mean or high cut-off 5 min Apgar scores and a bias toward high Apgar score to advocate the safety of home births is inappropriate.

There is simply no question that homebirth midwives are biased in assigning Apgar scores. Why? Cheyney says that it’s because homebirth midwives are stupid. Grunebaum implies it is because homebirth midwives don’t tell the truth.

Idiots or liars, take your pick, but either way, homebirth midwives are incompetent practitioners. It is hardly surprising then that all existing research on American homebirth (including MANA’s own statistics), all state statistics, and all CDC national statistics shows that homebirth with a non-nurse midwife dramatically increases the risk of neonatal death.

Thinking about homebirth? Perhaps you should think again.

  • batmom

    It strikes me that the homebirth midwives in these cases must think of APGARs as something like a gold star, instead of a diagnostic tool to help a team determine whether a newborn needs help. Thus, 10 is something to aim for or fudge, rather than merely an indicator that everything is fine.

    Tangentially, I think my son’s were 8 and 9. I have no memory, however, of how I came to know this information. I suspect the 9 was because of blue extremities (which persisted for a day or two); but what was the 8? No clue. All I know is that he came out and hollered his little head off.

    • Susan

      It’s been said below but Apgars aren’t really used to guide resus so much, they are one of many assessments made but in terms of guiding care. A minute is a long time and decisions to regarding what the baby needs are made on an ongoing basis according to AHA/AAP Neonatal Resuscitation Program guidelines which virtually all providers are certified in in the US. Even the homebirth people often have that credential, though they often go to one taught for out of hospital birth.

      http://karenstrange.com/

      Frankly I always look at this and think it looks pretty good. I am not saying they get some of their weirder ideas from her for all I know she could be a voice of reason.
      8 at one minute is usually for color and not a big deal. Those as still great Apgars. 8 and 9 and 9 and 9 are the most common Apgars and far MORE common than a 10…. which in hospitals is very rare because brand new babies almost always have acrocyanosis ( blueish hands and feet ).

  • Susan

    For the discussion of apgars, color and resuscitation. Lots of us fear white and wide open stare the worst … here is a nuts video reposting… how NOT to do a resuscitation. They cut away so we never see how they got baby to come around.

    • Lisa from NY

      Does slapping the foot make the baby breathe better?

      • Susan

        A few rubs to a foot or the back is normal to stimulate right after birth ( if it doesn’t work you move on to the next step,… you don’t waste time). Obsessive foot slapping of an obviously apneic baby… no. I could make a laundry list of everything they do wrong.

        • Sue

          Yep – this would be great for education in how NOT to do it. Too slow, too cold, poor bag-vale-mask technique…

    • Bombshellrisa

      So much wrong with this video-what is up with not wearing gloves? And why oh why did the one midwife dip her hand in that gross water and splash it on the mother’s arm. Yuck. This video should be a warning to anyone who believes home birth midwives are trained in NRP and understand when they should apply what they have learned

      • Susan

        I am always afraid the nuts will think it’s a success story.

      • Susan

        Yes, why? Especially who the baby is laying there limp and apneic. Is wash the tattoo part of neonatal resus? And when the other midwife gives blow by and the primary midwife scolds her and say “we don’t want to do anything too exciting” well, blow by IS kind of pointless if the baby isn’t breathing but somehow I think she thinks the other one is being a medwife.

        • Susan

          I also wonder what Blanket Jackson is doing at the birth…

        • Siri

          That head comes out so slowly, every cell in my body screams, SHOULDER DYSTOCIA! ! The midwife (probably a private midwife; NHS midwives wear uniforms to homebirths) has ample time to anticipate the need for resusc. The mother is a multip! It shouldn’t take that long! Aaaarrrggghhh.

    • Hiro

      This video made me want to vomit. I’m 22 weeks into my first pregnancy and I’ve been reading SOB for years now, and when I picture my baby born like that—blue and floppy with flappy busybodies ‘checking the cord’ and performing what they think is neonatal resus. Ugh. Just ugh.

      She was blue and floppy for so long!

    • Sue

      Watching that is seriously scary – including the pumping of oxygen into the stomach, holding the mask from the wrong side without properly opening the airway.

      (But LOLing about that torch! The lights are low for the family’s comfort, while the poor babe has a torch shone in its face!)

    • Elaine

      Oh good heavens. That’s horrible. I can’t believe people think that it’s suitable to just let the baby’s head hang out of mom underwater… how can that be good for the baby? And the bit where the older sibling is watching… did she see her baby sister almost die?

      I admit I watched with the sound off, because my kids are in the next room and because I thought it would probably be kinda creepy.

      A baby shouldn’t be that limp… and if they are you need to spring into action right away! Mom’s just holding and cuddling a limp baby for what seems like forever!

  • http://kumquatwriter.wordpress.com/ Kq

    I want to bump Young CC Professor’s brilliant suggestion for a MADD-style group, because it is GENIUS.

    “How about “Fighting Antiscientific Childbirth Education/Parents Against Lay Midwifery?”

    FACEPALM. Because I do it a lot.”

    • Susan

      I vote for this!

    • The Computer Ate My Nym

      Can we have a second featured comment? Because I love this!

  • Susan

    How on earth can someone mess up a 0 apgar score? Can’t count to zero?

    • Young CC Prof

      Presumably by saying, “Oh, that baby looks kind of dead,” rather than actually administering it.

      • Susan

        LOL… just blows my mind that Cheyney could write that. I mean, 0 for everything is very unambiguous.
        ( but your post reminds me of what some docs say about WNL ( within normal limits… we never look)
        Wasn’t that Midwife book by Chris Bohlajian about a midwife that couldn’t tell if her patient was dead?

        • Dr Kitty

          NAD… No Abnormality Detected or Not Actually Done.

          • Siri

            NS – Nice Smile. LB – Leggy Blonde. FFC – Family Friend of Consultant. These 3 categories of pregnant women got gold stars on their notes so they’d always be seen by obsteric consultant Mr P in person. I kid you not.

        • Siri

          She cut a live baby out of a supposedly dead woman, when in reality the mother may have ‘vagaled out’ (gee, I sound like an American! ). The book hinges on one bit of info that never comes to light…. very exciting.

          • Susan

            Yes good book I have liked all his books.

  • OBPI Mama

    Okay, looking at that chart in the post, my son should have got a 0 apgar score and he got a 1, I think. Wish I could remember his second score cause now I’m really curious!

  • anion

    “As poorly educated and poorly trained as I believe homebirth midwives to be, even I cannot imagine that they are mistakenly diagnosing babies as dead when they are not dead.”

    No, no, they’re not mistakenly diagnosing them as dead! You’re just a hater! Everyone knows HB midwives have the power to bring babies back from the dead! Just because they don’t have fancy “educations” and “degrees” doesn’t mean they can’t perform genuine miracles!

    It’s going to be in the next MANA stats: Number of babies resurrected. That’ll show you meanies!

  • Sue

    For the anti-scientists, it’s all or nothing, right?

    If a vaccine isn’t 100% effective, it ”doesn’t work”.

    So, there must be only two valid APGAR scores – 0 (dead) and 10 (alive). Everything else is just ”gradations”.

    • MLE

      Amazing how there is a huge spectrum for “normal” complications of birth and then these two extremes for the babies.

  • Anne

    I have long felt that the following subjective measures of maternal or perinatal condition were prone to abuse, and should not be used to compare outcomes between models of care.

    Apgar scores
    Maternal blood loss
    Perineal state

    When there is a vested interest for the patient and the caregiver NOT to diagnose a problem (neonatal cardiorespiratory compromise; PPH; obstetric anal sphincter injury)- that interest being to avoid escalation/transfer of care- the caregiver may not be a reliable witness.

    • Sue

      I love this quote:

      “Physicians are more likely to report fine gradations of either very low or very high Apgar scores, whereas home and birth center midwives are more likely to report Apgar scores of 0 or 10 more absolutely.”

      In other words, physicians are more likely to use the scale according to its descriptors, while HBMWs are more likely to make up a number.

      • The Bofa on the Sofa

        Midwives work in binary. Black and white.

        Doctors recognize shades of gray.

        • Amy M

          Or blue.

          • http://kumquatwriter.wordpress.com/ Kq

            Zing.

  • Stacy21629

    One more random thought/suggestion for Dr. Amy – I think a literature review is in order, either now or along with the yearly dead baby count. To keep a running tally (titles and major bullet points only, nothing in depth) for all the home birth literature as it comes out.

