Apgar Testing

Definition

Apgar testing is the assessment of the newborn rating color, heart rate, stimulus response, muscle tone, and respirations on a scale of zero to two, for a maximum possible score of 10. It is performed twice, first at one minute and then again at five minutes after birth.

Purpose

Apgar scoring was originally developed in the 1950s by the anesthesiologist Virginia Apgar to assist practitioners attending a birth in deciding whether or not a newborn was in need of resuscitation. Using a scoring method fosters consistency and standardization among different practitioners. A February 2001 study published in the New England Journal of Medicine investigated whether Apgar scoring continues to be relevant. Researchers concluded that "The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago."

Description

The five areas are scored as follows:

• Appearance, or color: 2 if the skin is pink all over; 1 for acrocyanosis, where the trunk and head are pink, but the arms and legs are blue; and 0 if the whole body is blue. Newborns with naturally darker skin color will not be pink. However, pallor is still noticeable, especially in the soles and palms. Color is related to the neonate's ability to oxygenate its body and extremities, and is dependent on heart rate and respirations. A perfectly healthy newborn will often receive a score of 9 because of some blueness in the hands and feet.
• Pulse (heart rate): 2 for a pulse of 100+ beats per minute (bpm); 1 for a pulse below 100 bpm; 0 for no pulse. Heart rate is assessed by listening with a stethoscope to the newborn's heart and counting the number of beats.
• Grimace, or reflex irritability: 2 if the neonate coughs, sneezes, or vigorously cries in response to a stimulus (such as the use of nasal suctioning, stroking the back to assess for spinal abnormalities, or having the foot tapped); 1 for a slight cry or grimace in response to the stimulus; 0 for no response.
• Activity, or muscle tone: 2 for vigorous movements of arms and legs; 1 for some movement; 0 for no movement, limpness.
• Respirations: 2 for visible breathing and crying; 1 for slow, weak, irregular breathing; 0 for apnea, or no breathing. A crying newborn can adequately oxygenate its lungs. Respirations are best assessed by watching the rise and fall of the neonate's abdomen, as infants are diaphragmatic breathers.

The combined first letters in these five areas spell Apgar.

Preparation

No preparation is needed to perform the test. However, while being born the neonate may receive nasal and oral suctioning to remove mucus and amniotic fluid. This may be done when the head of the newborn is safely out, while the mother rests before she continues to push.

Aftercare

Since the test is primarily observational in nature, no aftercare is needed. However, the test may flag the need for immediate intervention or prolonged observation.

Normal results

The maximum possible score is 10, the minimum is zero. It is rare to receive a true 10, as some acrocyanosis in the newborn is considered normal, and therefore not a cause for concern. Most infants score between 7 and 10. These infants are expected to have an excellent outcome. A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance, or perhaps just suctioning if breathing has been obstructed by mucus. While suctioning is being done, a source of oxygen may be placed near, but not over the newborn's nose and mouth. This form of oxygen is referred to as blow-by. A score in the 4-6 range indicates that the neonate is having some difficulty adapting to extrauterine life. This may be due to medications given to the mother during a difficult labor, or at the very end of labor, when these medications have an exaggerated effect on the neonate.

Abnormal results

With a score of 0-3, the newborn is unresponsive, apneic, pale, limp and may not have a pulse. Interventions to resuscitate will begin immediately. The test is repeated at five minutes after birth and both scores are documented. Should the resuscitation effort continue into the five-minute time period, interventions will not stop in order to perform the test. The one-minute score indicates the need for intervention at birth. It addresses survival and prevention of birth-related complications resulting from inadequate oxygen supply. Poor oxygenation may be due to inadequate neurological and/or chemical control of respiration. The five-minute score appears to have a more predictive value for morbidity and normal development, although research studies on this are inconsistent in their conclusions.

