Apgar
on Birth
Defects

Virginia Apgar, M.D.

For mothers, for fathers, for
grandparents, indeed, for all mem-
bers of every family on earth,
there is no greater gift than that
of a normal, healthy baby. Yet
those of us who spend much of

 

Dr. Apgar is vice president for medical
affairs, The National Foundation-March
of Dimes. She is the creator of the “Apgar
Score” which is now standard procedure
in many hospitals throughout the world.
Made within 60 seconds after birth to
determine a baby’s overall condition, this
vital clinical evaluation serves to alert
physicians to the need for emergency pro-
cedures,

A graduate of the Columbia University
College of Physicians and Surgeons where
she was the first woman physician to hold
a full professorship, she also holds a
master’s degree in public health from the
Johns Hopkins Unwersity. She is the
author of more than 60 publications for
physicians on anesthesiology, resuscitation,
and congenital anomalies,

20

our ume in hospitals or in the
homes of the physically or men-
tally ill know only too well that
every baby is not born healthy.

Many seem condemned from birth
to a life that some believe is worse
than death.

I address this not to those who
hang their heads and think, “How
tragic!” when they see a child with
multiple deformities, but to those
who look such children squarely
in the eye and ask, “What can I
do to help?”

Some kinds of birth defects can
be prevented. Many other condi-
tions which we cannot yet prevent,
we can treat. But before medical
professionals try to prevent or treat
these conditions, they should un-
derstand birth defects are
and what causes them.

Birth defects—those 1,000 or
more disorders that can kill, crip-
ple or retard—are mistakes in body
formation or function that happen
when a baby comes into being.
They may be caused by heredity,
by disease, or by something that
happens to the fetus in the womb.
kach year, in the United States
alone, an estimated 250,000 babies
—one almost every two minutes—

what

come into the world seriously de-
fective in some way. Some of these

conditions are so slight that tha
are but minor inconveniences. Cg
or blindness, for example, usualy
means that the individual canng
tell red from green. On the othg
hand, the baby born with multipy
defects involving many organs ma
die almost at once. Between the
extremes there are many cond]
tions that disable bodies and
minds, such as cleft lip, cle
palate, water on the brain, peng
spine, dwarfism, shortened or Misgg
ing arms, diabetes, cystic fibrosig:
heart defects, mongolism, and Othe
er forms of intellectual impaire
ment.

In absolute numbers, more thay
half a million lives are claimed
each year by birth defects, ome
60,000 deaths among children and
adults annually can be traced to
defective prenatal development,
An estimated 500,000 fetuses a year
are spontaneously aborted or still.
born because of abnormalities.

These appalling statistics ex.
plain why The National Founda
tion-March of Dimes, after organiz-
ing and directing the conquest of
polio, turned its attention and its
research resources to the fight
against birth defects.

What are the causes of birth
defects? Let us begin with a few
points about some of the thing¢
that do not cause birth defects
There is a great deal of supersti-
tion about birth defects that dates
back to antiquity and that even
today has a surprising number of
believers. For example, when a
child was born with a hareli:,, its
mother was often thought to have
been frightened by a rabbit during
pregnancy. Also, the arrival of a
deformed child was sometimes in
God's punishment.
The guilt and shame felt by some
parents of children born with
birth defects has its roots in such
ancient beliefs.

terpreted as

Neither the sudden jumping of
rabbits nor the wrath of an angry
deity causes birth defects. How
ever, we can blame heredity for
about 20 per cent of these dread
conditions. PKU, as an. exe iple,
Is an inborn error of metabvlis@

The Journal of PRACTICAL NURSIN@
quse>. by interference in the en:
onient of the developing fetus.
nfection of the mother by Ger:
gan measles or use of the drug
palidomide during certain stages
of pregnancy are environmental
agents which may have disastrous
eitects on the fetus.

oA combination of environmen-
ral aud hereditary factors working
rogether causes the great majority
of birth defects. The
younger than eighteen or older
than forty runs a greater risk of
giving birth to a baby with a de-

mother

fect than a woman in her twenties
or th-rties. The rate of mongolism,
which is caused by a chromoso-
mal abnormality, increases greatly
among mothers over forty. Just as
some individuals, because of in-
herited sensitivity, are allergic to
environmental things like pollens
and drugs, so the hereditary make-
up of an unborn baby may pre-
dispose him to damage from out-
side imfluences that would not
aflect another baby of different
genetic constitution.