    Much like the baby deaths at home birth there has been so much lately to have a running list would be great. Maybe this exists somewhere and I haven’t found it. I’m planning to take Dr. Grunebaum’s previous paper, this one and some on AMA risks to my friend planning a CPM birth center birth this summer. I’d love to have even MORE *recent* literature.

  • Stacy21629

    I also love this comment of Cheyney’s:
    “his discussion runs counter to contemporary democratic principles”

    Guess what, Melissa. A properly functioning democracy requires an informed electorate.

    She’d rather women be “free” and “autonomous” than properly informed. Because then she’d be unemployed.

    • http://kumquatwriter.wordpress.com/ Kq

      Also, science isn’t a democracy.

      • yugaya

        There was a problem with college graduates over here obtaining internationally standardized level of knowledge in a foreign language, something that they are required by law to do so that their university diploma is valid. So the local foreign language teaching mafia/lobby came up with perfect solution – they created their own local version of this level exam that supposedly tests the same thing like the international exams. Except that it does not – when we trialed their test materials at our school more than half of test items were one to three levels below the difficulty level that they were supposed to measure.

        Of course the pass rates as well as grades skyrocketed when local test was administered instead of international ones.

        I guess that this is the type of democratic improvements that Cheney would like to see introduced into homebirth Apgar scoring. :)

        • Mishimoo

          I have heard of a similar issue in Papua New Guinea, but do not have a decent source, so take it with a large grain of salt. Apparently, only 15% of the nursing students were getting high enough marks to graduate. One of the government ministers was informed of this problem and allegedly said “What is Australia’s graduation rate? Well, change the courses until our graduation rate is the same as theirs.”

          • araikwao

            Actually, that sounds suspiciously accurate..

          • Amazed

            Ahhh, education. One of the subjects that can always have me foaming at the mouth in no time at all.

            We repeatedly have people here – high ranking in system of education, I mean – who insist that we accept widespread but inaccurate forms as doublets because well, they are widespread. My answer is always the same: I say, “Why the hell should I cater to your illiterate Jo’s self-confidence? Make Jo learn the correct form!” A friend: “Yeah, let’s lower all of our standards, so every illiterate Jo can feel edIcated (in my language, educated and formed differ by a single letter).” My mom: “What’s wrong with your writing showing who attended school and who didn’t?”

            But hey, let’s all cater to your illiterate Jo’s self-esteem! Let’s make him feel edIcated! Cheyney says we should.

    • Amazed

      Aristotle abhorred democracy for good reason. I imagine it had something to do with the Cheyneys of his time. She’s a prime example of those he feared seeing in charge.

  • Stacy21629

    I wonder if the members/founds of MADD (Mothers Against Drunk Driving) take offense if someone says they are on a “crusade” against drunk driving.

    I’m ok with Cheyney’s title. She’s absolutely right. I am on a crusade against unsafe home birth. You betcha lady.

    • Beth S

      We should all form our own version: “Mother’s Against Infant Death.” I know MAID doesn’t sound right, but it fits.

      • Young CC Prof

        It could be MANDY, if I could find a suitable word starting with Y.
        Mothers Against Neonatal Death…. maybe by or from something?

        • Beth S

          Mother’s Against Neonatal Death Ya’all or Mother’s Against Neonatal Death by Yoni

          • Sue

            (We would need to either change ”mothers” to “people” or grant honorary motherhood to fathers, aunts and uncles.)

      • http://kumquatwriter.wordpress.com/ Kq

        Parents Against Lay Midwifery (PALM)? The logo could be a hand.

        • Young CC Prof

          But I oppose more than lay midwifery. I oppose the promotion of out of hospital birth, I oppose the promotion of natural birth above the safety of women and infants, I oppose the demonization of pain relief in labor, and I oppose teaching women that a c-section is the worst possible pregnancy outcome.

          And I oppose “discussion” forums that delete dissent, thank you ICAN.

          • http://kumquatwriter.wordpress.com/ Kq

            Granted, as do I. But that’s a pretty long acronym…

          • Young CC Prof

            How about “Fighting Antiscientific Childbirth Education/Parents Against Lay Midwifery?”

            FACEPALM. Because I do it a lot.

          • http://kumquatwriter.wordpress.com/ Kq
          • Susan

            Sounds like a good title for Dr. Amy’s next post!

  • Beth S

    OT: I need an outsiders opinion on this, I have a friend she’s 36 weeks, no history of Premature labor or delivery this is her third child, and she’s doing a VBAC as she has a proven pelvis (First child was a vaginal delivery, second was a C-section as her son was a massive 10 pounds). This child is breech, and she’s hoping it will turn before time to go to the hospital, however tonight she called me to ask if I’d ever heard of contractions that weren’t massively painful, and just seemed to be a tightening of the muscles in the lower part of her abdomen.
    She’s trying to avoid going to the hospital because it’s Kentucky Derby time for us which means traffic around here is going to be terrible. I’m not a professional by any means, and my advice was call you doctor and see what he says, but that I didn’t think that she should be worried just yet. I told her that if she was unable to get in touch with her doctor that she needs to monitor the muscle contractions and if anything and I do mean anything feels off she should go to the hospital stat, and that honestly I’d probably go just to get checked out anyway. Did I say the right thing?

    • Stacy21629

      I think you did fine. Has she had much in the way of prodromal labor before? With my first I had about 12 hours of fairly regular non-painful “Braxton-Hicks” type contractions before they started to get painful. Maybe that’s what she’s feeling?

      • Beth S

        Not with this one, she did with the first. She’s supposed to call me back and let me know what her OB says.

        • Mishimoo

          Hope everything is okay :)

    • Young CC Prof

      You know, I had those on and off for weeks before my son was born. I think it’s pretty common.

    • Bombshellrisa

      With my son, I never had any kind of pain with my contractions. The only reason I checked into triage was my water broke and I was 35 weeks with unknown GBS status. The EFM said I was having a contraction, they checked me and I was dilated to 9 and was complete by the three minutes it took to unhook the monitor and wheel me down the hall.

      • S

        My friend also got dilated to 9 with no pain whatsoever, first child. Just a visible tightening of the belly. (She did eventually have quite a bit of pain when the baby failed to progress.)

    • Siri

      Sounds like Braxton-Hicks practice contractions. They can get very powerful and regular, but aren’t dangerous. All the best to your friend!

    • Trixie

      That used to happen to me when I had to pee or if I was standing for too long, or I was a little dehydrated. If peeing, resting, and hydrating didn’t do anything, I’d call.

    • AmyP

      It sounds like Braxton-Hicks, but I LOVE the nurse line for this sort of thing.

      I didn’t have any identifiable Braxton-Hicks for my first pregnancy, but I did for my second. (I can’t remember if I had them for my third, so probably not.)

  • disqus_FeN6LaMBls

    OT – birth story posted today on BBC – this lady has NO idea how lucky she and her baby are. She seems so proud for avoiding a c/s

    http://community.babycenter.com/post/a45885811/april_2014_birth_announcements_-_no_comments_announcements_only?cpg=87&csi=2454027976&pd=-1

    “The contractions quickly got to 1+min long every 5 mins. We called our doula over around 9pm. At 10:30pm the contractions were 4-1-1 (4 mins apart, for at least a min, for at least an hour) so we went into the birth center. I was already 6-7cm dilated. I continued to labor to full dialation at about 7am. Then we started pushing! And I pushed for 9 hours! Oye. “

    • Young CC Prof

      So are the midwives! Letting a woman push for nine hours without even talking about transferring!

    • amazonmom

      NINE HOURS?!?!?! Was she even complete when she started pushing? So many HB transfers where oops she was pushing on a 5 cm or less cervix…

      • Bombshellrisa

        OT but Puget Sound Birth Center is building a birth center right by Valley Medical Center-so Valley is going to start seeing more of the train wreck transfers your hospital has seen.

    • Trixie

      Oh, her poor pelvic floor.

    • Jessica

      Pushing for nine hours for a baby that weighed less than 7 pounds? Holy hell. I shudder to think what will happen if she has a second (larger) baby out of hospital.

