Inter-Observer Variability of the Apgar Score of Preterm Infants between Neonatologists, Obstetricians and Midwives

Objective To assess the inter-observer variability of the Apgar Score (AS) across various perinatal Health Care Providers (HCP) taking care of newly born premature infants in the delivery room. Methods Design: Prospective observational study. Setting: 4 general hospitals and 3 university hospitals in Switzerland. Subjects: 43 neonatologists, 68 obstetricians and 55 midwives assessed the AS from 15 video sequences showing delivery room stabilisations or resuscitations of 15 preterm infants born below 34 0/7 weeks gestational age. Results Overall and for all observers, the mean inter-observer variability was low (ICC 0.72). There was a significant difference between the professions (p < 0.001) and hospitals (p < 0.001). The AS assigned by neonatologists for this group of preterm infants were significantly higher than the scores given by midwifes (p = 0.001). The scores assigned by obstetricians were the lowest for all infants; the difference from neonatologists being -0.53 (pairwise comparison). There was no significant difference between the AS assessed by professionals working in university hospitals compared to HCPs from general hospitals (p = 0.86). For all observers and in the majority of the sequences, heart rate showed the lowest and skin colour the highest standard deviation. Conclusion Our study revealed a relatively high inter-observer agreement in assessing the AS for premature infants among all perinatal health care professionals for the whole group of infants. A significant difference however was seen between the AS given by the different perinatal professional groups and between hospitals. A clearer definition and assessment method of each Apgar parameter in the setting of infants born premature and of resuscitation measures are needed. This may contribute to reduce the variations between professionals and hospitals, and to increase the value of this scoring within national and international databases to describe study populations for research, for benchmarking in neonatal intensive care and for comparison of outcome data.