Once we know © something
about the causes of birth defects,
we cin begin to see ways of pre-
ventng these conditions from oc-
curing at all. Birth defects preven-
tion should begin before marriage.
Proper diet, maintaming normal
weight and good hygiene, as every
nurse knows, are conducive not
only to the good health of parents,
but also to that of their potential
offspring.

The couple with a family his-
tory of hereditary abnormality may
want to seek professional counsel-
ing on their risk of having a de-
fective child. Certainly all people
should marrying a
clos: relative is potentially dan-
®erous increases the
chances of bringing together po-
tentially harmful genes. Also, tests

have been developed for spotting

realize that

because it

hereditary carriers of a few disease
traits such as galactosemia, sickle
fell anemia, and the blood de-
ficiency, agammaglobulinemia. It
Bhould be noted that there are tests
tor German measles immunity, and
Within the next few months we

‘DcToBeR, 1968

 

This young victtn, of @ condition which
caused him to be born without arms is
greeted by nurse Sisan Brompass and plrys-

ical therapist Shirley ©. Fisher at the
Birth Defects Cenier associated with the
University of North Carolina School of
Medicine, Chapel Hill

Dr. Apgar in the delivery room >

should have a vaccine to prevent
the kind of tragedy this “mild”
disease can cause when a woman
has it in early pregnancy.

Perhaps the greatest
ment in birth defects prevention
is the Rh vaccine that Is now on

advance-

the market. Rh incompatibility is
a condition which once killed or
10,000
babies born in the United States

caused brain damage in

each year. In recent years about
95 per cent of these babies were
saved at birth by means of ex-
change transfusions, An estimated
40 per cent of stillborn Rh babies
could be saved by new techniques
of transfusion before birth. But,
with the new gamma globulin in-
jections given to Rh_ negative
women within 72 hours after the
birth of their first baby, complete
prevention of the condition is now
possible.

nine months, the
most important thing an expectant
mother has to think about is prop-
er prenatal care. By prenatal care
I mean, generally, what is or is not
done during pregnancy. The first
thing any woman should do when
she even suspects she is pregnant
is to see a doctor. He will advise
her on some of the important
aspects of prenatal care such as
X-rays (low back and pelvic X-ray
pictures are to be avoided); heavy
smoking (studies show that when
the mother smokes excessively, the
baby may weigh less than normal,
and if the baby is born premature-
ly, this difference could affect its

For about

 

survival); and drugs
tant mother should not take any
drugs—including aspirin and pain
killers—without =a
from a doctor who knows she is
pregnant) .

When a baby is born with a
birth defect there is a great deal
professionals can do to

(an expec-

prescription

medical
help. We can control many con-
genital diseases, repair handicap-
ping conditions, or in other ways
restore children to health and a
useful life. One of the keys to
success is the earliest possible de-
tection of the condition and prop-
er treatment. Here are some ex-
amples of what can be done:

Open Spine. Little more than a
decade ago, the child born with
spina bifida, or open spine, was
more often than not the victim of
fatal Today, surgeons
can close and repair the spinal
opening in all but the most severe
cases. Many of these children who
are partially paralyzed below the
waist because of spinal nerve dam-
age need the attention of various
specialists to see through
years of learning to walk with
braces, adapting to special proce-
dures because of loss of bladder
and bowel control, and adjusting
mentally and physically to family,
school, and community life. The
results—victory over handicap—are
as inspiring and gratifying as simi-
lar triumphs by victims of acci-
dents, polio, and other crippling
conditions.

Hydrocephalus. For the victims

infection.

them

21
 

t
ma
)

A nurse at the Birth Defects Center in the Boston City Hospital looks after a “preemie”
in an Isolette. Many preemies are victims of some type of birth defect.

of hydrocephalus, or water on the
brain, special tube devices called
shunts have been developed to
drain excess fluid harmlessly from
the head into other parts of the
body. This life-saving device can
often prevent retardation and ab-
normal skull expansion,

Clubfoot. Babies born with club-
foot twenty or more years ago
more often than not, left
untreated in their early months in
hope that spontaneous Improve-
ment Pediatricians
and orthopedists now know. that

were,

would occur.

the idea of any spontaneous im-
provement in true clubfoot is
wrong—rather, growth and in-
creased weight increase the prob-
lem. Today, doctors treat clubfoot
immediately by forcing the feet
position — thus
stretching the shortened muscles
ind ligaments and aligning the

hones into a more natural relation-

into a normal

22

ship. In the large majority of cases,
casts, braces, and corrective shoes
will correct the condition before
the child is ready to walk. Occa-
sionally, surgery is also needed.