  • Montserrat Blanco

    All the babies I remember being born at the hospital during my medical training were pink with blue hands and cried a lot, I am not an OB, so no lots of experience here, but the amount of blue and limp babies in homebirth photos is certainly disturbing. I am pretty sure a blue baby at the hospital would have meant a neonatologist at the delivery room in less than one minute… ( fortunately it did not happen during my short rotation, but we literally run to the birth of a baby with meconium during my Peds rotation: baby was perfect and pink). I still do not get how that can be just a “variation of normal”. At the hospital I did my rotation there was continuous electronic fetal monitoring, of course. A dubious trace spotted by the CNM meant an OB in the room in two minutes.

    • ArmyChick

      Or like my daugther’s birth: there were 2 neonatologists in the OR. I had a high risk pregnancy due to my high BP. There were many medical professionals during my c-section. I was in good hands and they put me at ease. Wonderful medical staff at the hospital. I could never put my life or my daughter’s life in danger over a birth experience. It would be reckless and selfish.

      Once you become pregnant and decide to carry full-time you become responsible for the well-being of your child. Deliving in a safe place where REAL medical professionals are present is part of being a responsible parent. You learn that the world does not evolve around you anymore.

  • http://kumquatwriter.wordpress.com/ Kq

    Perhaps a future post might compile these terrifying blue-white-gray baby pictures (sourced and including their happy craptions – not a typo). Perhaps compared with some healthy pink and red newborns for comparison.

    • Beth S

      I’d love to see this!

      • Amazed

        With my Moulded Sweet Cookie… err, I mean cutie, from the comment section of the previous post. Might do them some good to see what a real variation of normal looks like – moulded head, whitish fingers, red face, baby that looks healthy for two and a half. No need to convince his mother that his condition is a variation of normal – it’s clear that it is.

        • Beth S

          I refused to let the DH take pics of DD’s cone head, but yeah your moulded sweet cookie looks nummy (I almost wrote that molder sweet cookie which is not so nummy.)
          Although the mummy baby is still going to give me nightmares.

          • Amazed

            Not really mine. He’s Mishimoo’s. He’s mine in that I want to eat him the moment she lets me to.

          • Beth S

            Yeah I know what you mean. And that was supposed to be molded sweet cookie in the second comment I’m exhausted here.

          • Amy M

            Ha! They had to use the vacuum on one of my twins, and he was turned to the side a bit, so one side of his head was cone-headed. He looked all lopsided and weird for a day or two, but it settled. We kept the hat on him. (It was so cute with the hats on anyway, the hospital sharpied an A on one hat and a B on the other!)

          • Amazed

            I’ve said it before but I was a vaccum-assisted delivery and my head was so distorted that for a while, my dad thought I had sustained brain damage. My baby pictures start when head was somewhat restored but my, if that was the restored version… And being mostly head, there was lots of room to look scary. No wonder Dad freaked out.

        • AmyP

          I think that the emphasis on “peaceful birth” is in part a justification of all these grey, white and blue babies that don’t come out crying vigorously.

          • Amazed

            Absolutely!

          • KarenJJ

            I agree. Let’s swap “peaceful” for “lethargic”. It’s about the only time my babies and toddlers were “peaceful” and it was because they were sick and feverish (or sleeping and even then when I checked them at night I always liked to see them breathing before I went to bed myself).

          • CognitiveDissonaceHurts

            No, no, no. I didn’t want my babies to cry. I wanted them to coo and look wonderingly into my eyes.

          • Amazed

            Judging by those pictures, too many of those white babies don’t have enough strength to keep their eyes open, let alone look wonderingly into anyone’s eyes.

        • Mishimoo

          It would be interesting to compare with a homebirth, if possible. He was an 8lb low-risk, CNM-care, 40+2 weeks occiput posterior delivery in hospital with nuchal cord, a few late decels, pitocin-augmentation, manual reduction of an anterior lip, light meconium staining, and mild shoulder dystocia. Apgars of 8 and 9, with CNMs who said that it was a difficult delivery for both of us. Vitamin K shot within minutes for him, intramuscular pitocin for me as soon as the (as it turned out, calcified) placenta was delivered.

          • Mishimoo

            I should probably also point out that he was a third baby, with a 35cm head circumference despite the moulding, and had wifi CEFM.

    • Renee Martin

      This is a FANTASTIC idea. Dr Amy- please, please do this! It would be a great follow up to this post, and could educate dome o these idiots about what babies are SUPPOSED to look like.
      Darby the killer Partner has some blueberry babies on her page. She KILLED Shahzad Sheik.

  • OldTimeRN

    I could count on one hand the number of 10 apgars I’ve given out. Most if not all babies still have blue fingers and toes.

    • Susan

      Me too. I think maybe two in 25 years and both times I was flabbergasted that the baby hands and feet were actually pink at five minutes…

      almost never see anyone else give them either.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    I doubt my daughter’s (hospital born) APGAR scores – 7 and 10 at 1 and 5 minutes respectively. She was not breathing at birth, she got a 0 for that alone, not breathing means not crying, and I don’t think she was all pink….it would be interesting if “baby friendly” institutions also are more likely to inflate scores. My son’s on the other hand (cesarean born) were 9 and 9.5…and I trust those scores far more.

    • CanDoc

      Possibly the case, but even a baby that started out not breathing usually makes a reasonable Apgar score by 1 minute – a minute is a LOT of time for early resuscitation to happen. And 7 is a pretty typical Apgar for a baby who started “flat” then came around with a little stimulation and ventilation. (As opposed to the typical 8s and 9s of the vigorous screamers.)

      • Phascogale

        I was going to come in and say exactly this. 60 secs is a long time and there are lots of babies that look a bit flat and not doing much when first born to breathing well, looking pink and possibly crying at one minute of age.

        • Renee Martin

          60 seconds is a long time. Imagine how long those HB babies don’t breathe for….

      • ihateslugs

        Totally agree! A minute is actually quite a lot of time in terms of intervention, and it’s really a benchmark for a reason. The NRP (neonatal resuscitation protocol) literature shows that most babies respond very well to stimulation (rubbing with a warm towel or blanket), drying, and warmth. A few good “lusty cries” as we like to call them, and they show a dramatic improvement. Even if they go on to need a little oxygen or positive pressure ventilation, very few actually need more resuscitation. BUT, that being said, any baby who comes out looking worrisome should have appropriate assessment and care started immediately. Once the baby is looking better, there is plenty of time for skin-to-skin, breastfeeding, and bonding. I get so upset when I see these pictures of babies who really should NOT be on mommy’s chest while folks are snapping pictures. In my opinion, it is reflective of either complete ignorance or willful defiance of what is right for the baby!

    • Ob in OZ

      Don’t trust a 9.5. Like moderate preeclampsia, there is no such thing.

      • Sue

        (Or “a bit pregnant”?)

    • amazonmom

      Nah we mock our coworkers pretty hard if they start handing out the 10s like candy.

  • Beth S

    Sadly I didn’t even know what an APGAR was with my first child (I was seventeen and placed the child with a wonderful family who could give her the care I never could.) With my DD almost ten years later I didn’t get them because I was just grateful to be alive to see her grow up. With this pregnancy I’ve been researching different birthing options and to me it seems that someone who has an abundance of 10 APGAR scores is more than likely inflating those scores to sooth their own egos. I’m at 34 weeks and I feel nothing but complete confidence in my team because when asked about their mean APGAR scores, every single professional I’ve dealt with has come between 7-9. Well except for my MFM but he deals with high risk pregnancies and he explained why his scores were what they were.

  • Gene

    I’ve been at probably 500 deliveries during my career. And I’m the one assigning APGAR scores. I remember exactly ONE baby with a score of ten at one minute (and we talked about him for weeks since it was so unusual). And by five minutes, maybe 20% got to a ten. The vast vast vast majority of term healthy newborns had an APGAR of nine (-1 for acrocyanosis – pale feet and hands). Either these women don’t know how to take an APGAR or they are lying through their teeth.

  • Young CC Prof

    Maybe the midwife Apgar-ifier just goes to eleven.

    • Jessica S.

      Or more likely, “eleventy”. They have “other ways” of counting. :)

    • Captain Obvious

      Baby delivered at home, add one APGAR point. Mom gonna breastfeed, add one APGAR point. Etc etc. I am surprised we have not seen an occasional 11 or 12 in midwive charts. Oh yeah, charts don’t always exist, so in the mommy blogs then.

    • Renee Martin

      With those scores, they have to go to 50 to be accurate….

