Delivery-room intervention, early neonatal outcomes and risk factors among term infants with a low 5-minute Apgar score: a case–control study in a regional Australian hospital

Objective To examine delivery-room escalation and early neonatal care requirements among term infants with compromised transition at birth, using a 5-minute Apgar score <7 as a pragmatic marker, and to identify associated maternal and intrapartum factors. Design Unmatched case–control study. Setting Regional Australian hospital. Patients Infants born at ≥37 weeks’ gestation from 2018 to 2022. Cases were infants with a 5-minute Apgar score <7 (n=91) and controls were infants with a 5-minute Apgar score ≥7 (n=91). Interventions Clinical interventions and escalation were assessed from medical records. Main outcome measures Delivery-room interventions and escalation (including emergency/code blue activation), admission to special care nursery (SCN) or transfer to tertiary care, and maternal and intrapartum factors associated with Apgar score <7 at 5 minutes. Results Among 4,344 term births, the incidence of 5-minute Apgar score <7 was 2.09%. Resuscitation was required in 91/91 (100%) cases and 37/91 (40.7%) controls; code blue activation occurred in 37/91 (40.7%) cases and 2/91 (2.2%) controls. SCN admission occurred in 74/91 (81.3%) cases; controls were more often managed on the postnatal ward (46/91, 50.5%). Transfer to a tertiary centre occurred in 6/91 (6.6%) cases. In multivariable analysis, caesarean delivery (aOR 2.60, 95% CI 1.21- 5.58), prolonged rupture of membranes (aOR 2.91, 95% CI 1.06 - 0.95) and shoulder dystocia (aOR 9.38, 95% CI 1.07- 82.54) were associated with Apgar score <7. Previous caesarean section (aOR 0.31, 95% CI 0.11- 0.87) and morphine administration prior to delivery (aOR 0.13, 95% CI 0.05- 0.38) were inversely associated. Conclusion In this regional term birth cohort, a 5-minute Apgar score <7 was associated with increased delivery-room escalation and higher likelihood of SCN admission or tertiary transfer.