JOG“ LETTERS

Second Stage of Labor

I was delighted with the compre- hensive article “A Second Look a t the Second Stage of Labor” (June 1996 JOGNN). I forwarded it among the medical and nursing staff members. It was well refer- enced and logical.

I have been an obstetric nurse and childbirth educator for most of my 30-year nursing career and have seen many changes. It has always been my goal to help women labor in an active model with nonphar- macologic means of pain control used before pharmacologic ones. It seems that just by being up and about, women in labor feel stronger and more in control. This article reinforced many of the prin- ciples I have felt strongly about and expanded on them.

Thank you for this excellent article.

Janice Wood RNC, IBCLC Bremen, M E

I read with much interest “A Second Look at the Second Stage of Labor” (June 1996JOGNN). I was especially pleased to read that the authors think as I do, that each woman must be re- spected as a unique individual, and that the second stage is not nearly as unvarying as was once thought.

Marion J. Kerns, MS, RN MaternaKhild Clinical Instructor University of Maryland Baltimore, M D

Apgar Score

In Understanding the Apgar Score (May 1996 JOGNN) the author pro- poses that pulse oximetry and/or elec- trocardiogram (ECG) may be benefi-

cial in assessing color in the newborn. In this day of more family-friendly delivery rooms, it seems impractical to slap a pulse oximeter on a new- born at birth. In the delivery room, 1 minute passes by quickly, and not many parents would want the nurse to step in and attach a machine to the newborn whom they are trying to welcome into the world. I work in a high-risk hospital, and though it may be possible to do this to newborns in distress, healthy newborns are placed on the mother’s stomach. The parents hold their newborns, who are dried there. I don’t think the staff would consider it practical to attach an ECG or a pulse oximeter to a newborn in distress because of the delay it would cause in resuscitative efforts.

When discussing the nurse’s role, the author writes, “Labor and deliv- ery staff. . . can educate expectant parents about the purpose of the scoring system (i.e., to guide the re- suscitative efforts of delivery room personnel).” Apgar scores never are used to guide resuscitative efforts! The first step in resuscitation is dry- ing, and that should take only a few seconds. Drying is followed by as- sessment and then intervention. All this happens well before 1 minute has passed, when the first Apgar score is assigned.

Parents who attend childbirth classes frequently ask what the Ap- gar score is and follow their question with, “not that I really know what that means.” What the Apgar score means to delivery room staff mem- bers is a rapid, all-inclusive state- ment of how the baby did a t deliv- ery, so that when looking back, there is a summary of your evaluation, not an evaluation to guide future events.

Cynthia Hodgins, RN Round Rock, TX

Author’s Response

I hope the following is helpful in clarifying my suggestion of using pulse oximetry in quantifying the color determination of the Apgar score.

Apgar scores are part of the per- manent medical record. Often when the birth outcome is questioned, the Apgar scores are cited as evidence of the newborn’s condition in the im- mediate neonatal period. Hence, it is imperative that Apgar scores be as- signed accurately, with the minimum of subjectivity. As I mentioned in my article, “the ability of the nursing profession as a whole to assign Ap- gar scores correctly is low.” I hope the nursing profession will embrace research to refine an assessment tool, helping to remove subjectivity.

I am not suggesting the use of pulse oximetry to quantify the color component of the Apgar score with- out undertaking the necessary re- search to demonstrate its usefulness. Practice must be evidence-based, and perhaps through such research, the reader’s concerns about parents’ at- titudes to applying an oximeter sen- sor to the newborn immediately after birth could be systematically exam- ined. To quantify saturation ranges with an Apgar color component score of 0, 1, or 2, it is necessary to include “normal” newborns in the research. This would mean applying an oximetry sensor as the attach- ment process is beginning. However, this would not be done without first obtaining informed consent.

Further, my suggestion to use an ECG was not for the assessment of color. Rather, I pointed out that syn- chronization of a pulse oximeter with the ECG may help to minimize some of the technical difficulties as-

JanuarylFebruary 1997 JOGNN 25