  • dancingguest

    FYI: Over on Apartment Therapy, a poster is contemplating the logistics of a home birth in a tiny apartment. Any commenter want to go inform the mom of what the real risks she is taking? The thread is here (and it is all pro-home birth comments):
    http://www.apartmenttherapy.com/on-home-birth-in-a-small-apartment-202945

    • MLE

      Just one minor point among the many issues here. Do you really want to try out a birthing tub/pool in an apartment where water beds are most likely prohibited due to weight restrictions??

      • Young CC Prof

        Wasn’t there an incident where someone broke their floor with a birthing pool?

        • Trixie

          Nah, just trust floorboards.

          • Beth S.

            I’m sure my DH would just love cleaning up the water and all the gunky stuff from the floor. His OCD wouldn’t even allow him to enjoy the birth of his child.

      • Irène Delse

        I bet the landlord (and the people who live on the floor below her) wouldn’t be thrilled by a birthing pool overflowing and causing water damage, even if it doesn’t break the floor. Water is heavy. And it has this tendency to flow downhill.

        • MamaBear

          “Excuse me mam, but your water filled with fluids, feces, bacteria, and mecomuium are leaking on my brand new Orintial rug,”says ticked off neighbor.

          • AmyP

            I don’t think that’s exactly how NYCers would express that thought.

          • Amazed

            “You only want to ruin the beauty of birth!” midwife replies.

    • Alannah

      I don’t have a login, but could someone PLEASE point out to the lady who brags about giving birth on the 5th floor of a building without elevator what an insane risk she took?

      In homebirth mecca aka the Netherlands you are risked out of homebirth if the ambulance crew can’t get their gurney down from your apartment easily. You know, just in case birth doesn’t turn out as trustworthy as expected.

      • Busbus

        Wow. I had my first birth on the fourth floor without an elevator. It never even occurred to me that that could be a problem. My midwives sure didn’t mention it, either. I’m glad I didn’t have to find out.

  • Mac Sherbert

    Is it odd that the hospital didn’t tell me the Apgars for my babies? I always just asked if they were ok?….got a yes and everyone moved on. I’m sure the Apgars are in their records somewhere it’s just no one ever volunteered the info.

    • LovleAnjel

      I wasn’t specifically told, either, but I heard them being called out by the nurse.

      • Beth S

        I didn’t even think to ask with DD because I’d given birth in the ambulance in front of my house and by the time I got to the hospital I was seizing. Yay Epilepsy!

    • Anj Fabian

      It was on our discharge papers.

      • Amy M

        Ours too. I found the notes later and was able to read everything that happened, which included nothing really worrisome during the birth. Definitely reassuring. Course if one of my sons does something stupid, I can’t blame it on his birth….

    • Young CC Prof

      You know, I don’t remember when I was told, whether they were called out by the nurse or if someone told me later that day.

    • Amanda

      I wasn’t told and have no idea what they were. I am curious though, I wish I knew! I didn’t think to ask when we got to recovery and my husband didn’t know to listen for them.

    • Lion

      In South Africa the algae scores at one and five minutes are written on our baby’s health cards, which are used at clinics for recording their weight and growth and their vaccinations. We have to supply the cards at school enrollment.

      • Lion

        Algae should read as Apgar.

        • Young CC Prof

          Seedling get algae scores. They’re rated on height, symmetry of their first pair of leaves, color (green vs white), how rapidly they shift towards the light, and the response of their stomata to changes in humidity.

          • Wishful

            Great you made me get coffee on my laptop…

        • ihateslugs

          Oh, see now I’m bummed! Thought you really had an algae score that related directly to water births. Obviously, no water birth gets you a 0, but a full koi pond experience might add up to a 10.

    • lawyer jane

      They were in our medical records. My little guy had to go to the NICU for TTN for a few hours, so I was surprised that his apgars were 5 and 9. I guess that a good Apgar does not rule out respiratory problems.

      • yugaya

        Over here newborn gets a discharge letter that you take to baby’s first check up, and they write the APGAR score from it and everything into the preschool health chart booklet which is all the medical info from birth to 7 years like family medical history, chronic illnesses, vaccines, annual check ups. There is also the same information supposedly stored in computers too, but I am yet to see that system work in real life because every time they tried to pull our electronic patient files in a hospital or a non-regular doctor’s office it failed miserably. :)

      • KarenJJ

        I think my TTTN baby was a 9 as well. He wasn’t diagnosed with TTTN until he was being weighed an hour after birth and his hands and feet were getting more blue and he was grunting softly.

      • Elizabeth A

        Good apgar absolutely does not rule out respiratory problems. I mentioned below, my daughter’s apgars were 9 and 9. But she was a preemie with respiratory distress, and was rushed straight to the nicu for care. Apgar doesn’t subtract points for tachypnea, tachycardia, or any of a thousand other situations requiring immediate care.

        My (layperson’s) opinion is that it’s a measure of whether the baby is alive, and how emphatically. Are the basic cardiac and respiratory systems functioning? Your baby could be a micropreemie with congenital health problems and still have an apgar of 9 at birth.

    • The Bofa on the Sofa

      I don’t know our babies’ apgar scores. Why would I care? I think our first was initially 7 (he was 37ish weeks), but I don’t know for sure.

      What I remember more is when the pede examined him on the first day and declared him “practically perfect in every way.” My wife said, “Cool, our pede quotes Mary Poppins!” I said, “What you do mean ‘practically’ there, Bucko?”

      • Beth S

        My DH and I were talking about DD’s APGARS he got them when I was knocked out and he demanded to know why they were 9 when both of his previous children had been ten. The Ped had never heard of that happening so he just shrugged it off. Turns out his ex-wife lied to him about the APGARS to keep him from freaking out. I might just do the same thing with this one lol.

    • theadequatemother

      No it’s not odd! Apgars only tell us if we need to intervene and resuscitate in the first minutes of life. They streamline the NRP process whih is a great thing. But they do not, by themselves prognosticate. Most of our parents get told bc they are curious. in my less rotations I was taught to ask if the kid needed resuscitation at birth or time in the NICU but not to ask about Apgars.

      Mine were 9,9 and 8,9 and the second needed PPV to et to 8. When he has trouble with abstract concepts later I’m totally going to blame the lack of epidural.

      • AmyP

        Theadequatemother didn’t get an epidural!!!!!

        Was that planned?

        • theadequatemother

          No. It was *disappointing*

          • AmyP

            Are you going for a “healing epidural birth”?

    • Rabbit

      I don’t know them for any of my kids. I know my first was the lowest, as he had some problems transitioning and they took him to monitor his breathing for a few hours. The other two were handed to me right away, so I’m assuming they were fine. My second had blue feet, so not a 10 there!

    • MaineJen

      I only found out my kids’ because I sent for my medical records after both deliveries. (Just because I’m nosey.) I think if everything is okay, they don’t tell you.

    • KarenJJ

      I didn’t get told mine, but found a folded piece of paper that recorded the birth details in my state government “baby book” (where we can also recorded growth and vaccinations). It looked like a copy of an official document so I suspect the statistics are gathered (either by the hospital of the government) for some reason where I gave birth (not the US).

    • Jessica

      I don’t recall hearing what my son’s were and they didn’t tell us, either. Since he was crying before the cord was even clamped I didn’t worry. (And the best sound I’ve ever heard in my life was that cry.)

  • Zornorph

    My son’s Apgar scores were 8/9. I was disappointed ’cause I wanted a perfect 10! Then I could have gone and bragged about it on Facebook. Then a week later the kid had infant jaundice and I had to post songs by reggae artist Yellowman instead.

    • Amy

      My husband’s got AB blood and I’ve got O, which landed my firstborn with pathological jaundice. The kid looked like an Oompa Loompa for two months. I used to wonder if she’d ever be a normal color.

  • Trixie

    I’m not sure we have to pick between Cheyney’s and Grunebaum’s assessments. I think most homebirth midwives are both idiots AND liars.

  • k_cayte

    One of my providers described an APGAR score of 10 as really for cases where the newborn cuts their own umbilical cord. :D

    That’s why I was thrilled when my daughter got a 5 minute APGAR of 10…until they said, “Well, her extremities are still a bit blue…” and they knocked it down to a 9. Still thrilled, she was born thriving!

