February 25, 1966
Dear Doctor Poch:
Do I not remember you as an outstanding student in the anesthesia elective?
I think I can settle your battle.  Recently I have been reviewing the records of several hospitals who have been using the scoring system for years.  I am appalled at the scores given by obstetricians to the babies they deliver.  The scores are much too high.  The same is true of those given by midwives in Finland, who gave 83% of their babies a score of 10!
Ideally, I think the order of persons assigning the score is 1) a pediatrician (hardly ever present for the actual delivery), 2) anesthesiologist or nurse anesthetist (if there is one), 3) circulating nurse.  These nurses are excellent, with much experience and no personal involvement with that particular baby.
The exact timing for assigning the sore is 60 seconds after both head and feet are visible.  Of course if resuscitation is obviously needed, as with a nonpulsating prolapsed cord, one does not wait at all, let alone 60 seconds, to start ventilation.  The most convenient way to keep track of the 60 seconds is to have a small shelf built, on to which is screwed an automatic time setter.  Have it set for 55 seconds.  The nurse starts the timing as soon as both the top of the head and soles of the feet are visible.  Fifty-five seconds later a bell goes off.  The score can be decided in 5 seconds, and recorded.  All babies with scores of 4 or under need artificial ventilation in my opinion.  Only a few need endotracheal tube -- 1% at Sloane.
If you have other questions, please let me know.  Best wishes.
Sincerely yours,
Virginia Apgar, M.D., M.P.H.
Director, Division of Congenital Malformations