Congenital heart defects. It is
possible to correct many congeni-
tal heart defects so that children
who would otherwise be con-
demned to invalidism and early
death can grow up to lead normal
lives.

Incomplete esophagus, dia-
phragmatic hernia. These and oth-
er once-fatal malformations of in-
ternal organs may now be repaired
within hours after birth by pedi-
atric surgeons.

Genito-urinary defects. Surgeons
have been making great strides in
developing techniques for treating
ureters,
and the whole genito-
urinary system.

Other defects can be treated by

abnormalities in kidneys,
bladders,

special diets to either remove
food substance the body cangj

  
  
    
  

handle or to provide ex

are now being fitted with artifict
limbs almost as soon as they
ready to walk or grasp.

A decade ago many of them,

look for babies born with birth
defects. A great deal of research #

of these complex
Much of it is being conducteg
with government funds; some ig
supported by groups devoted t@&
one or another kind of defec¢ i

The National Foundation
March of Dimes finances a broadg
nationwide program of research i ins
to the causes of birth defects wi
an eye toward both prevention and,
better treatment. Scientists are 08
ploring the nature of the her
tary material, DNA. ‘They
studying cells, chromosomes,
chemistry, body systems, and
numerous problems of diagno
and treatment of specific cond!
tions,

 
 
   
 
    
 
  
   
   
   
   

At the same time it is expanditl
its nationwide network of B

.

which now nuf
bers more than 100, to provid
what we term “the team concep
of treatment for the “total chil

When a baby is born with &
birth detect, his parents need
advice, reassugg

Defects Centers,

most immediate

ance, and perhaps financial °,
The baby ma

necd the kind of care that only.§

other assistance.
number of specialists can provi
This “might involve taking oe
gist to neurosurgeon
pedist. It might mean refe
from physician to physician,
from town to town. ;
. : 2 Ca

A Birth Defect Treatment

The Journal of PRACTICAL NUR
 

bove) Arthrogryposis is a birth defect
t twists and stiffens the arms and legs.
x 3 year-old victim Laura Wagoner,
alhini.s does not come easily. Here she is
ped at the Birth Defects Center asso-
ted with the University of North Caro-
na School of Medicine, Chapel Hill, by
. Loren G. MacKinney.

   
   
 
 
 
   
   
  

ight) Joan Rutten, 6, Falls Church, Va.,
seriously crippled by multiple birth de-
ects. Nurse Mary A. Jackson removes body
set and leg braces prior to check-up
amination at Children’s Hospital of the
istrict of Columbia.

fer provides complete diagnostic

services and the best of care in a
‘single setting. Perhaps as many as

Bcroser, 1968

examine the

16 specialists will

child, evaluate his problems, and
plan about
them. This is the team concept
of medical care.

When we speak of treating the
“total child,” we
interested in more than the medi-
cal aspects of his problem. There
are medical social workers on the
center teams to help the parents
whose problems with a birth de-
fects child do not end when they
leave the clinic. It

what can be done

mean we are

should be

noted, also, that these Birth De-
fects Centers are associated with
medical schools or teaching hospi-
tals. “Feaching medical students
and other professionals to care for
birth defects victims is thus an
integral part of the center pro-
gram.

With the expansion of facilities,
the blossoming of research, the
improvement of medical care, and
the awakening of interest in the
American people, the victim of
birth defects can hope to lead a
relatively normal and useful life
and certainly a life that is well
worth living. Moreover, medical
science is on the threshold of new
discoveries that will lead to the
prevention of many of these dread
conditions. Litthe more than a
decade ago there were relatively
few professionals or private citi-
zens who had any hope for the
victim of birth defects. Today
there is more than hope—there ts

the joy and triumph of progress.

23