    • Jennifer2

      I was told my son’s Apgars were both 10s. This was said in jest when it was mentioned that I’m a lawyer (as in, “Oh, you’re a lawyer? Then don’t worry, his Apgars were both 10s!”). From pictures, I know he was screaming, alert, and moving. But his hands and feet took a while to pink up. I would believe he had Apgars of 7 or 8 and 9. But not both 10s. I hope it goes without saying that he was and is a perfectly healthy child.

      • Young CC Prof

        Dr. Sloan’s book also has a story about a father who was very upset that his child scored a 9 instead of a 10, and kept trying to get Sloan to change it.

        • Jessica S.

          Legend has it that my dad did this at my birth, and apparently it worked. My dad is VERY persuasive (trying to use a kind word) so I wouldn’t be totally shocked if the story was true.

          I also would not be shocked if the doctor or nurse had the smarts to simply tell him what he wanted to hear. That’s what I would’ve done. ;)

  • Amy M

    “Readers
    have shared their concern for the blue color of water-born babies, even
    suggesting we remove such pictures from our website. This is a normal,
    physiologic event. Babies in utero are in fact blue. When born gently
    into water, they are not alarmed by the noise, the coolness of the air,
    or even gravity, so don’t gasp and cry as a more medical-managed-baby
    would born on land. Instead, babies born into warm water ease into
    breathing and therefore pink up slower than one might have become
    otherwise accustomed. The umbilical cord is still attached to mom and
    they continue to have appropriate heart rates and oxygenation. A gentle
    birth is physiologic.

    Aggressive stimulation that causes the newborn discomfort and crying
    has not proven beneficial. In fact, far more evidence has been published
    to strengthen our understanding that increasing the blood oxygen levels
    above those exhibited by healthy babies born at term provides no
    advantage and several studies have demonstrated that cyanosis can be
    normal for the first few minutes following birth. Skin color can be a
    very poor indicator of oxygen saturation and has therefore, been removed
    from the list of primary clinical signs to assess within the American
    Academy of Pediatrics Neonatal Resuscitation course. – See more at: http://believemidwiferyservices.com/services/waterbirth/#sthash.bcworBhx.dpuf

    I found that gem at: http://believemidwiferyservices.com/services/waterbirth/

    Babies in utero are blue? What? (If this is actually true, by all means, someone set me straight, but I’ve been thinking about it and it makes no sense. Why would they be blue? They receive oxygen the whole time, barring some kind of cord accident. There are pictures of fetuses in utero, and they never look blue.)

    Is there any truth to the last bit about the primary clinical signs to assess with the NRP? I know that is different than Apgar score, but perhaps the midwives don’t know that, or are relying on their audience not to know.

    • Karen in SC

      No proven benefit? How about being the way babies have been born for thousands of years?

      It’s the “gentle birth” that has no proven benefit. Maybe those minutes staying blue, cold, not breathing might have some consequences later. I’d love to see retrospective studies on all these babies though newborns are notoriously resilient so it may not matter, but STILL. Who wants to take a chance?

      • Young CC Prof

        I just thought of a way to do such a study AND minimize confounding variables. Some delivery places changed their policies on water birth following the joint statement. Compare babies who got a water birth to babies whose mothers planned one but didn’t get one.

    • C T

      I’m at 33.5 weeks, and these pictures are just too dear – http://www.epigee.org/fetal3.html
      Also, if they were always blue in utero, wouldn’t that mean they were oxygen-deprived the whole time? What an odd claim.

      • Amy M

        yeah, that’s what I was thinking..and just like the pics I’ve seen before, the fetal pics you posted do not show blue fetuses. Maybe they were smurf midwives before they moved on to people.

    • Guesteleh

      Those fucking idiots. I looked it up and here’s what they actually say:

      Other studies have shown that clinical
      assessment of skin color is a very poor
      indicator of oxyhemoglobin saturation during the immediate neonatal
      period and that
      lack of cyanosis appears to be a very poor
      indicator of the state of oxygenation of an uncompromised baby
      following
      birth.

      http://pediatrics.aappublications.org/content/126/5/e1400.full

      • Guesteleh

        More from the same article:

        Newer pulse oximeters, which employ probes designed specifically for neonates, have been shown to provide reliable readings
        within 1 to 2 minutes following birth.41,–,43
        These oximeters are reliable in the large majority of newborns, both term and preterm, and requiring resuscitation or not,
        as long as there is sufficient cardiac output
        and skin blood flow for the oximeter to detect a pulse. It is
        recommended that
        oximetry be used when resuscitation can be
        anticipated,2 when positive pressure is administered for more than a few breaths, when cyanosis is persistent, or when supplementary oxygen
        is administered (Class I, LOE B).

        • Amy M

          So basically…don’t go by color, use the pulse-ox, because even a pink baby might need a bit of help. The common sense inverse of this would be that if the baby is actually blue, simply ignoring it is the wrong course of action. If one is doing it correctly, the pulse-ox is being used anyway, for all newborns, so all blue babies (in a hospital setting anyway) will be seen to, because all babies are seen to.

          • Jenny_from_da_Bloc

            Of
            course we use a pulse ox, but that takes a minute or two to get a reading, but
            usually when a baby is that color blue and not crying/breathing we get right to
            work. It doesn’t take a rocket-scientist to know to kid needs O2, a heat
            source, positioning the head to open the
            airway, clearing the airway if necessary with a bulb syringe/suction
            catheter and stimulating breathing. They butchered the guidelines

    • NatashaO

      Thinking of when animals are born… they plop right out onto the ground (sometimes falling a few feet), and mom starts pawing or nudging them, starts licking their bodies and faces….. seems not so different than placing baby on mothers chest and drying them off a bit…..

    • NatashaO

      NRP now recommends using a pulseoximeter to gauge oxygen status, rather than eyeballing the color. Saturation increases quickly, but it can take up to 10 minutes for baby to reach 95% saturation. Even at 85% the baby can still look cyanotic. Babies oxygen saturation in utero is pretty low, so yes, they can look a bit blue when they first come out. NRP now recommends starting with room air resuscitation rather than with supplemental oxygen.

      • Guesteleh

        But they are assuming that blue, aka cyanotic, doesn’t matter when what the guidelines actually say is that even a baby who isn’t cyanotic can be oxygen compromised so you need to use a pulseoximeter to be sure. Not, oh let’s ignore cyanosis in a newborn. Those fucking assholes.

        • NatashaO

          Its an assessment process… and cyanosis is cause for concern- not to be ignored…. but if it is rapidly improving, baby’s heart rate, tone and respiratory effort are good, the cyanosis will resolve. As a resuscitation nurse, that waterbirth picture gives me grey hair!

          • Captain Obvious

            Look at inga’s birth from Rixa Freeze. Curious to see your assessment.

            http://rixarixa.blogspot.com/2011/03/ingas-birth-story-part-1.html?m=1

          • yugaya

            I can’t fathom how and why anyone puts all of that out there online. Lo and behold, posting birth porn videos is gonna be the next NCB medal achievement marker I tell ya.

          • NatashaO

            I have seen that one… it is horrifying! The first steps of NRP are to dry warm and stimulate… which we are doing while the cord is still attached after baby is plonked onto mom’s belly… and that sometimes alone perks a non-vigorous baby right up. However, if not, I am checking the pulse while telling the OB to cut the damn cord NOW so I can take the baby to the warmer for some further resuscitation. A good heart rate is reassuring, but that does not cancel out the other issues that are going on… as if you don’t fix those other things, the heart rate won’t be good for long. A baby who is blue/pale, floppy, not crying or breathing is not normal and not one to ‘watch and wait’—> you do something, and “I am so sorry if I make your baby cry” (snark) is what I say to the NCBers-> it is more important that your baby BREATHES at this point in time. They have just been squeezed out of a vagina, for gods sake- they can handle being rubbed down a little bit!!!! Its not like I am holding them upside down and spanking them! Just to be clear- I am NOT a NCB person, and not a fan of homebirth. My least favorite part of my job is to take care of babies that are brought into our ED after a home birth/poor resuscitation fiasco. As a nurse, I have seen waterbirth babies, and in my experience they are usually less vigorous than we normally see…. and it takes them a little longer to start hollering. Again, you need to do something. And logistically it is a pain in the ass with water births. And yes, we have a fish net pooper scooper too… gag.

          • Jessica S.

            “Gag” is right!

        • Young CC Prof

          Neonatologist says: A baby who is somewhat blue immediately after birth is sometimes OK, and occasionally a perfectly pink baby is not OK. Rely on more than one sign.

          Midwife says: See? Blue isn’t a problem at all!

          • Anj Fabian

            Neonatologist:
            Check everything. Twice.

            Midwife:
            Looks good to me!

          • Amazed

            Mom: She was born so calm and quiet because I had a glorious 72 hour labour with much soaking and snacking. Isn’t she the lovieliest shade of blue?

            Me: Arrrrggggg!

        • Susan

          Yes, exactly. Not, ignore blue… get SaO2 to see if everything is ok before giving O2 to a baby who doesn’t really need it. Another perfect example of how mainstream medicine changes firmly held beliefs because research supports the change where homebirth midwives like only the “evidence” that supports what they want to believe.

    • Mac Sherbert

      “pink up slower than one might have become otherwise accustomed…”

      Ok, but is that a good thing? I’m guessing they don’t know.

      • Anj Fabian

        Lower heart rate and lower respiration effort would cause a baby to “pink up slower”.

    • Zornorph

      Yo listen up here’s a story
      About a little guy that lives in a blue world
      And all day and all night and everything he sees
      Is just blue like him inside and outside
      Blue is his house with a blue little window
      And a blue corvette
      And everything is blue for him and himself
      And everybody around
      ’cause he ain’t got nobody to listen to

      I’m blue da ba dee da ba die…

      • http://kumquatwriter.wordpress.com/ Kq

        My son LOVES that song. He had a blue slinky that he calls his “daba dee slinky”

        • Beth

          Now I’ve got the slinky jingle stuck in my head
          Slinky slinky, it’s such a wonderful toy
          it’s fun for a girl and a boy
          it’s fun for a girl and a boy

      • Amazed

        Blue, blue, my world is blue.
        Blue is my world, now I’m without you.
        Grey, grey, my life is grey…

        Love this one. Someone cares to make it a homebirth slogan? They love them blue babies they see through their pink-coloured glasses.

    • lawyer jane

      Here’s an interesting description of the criteria: https://circ.ahajournals.org/content/122/18_suppl_3/S909.full

      Looks like color alone does not indicate need for resuscitation; breathing/crying and muscle tone are better indicators. But both of the pics of blue/white babies we’ve seen here recently look like they are totally floppy and not breathing, in addition to the worrying color.

      • NatashaO

        Yes, the floppy and not breathing part is definitely a game changer!

    • Young CC Prof

      I find the name “believemidwifery” to be ironic, as I do NOT believe that routinely blue newborns are a sign that you’re doing things right.

    • Irène Delse

      Babies are blue in utero? That’s a new one. It’s amazing what the will to believe can make people do when facts don’t go their way…

      • The Bofa on the Sofa

        The answer is white, right? I know that when my first was born (during the c-section), I got curious when the doctor said, “There’s his little boy part” and peaked over the screen. I was surprised to see how white he was (his head hadn’t come out yet).

        Of course, the second he got out, he started screaming to high heaven (and didn’t stop for 45 minutes) and he went pink pretty darn quick (by the time the doctor had cut the cord and showed him to us)

        • Jessica S.

          Yeah! I’m thought my son looked whitish, too, but it could just have easily been all the gunk not totally cleaned off. (He was a CS, too.) But he also pinked up fast.

          • The Bofa on the Sofa

            Here’s my guy at about 1 minute. Screaming at the top of his lungs.

          • Mishimoo

            Awww <3

          • Amazed

            Saying, “I’m alive, I am here, I’m fine and if you can’t take the noise, well, you should have thought about ear plugs. What? I thought you were the adults here?”

            :Lovely.

          • Jessica S.

            Oh yes, that’s a healthy scream! Here’s my boy – I don’t know what his score was, but I know he was healthy! And big! I don’t remember him crying a whole lot; then again it was 1:30am and we’d been in the hospital for two days so I was out of it. I think he was more annoyed, like “Hey! I was comfortable in there! What the hell?!”

    • The Bofa on the Sofa

      You know, even IF it were true that blue color is normal in a water birth, that is not a consideration in an Apgar assignment. As described, the Apgar is supposed to be an objective assessment based on simple observables. You don’t get to change the criteria because it was a water birth and say, “Oh, the baby is blue, but I’ll give it two anyway because it was a water birth.”

    • Jenny_from_da_Bloc

      Those people are nuts!!!! I just had a good laugh reading that!

    • Captain Obvious

      Debunked. Google in utero surgery. Babies are not blue.

      • Captain Obvious

        In utero surgery

        • Young CC Prof

          That picture is the most amazing thing ever.

    • CanDoc

      No, no, no. Babies in utero are NOT blue. When I pull them out at Cesarean section, they are decidedly PINK. And if they come out breech at cesarean section, their bum and torso and legs come out before their head, so I know they’re pink BEFORE their head comes out and starts the breathing going. Pink. Pink, pink pink. And on the occasions when they aren’t pink (eg when they’re white and floppy), we all stress out a little until they are.

      • Allie P

        What color are they if they aren’t white babies? I saw a Pakistani/Indian baby born and he was very pale and then turned brown as soon as he started breathing.

      • araikwao

        Thank you, polycythaemia!

  • Ellen Mary

    I didn’t know the nurse normally assigned the Apgars in the hospital, I am nearly positive a Pediatrican assigned mine, both times.

    • Pilo

      It depends on the hospital workflow and the type of delivery. If there is a situation that warrants calling in a resuscitation team (pediatrician, respiratory therapist, neonatologist, etc.), then it is often a group effort or the person with the most training will do it.

      • Ellen Mary

        Is a team always present at an unplanned Cesarean?

        • KarenJJ

          I had more people at my unplanned c-section then my planned, but I don’t know why.

          • Mer

            Seems like there would be more people at an unplanned csection since they’re done because things aren’t going well right then and baby needs out fairly quickly. A planned csection would let people have some time to get ready I would think.

    • NatashaO

      In my hospital, a pediatrician is not typically (almost NEVER) at the birth, unless we have called them to come in because we had concerns. Usually it is the OB/Midwife, a labor nurse, and a baby nurse. The labor nurse or the baby nurse (both of whom are NRP trained) assign the APGARs.

      • Amy M

        There was a pediatrician at the birth of my babies, but they were slightly premature twins, so extenuating circumstances. Not sure who called the Apgar scores though, I didn’t even hear it at the time. There were quite a number of people in the room, including at least 3 nurses, so maybe one of them.

        • Young CC Prof

          There were two baby nurses for my son, waiting in the corner of the OR. Of course, he was a prelabor 37-week c-section for fetal health concerns, so the possibility of needing respiratory support was not all that small.

  • 2boyz

    Both of mine had 5 minute Apgars of 9. My husband always jokes, Where did they lose the point? I don’t know anyone who actually got a full 10. Of course, this is talking hospital births. I don’t actually know anyone who gave birth at home (just one who attempted and was transferred. Baby and mom were fine, Thank God).

  • Julia

    Just wondering how long it will take until the NCB folks will use this study as proof that “physiologic” birth is superior to hospital birth because it obviously results in much better apgars!

    • Anj Fabian

      Except for the dead babies – and their scores don’t count because they are dead.

      Do dead babies EVER count in the home birth world?

      • Jessica S.

        No. The only dead babies that count in the home birth world are the ones that die in hospitals. Even if they’re HB transfers, as long as they get buried in the hospital records. :/

    • Young CC Prof

      I’m calling twelve hours. Before the sun sets on the Eastern Seaboard tonight.

    • Amy M

      None of them liked the “induction reduces Csections” article. The few ncb sites I saw that mentioned it, all the comments basically decided the authors were lying because it didn’t support their beliefs.

      • Young CC Prof

        The final project in my basic statistics class is to find an article about some form of science that uses statistics in some way, and critique it. Other than not doing it, or doing an obvious five-minute job, the only way to get a bad grade is to do that.

        I don’t care if agree with the article, disagree, make fun of it (I love it if you make fun of it!) but the one thing students may not do is say, “This article is wrong because I don’t like the conclusion.”

  • PrimaryCareDoc

    “Fine gradations” of Apgar scores? WTF is Melissa Cheney smoking?

    Also- I think I am developing a massive crush on Dr. Grunebaum.

    • Guesteleh

      See my post below :)

      • Amazed

        Chicks who have a crush on Evil Crusader, tell off * waves hand*

        • Durango

          I think Paul Offit is pretty great too, he’s another Evil Incarnate.

          • Trixie

            Oh yes!

          • NatashaO

            big fan of his!

          • yugaya

            Grunebaum is a non-native speaker, and I assign extra points for that with more bias than homebirth midwives do for a perfect waterbirth. :)

        • Beth S

          I think I just found my freebie. DH wants Jennifer Aniston I want Evil Incarnate.

    • Trixie

      Right there with you. I hit fangirl status right around when he tweeted Jenny McCarthy about his ideal qualities in a mate. https://twitter.com/ObMD/status/444743965431308288

  • Amazed

    Such a pity that the name One-Who-Must-Not-Be-Named is already wasted on mean ol’ “Dr” Amy. Now, the real evil impersonated by real Dr Grunebaum will have to go with the meager Evil Crusader, I guess. I love him.

    Bite me, Missy, Jen, and co. The “homebirth = less safe” trope has found a glorious defender who you cannot compare to where credentials are concerned.

    The more studies come out, the fewer excuses I can find for homebirth mothers being deluded. OK, say, Bambi and Liz had to work with what they had – the Johnson and Daviss joke of a study. But now? Literally every few months a new study comes out and they all point at one direction.

    I never doubted that those APGARS were inflated. Actually, I was stunned at how many people take blue babies as normal. I was in for a new shock when a link in yesterday’s comments made me realize that a mummy-white baby was supposed to also be normal.

    Was it my screen, by the way? I see the baby as chalk-white, as if painted with lime but others see blue or grey.

    • Elizabeth A

      When I first saw the photo, I actually thought the baby part had been processed in black and white for some reason.

      • Amazed

        I am currently working on a book where parts of a woman’s body are found in different locations and one of them was a crude crypt with the quarter covered in quicklime. When I saw the picture, I freaked out!

    • Guesteleh

      No disrespect to Amy, but when you have the head of maternal-fetal medicine at a major academic center sounding warnings about homebirth, it’s a lot harder to dismiss. They can’t call him “Dr” Grunebaum.

      • Amazed

        My point, exactly. Missy is trying, though. She’s a fighter, this one, we have to give her that.

      • Amy Tuteur, MD

        Actually, they are most definitely trying to dismiss him. That’s the whole point of the Cheyney’s rant about a “crusade against homebirth.”

        • The Bofa on the Sofa

          Yeah, that damn Grunebaum is obviously on a crusade against homebirth. He keeps doing those studies and finding out how dangerous it is. He is only doing that because of his bias against homebirth.

          Someone who supported homebirth would never be doing that. They wouldn’t need no stinkin studies.

  • Guesteleh

    I think I’m developing a massive crush on Amos Grunebaum.

  • Elizabeth A

    I like Dr. Grunebaum so much.

    I feel pretty strongly about APGARs, and their limitations. I love that this metric exists. I think it’s important, and a good means of determining absolute standards for comparison. I also think that sometimes NCB in particular reads too much into it – “She was born with an APGAR of 9 and they still whisked her away from me for treatment!” being the most common problematic example. (My daughter was born with APGAR of 9, because APGAR doesn’t subtract points for tachypnea signaling respiratory distress.)

    It’s possible that midwives are, consciously or unconciously, using APGAR not as a measure of neonatal well-being, but as a standard for how much help to call for. The easiest judgment call to make is the one where you ask for no help and don’t have to explain anything to anybody. The second easiest call is when you declare a disaster and ask for all the help. When you ask for just a little help, you start having to exercise judgment, and that gets complicated. And homebirth practitioners are supposed to work with each client individually for as long as it takes, and get macho about long labors, which greatly increases the odds that a midwife will be very tired when making this call.

    (Sort of OT – If you feel gruesome, you can listen to the police channel tape of
    the Marathon Bombing – the officer closest to the incident is given
    control of the channel and begins calling for what seems to have been a
    previously established disaster protocol in which ALL the ambulances are sent,
    ALL the roads are shut down, and so on. It is very good emergency
    planning to make sure that your guys don’t have to think too much if the
    situation gets overwhelming. Comparatively, it is bad emergency
    planning to have the emergency handled by one, probably exhausted,
    person with few resources at her disposal and insufficient extra hands
    to call for help.)

    • The Bofa on the Sofa

      I like Dr. Grunebaum so much

      I’m pissed at him. He never responded to my email. Blew me off, he did!

      • Guesteleh

        What did you email him? I wouldn’t be surprised if he’s ignoring mail from people he doesn’t know simply because of the crazy shit he must be getting from homebirthers.

        • The Bofa on the Sofa

          I asked him for some clarification about what populations he used for comparison in his homebirth deathrate study (the one that found that the death rate for cab drivers was 4 times higher). I was trying to figure out compared to what, because that wasn’t clear in the paper.

          We discussed it here.

          I’ve written a lot of emails to authors over the years asking for these types of clarifications, and have gotten many of them myself, so I know how to ask these things. It was anything but confrontational.

          • Guesteleh

            Maybe you’d get a response from a coauthor? Or can you submit a question to the journal?

  • madwife

    Yep. .. good apgars here

    • Karen in SC

      Taking the pulse of the freakin’ CORD??? What the HELL is that all about?

      • Irène Delse

        It’s scary. Not only that poor baby, but the fact that this website uses the picture as if things were going well there! If this is what “variations of normal” means for them, well… It goes to show what their health advice is worth.

      • NatashaO

        Actually, taking the pulse from the cord is valid. It is a quick way to get the heart rate in the first few minutes of life.

        • Amazed

          But it it an appropriate course of treatment of a newborn who is visibly unwell?

          • NatashaO

            no. that baby needs some help! the pulse just gives us some information about how much.

          • Anj Fabian

            Yes, that’s a good heart rate. Score 2 for that.

        • Anj Fabian

          The caption is apparently meant to be reassuring.
          That’s what I find stunning.

          In addition, if the placenta is supposed to be providing life support and oxygenation at that point (which the trust birthers insist), it’s not doing a very good job of it!

    • Amazed

      They are fucking delusional! I thought mom wanted a baby, not a cord? Wait, we already know that there are moms who want vaginal birth first and foremost.

      • madwife

        Ahhh you gotta read the link I posted. .
        I think as a fellow tuteurite… you’ll recognize the author

        • Amazed

          Ah our resuscitation expert! Even then, her ego was so big, it would hardly fit into that birthing pool.

          Barf.

    • Elizabeth A

      Going by the chart above, that baby should have an APGAR of 5 or lower. He’s limp, with no apparent reflex irritability, and his hands are blue-ish. I would be shocked if he’s making any noise, so possibly more like 3. That kid needs to come out of the pool.

    • Anj Fabian

      My first shock was the image of the baby.
      My second shock was the caption.

      • Hiro

        My first thought was ‘Oh great the baby still has a heartbeat. Now it needs oxygen’

    • Burgundy

      I thought they were measuring core pulsing because the baby was nearly dead and they couldn’t find the baby’s heartbeat. (just a guess from a lay person, I have no idea what’s what when come to birth. Both of my kids were clean and pink by the time I got them)….

    • Young CC Prof

      Wasn’t someone saying the other day that the umbilical cord drains blood OUT of the baby unless the baby is below the placenta? That baby is like a foot straight up from the placenta.

      Also, the baby is OUT, so the placenta is presumably detaching. Oh, wait, I forgot, placentas are magic and nourish the baby all by themselves.

      • Irène Delse

        Indeed. What a time to practice delayed cord clamping, instead of giving the baby real medical attention!

      • madwife

        http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html

        Heres all you need to know about neonatal resus!
        ,no need to thank me. .

        • Hiro

          “Resuscitation of a baby after birth is turned into a huge deal at the hospital…”

          Really? Really?!

          • Siri

            Yep. They panic and stress the baby by placing it on a hard surface to save its life. That baby in the photos would clearly be traumatised by that. And you can tell by the baby’s colour that it is getting plenty of oxygen from the cord. If you need further proof, consider Lisa Barrett’s unblemished record.

            P.s. what component of room air is needed by the baby? Obviously not oxygen; Lisa says it isn’t.

        • Siri

          Well, Lisa should know; she has saved so many babies’ lives over the years.

      • Elaine

        Does it really? With both my babies I got to hold them right away before the cord was cut, and I was holding my son at chest level, above placenta, and the only reason I had to hold my daughter down around my stomach was because her cord was pretty short. And I delivered in hospitals with CNMs, so I would assume they’d know.

        That is one scary picture. Both of mine came out pink & active. I’m glad that bagging the baby while mom is holding it worked so well in that instance. What if it hadn’t? A floppy greyish newborn is a problem you want to throw all your resources at quickly. Also, how often do homebirth providers retrain with NRP, and how often do they practice? I’m technically certified to use a bag-valve mask in CPR (not on neonates, though), but having done it once in CPR class doesn’t mean I’m going to be really awesome at it. And brand-new fresh neonates require a special touch; you’d want someone who really knows what they’re doing, not the homebirth equivalent of someone like me.

        • Young CC Prof

          How often do HB providers train on NRP? A lot less than the baby nurses at a major maternity hospital. Some of them probably re-up once a year.

        • Young CC Prof

          Once the lungs open, the umbilical blood vessels constrict sharply either way. Hence why lotus birth doesn’t usually cause sepsis and/or hypothermia, although it’s still freaking weird.

      • Siri

        I’m 45, and have never had to take a breath, thanks to my lotus-birthed BFF placenta. She pongs a bit, but she gives great oxygen. I keep her in my handbag, along with a pine-scented air freshener.

    • Beth S

      That baby is alive? I know if my child were born looking like this I’d be freaking the heck out because it looks dead.

      • Amazed

        If you want to stay awake tonight, go to the mummified baby from the yesterday post comments. They swear it is alive. The dad’s stupid grinning face haunted me for a while, though. Those idiots didn’t even realize what they were facing.

        • Beth S

          Thanks for the nightmares, I know what I won’t be doing tonight. Which might be a good thing since DH elbowed me in the nose last night and almost broke it. (We’re both restless sleepers, hence our version of co-sleeping is a bassinet by the bed.

    • Captain Obvious

      Apparently the APGARS are over rated and the blood loss is under rated.

      Rixa Freeze…
      “Because I didn’t follow the NRP flowchart to the letter, I was ignorant and uninformed. Never mind that Inga responded almost immediately to the mouth-to-mouth and had an Apgar of 9 or 10 by time she was 2 minutes old.
      Everything turned out fine, but YOU OR THE BABY COULD HAVE DIED! Yes, I could have had a hemorrhage, even though I lost only 10 cc of blood. Yes, the baby could have needed more extensive care, but it didn’t and skilled help was on the way. Yes, I could have had a heart attack or an amniotic fluid embolism. But I didn’t.”

      Inga’s APGARs at 1 minute (7:49-8:49) was a 1! Did she even feel the umb cord for the HR? First little gasp was at 1′ 12″ after birth. A lot of evaluation, warming (loss of body heat evaporation), stimulation, or preceding with PPV could have occurred during that first 1′ 12″. The first half hearted blow by breath wasn’t til 8:46. First gasp by baby was at 9:03, thus 1 minute APGARs of 1. At 9:49, Inga still gasping poorly and coughing. “Unofficial APGARs at 2 minutes”, maybe a 4 or 5. First decent cries at 10:08 of the video, 2 min 19 sec after birth. At 5 minute APGARs appears to be 7 or at best 8.

      http://rixarixa.blogspot.com/2011/03/ingas-birth-story-part-1.html?m=1

      NRP at its best! Wait for a minute, and wait for it, wait for it, come on, come on. Then blow into the face of a depressed baby.

      • Susan

        When I watched her video I look at that hyperextended head and think that baby’s airway is blocked off and that’s the whole reason the baby ends up needing mouth to mouth in the first place. Watch it again and look at how she is holding the baby until she notices something is wrong….curious if others see what I see there.

    • Julia

      Ok, that baby is making me cringe – looks remarkably like the full term stillbirth I was the nurse for last summer (one of those horrible unexplained demises – healthy normal pregnancy, came in because baby isn’t moving as much and no heartbeat – devastating). Ugh. And, in terms of APGARS, after 5 1/2 years of being an L&D nurse, I have given exactly two 10s. And both time, I really couldn’t believe it, because it is so rare for a baby to not still have bluish hands and feet at 5 minutes.

  • NatashaO

    LDRP nurse here. I have assigned APGARs on hundreds of babies… and can’t remember the last time I gave a 10/10 at 5 minutes. Those little hands and feet are still blue tinged at that point! Parents often wonder why their baby is not ‘perfect’ when they ask about the APGARs. I tell them that their baby is perfect, and that a 9/10 at 5 minutes is “perfectly normal”.

  • Burgundy

    I saw a really blue baby pictures from yesterday’s link. I wondered what was his score assigned by the home midwife, 5 or 7?

    • Elizabeth A

      Who could forget that baby. God, poor kid.

      I looked through the story for any indication of midwife-assigned APGAR, and didn’t see one. I’d be shocked if the midwife assigned him less then 7, but unsurprised if a hospital put it as low as 4.

  • Pilo

    I previously worked in a position where I assigned Apgar scores to hospital-born babies. I worked full-time and assisted with the birth of 3-8 babies per shift. I would see a 5 minute Apgar of 10 maybe once every 9-12 months, and that was with a much larger sample size than the practice of any homebirth midwife.

  • fiftyfifty1

    Just like Cold War gymnastics scores.

  • fiftyfifty1

    Homebirth midwives use an APGAR score of 10 to trick mothers into believing that the act of homebirth itself is physiologically better for baby than hospital birth could ever be. I remember my mother remarking happily that while all her hospital babies had been 9, when she birthed at home it was 10.

    • Elizabeth A

      The difference between Apgars of 9 and 10 isn’t meaningful – both indicate a baby that’s doing fine – so I wonder at the extent to which home birth practitioners feel that they need to be really accurate about the difference.

      • fiftyfifty1

        If the difference “isn’t meaningful” why are they inflating it? It’s obviously meaningful to the homebirth midwives. They use it to inflate their averages and fool gullible moms and policy makers.

  • Jocelyn

    Awesome article! I looove all these studies by Dr. Grunebaum.

    Also, one little typo: three paragraphs up from the bottom; “midwives aren’t tell the truth.”

    • Amy Tuteur, MD

      Thanks. Fixed it.

  • Mel

    But, but as long as the magical umbilical cord is attached, the infant HAS to be correctly oxygenated – no matter what our fallible eyes or pulse oximeters says. That’s why we have “other ways of knowing” – like an unquestioning belief in magic.

  • Alice

    I think you’re being unfair here. Dr. Apgar herself states that the person delivering the baby should not assign the score. Therefor the issue is not that the hb midwife is lying or incompetent (while that may be true, its immaterial here), but that the set up is inadequate for accurate scoring as there is not an observer available to record the Apgar score.

    And the fact that women birthing at home do not have adequate resources for medical care is the real issue, so I think your general point still stands.

    • fiftyfifty1

      But the inflated scores at out-of-hospital birth go beyond what Virginia Apgar was warning about. We know that because this inflation of scores is seen in midwife birth centers too where there is almost always more than one attendant. And it’s clear to me that it’s mostly due to lying, not lack of ability to do it, because the effect remains even for homebirth CNMs who certainly do know better. It’s lying, pure and simple.

      • Irène Delse

        Or sometimes, delusion? Many NCB advocates seem to live in a parallel universe of their own design.

        • Anj Fabian

          I sometimes think that CPMs will give a 10 to any baby alive, wriggling and breathing.

          • yugaya

            The thing about any standardized assessment done by a human is that you really need to know the criteria

    • MLE

      It’s incompetent to discard the rules yet again as if they above it all.

  • moto_librarian

    And I’m sure that Missy Cheyney will continue her complaint about Dr. Grunebaum and his “crusade” against homebirth. It’s called research, Missy. You might consider actually doing some for a change.

  • Karen in SC

    Can I get Dr. Grunebaum to be my OB? Oh wait, I’m past menopause….

  • moto_librarian

    The more evidence that comes to light, the less defensible homebirth becomes. Even my younger son who needed a bit of help to get going right after birth (O2 via CPAP, deep suctioning for mec, etc.) NEVER looked as blue or grey as many of the babies I see in homebirth pictures.

    • http://gamesgirlsgods.blogspot.com/ Feminerd

      I don’t know how I looked when I was born, but I had a cord wrapped around my neck and had a 0 for color my mom says. But I cried and wasn’t that floppy … and I still went into an incubator for 10 minutes to make sure everything was okay.