DR. VIRGINIA APGAR (1909–1974)

As one of very few female medical students at Columbia University College of Physicians and Surgeons in New York during the early 1930s and one of the first women to graduate from its medical school, Apgar knew that her goal of becoming a surgeon would not be achieved easily in a male-dominated profession. Reluctantly, she switched her medical specialty to anesthesiology, she embraced her new field with typical intelligence and energy. At this time, anesthesiology was a relatively new field, having been left by the doctors mostly to the attention of nurses. Apgar realized immediately how much in need of scientifically trained personnel was this significant part of surgery, and she set out to make anesthesiology a separate medical discipline. By 1937, she had become the fiftieth physician to be certified as an anesthesiologist in the United States. The following year she was appointed director of anesthesiology at the Columbia-Presbyterian Medical Center, becoming the first woman to head a department at that institution.

As the attending anesthesiologist who assisted in the delivery of thousands of babies during these years, Apgar realized that infants had died from respiratory or circulatory complications that early treatment could have prevented. Apgar decided to bring her considerable research skills to this childbirth dilemma, and her careful study resulted in her publication of the Apgar Score System in 1952.

KEY TERMS

Acrocyanosis— A slight cyanosis, or blueness of the hands and feet of the neonate is considered normal. This impaired ability to fully oxygenate the extremities is due to an immature circulatory system which is still in flux.

Amniotic fluid— The protective bag of fluid that surrounds the fetus while growing in the uterus.

Neonate— A term referring to the newborn infant, from birth until one month of age.

Neonatologist— A physician who specializes in problems of newborn infants.

Pallor— Extreme paleness in the color of the skin.

Resources

BOOKS

Feinbloom, Richard I. Pregnancy, Birth and the Early Months. Cambridge, MA: Perseus Publishing, 2000.

Pillitteri, Adele. Maternal & Child Nursing; Care ofthe Childbearing and Childrearing Family. 3rd ed. Philadelphia: Lippincott, 1999.

PERIODICALS

Casey, B. M., D. D. McIntire, and K. J. Leveno. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants". New England Journal of Medicine 344 (February 15, 2000): 467-71.

OTHER

Apgar, Virginia. A Proposal for a New Method of Evaluation of the Newborn Infant. 〈http://www.apgarfamily.com/Apgar_Paper.html〉.

The National Childbirth Trust. 〈http://www.nctpregnancyandbabycare.com〉.

PregnancyWeekly.com 〈http://www.pregnancyweekly.com〉.

Apgar testing

Definition

The Apgar scoring system evaluates the physical condition of the newborn at one minute after birth and again at five minutes after birth. The newborn receives a total score (Apgar score) that ranges from 0 to 10 based on rating color, heart rate, respiratory effort, muscle tone, and reflex irritability.

Purpose

Virginia Apgar specialized in anesthesiology and childbirth . She developed the Newborn Scoring System, later called the Apgar score, in 1949 for practitioners to use in deciding whether or not a newborn needed resuscitation. This score provides a uniform method of observation and evaluation of a newborn infant's need for resuscitation immediately after delivery at one minute and again at five minutes. The score is significant because one person in the delivery room evaluates the infant using five signs in an objective, standard and measurable manner. Research published in The New England Journal of Medicine in 2001 concluded that the Apgar scoring system remains as relevant for the prediction of neonatal survival in the early 2000s as it was in 1949.

Description

Five factors are considered in the evaluation of a newborn and the word Apgar can be used as a mnemonic to remember them, i.e., A = Activity (or muscle tone); P = Pulse; G = Grimace (or reflexes to stimuli); A = Appearance (or skin color), and R = Respiration. Scores are given as follows:

• Activity: Limpness, no movement at all = 0; some flexion of the limbs = 1; active movement, vigorous movements of arms and legs = 2.
• Pulse: No pulse = 0; pulse below 100 beats per minute (bpm) = 1; pulse over 100 per minute = 2. This is the most important assessment and can be determined by auscultation with a stethoscope or palpation at the junction of the umbilical cord and skin. A newborn heart rate of less than 100 bpm indicates the need for immediate resuscitation.
• Grimace: No response to stimuli = 0; some response, a slight cry or grimace = 1; active response, coughing, sneezing, or vigorously crying = 2. The stimuli used to evoke a response can be the use of nasal suctioning, stroking the back to assess for spinal abnormalities, having the foot tapped.
• Appearance: The whole body is blue, gray, or very pale = 0; acrocyanosis, i.e., trunk and head have a pink skin color and hands and feet are blue = 1; pink all over = 2. Newborns with naturally darker skin color will not be pink, but pallor is still noticeable and especially in the soles of the feet and palms of the hands. Skin color is related to the newborn's ability to oxygenate its body and extremities and is dependent on heart rate and respirations.
• Respiration: No breathing, apnea = 0; slow and irregular respiration = 1; good regular respiration, especially accompanied by crying = 2. Respirations are best assessed by watching the rise and fall of the neonate's abdomen since infants are diaphragmatic breathers.

Preparation

Essentially no preparation is needed to determine an Apgar score. Clinicians have suctioning equipment available and may use it during the birth process for nasal and oral suctioning to remove mucus and amniotic fluid. This is usually performed when the head of the newborn is safely delivered while the mother rests for her final push. The Apgar score should not be performed by the individual doing the delivery, but by the labor and delivery nurse or nursery nurse.

Aftercare

The Apgar score is primarily observational in nature and its only purpose is to alert the healthcare provider that the baby may need immediate assistance or prolonged observation in the nursery. It provides a means of monitoring the effectiveness of interventions and a process of determining which interventions are valuable.

Normal results

It is important to note that an Apgar score is strictly used to determine a newborn's immediate condition at birth and that it does not necessarily reflect the future health of a baby. The maximum obtainable score is 10 and the minimum is zero. It is quite rare to receive a true 10 as some acrocyanosis is considered normal and not a cause for concern. A score of 7 to 10 is considered normal, and these infants are expected to have an excellent outcome. A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance or in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen referred to as "blow-by" may be placed near but not directly over the nose and mouth of the neonate during suctioning. A score in the 4–6 range indicates that the neonate is having difficulty adapting to extrauterine life, which in some cases may be related to medications given to the mother during labor, prematurity , or a rapid delivery.

A low Apgar score provides a warning signal that the baby may have hidden health problems, such as breathing difficulties or internal bleeding. With a score of 0–3, the newborn is unresponsive, pale, limp, and may not have a pulse; therefore, an infant with a score of 0—3 needs immediate resuscitation. An ongoing evaluation is continued during resuscitation and documented again at five minutes. In the event of a difficult resuscitation, the Apgar score is done at 10, 15, and 20 minutes as well. A newborn with an Apgar score in this range generally requires advanced medical care and emergency measures, such as assisted breathing, administration of fluids or medications, and observation in a neonatal intensive care unit (NICU) by a neonatologist. An Apgar score of 0–3 at 20 minutes of age, for example, is indicative of high rates of morbidity (disease) and mortality (death).

Risks

There are no risks involved with the Apgar scoring process. It is an evaluation of the baby at birth to determine if any resuscitation procedures are needed.

KEY TERMS

Acrocyanosis —A condition characterized by blueness, coldness, and sweating of the extremities. A slight cyanosis, or blueness, of the hands and feet of the neonate is considered normal. This impaired ability to fully oxygenate the extremities is due to an immature circulatory system which is still in flux.

Amniotic fluid —The liquid in the amniotic sac that cushions the fetus and regulates temperature in the placental environment. Amniotic fluid also contains fetal cells.

Apnea —The temporary absence of breathing. Sleep apnea consists of repeated episodes of temporary suspension of breathing during sleep.

Extrauterine —Occurring outside the uterus.

Neonate —A newborn infant, from birth until 28 days of age.

Neonatologist —A physician (pediatrician) who has special training in the care of newborn infants.

Pallor —Extreme paleness in the color of the skin.

Parental concerns

Parental concerns may be addressed if the Apgar score is low at five minutes and then again at 10 minutes. The healthcare provider should address the possible risks associated with a low score and advise the parents as to follow-up care. A persistently low Apgar score could indicate neurological problems and the parents would want to obtain additional treatment for the baby to ensure appropriate development. Children with cerebral palsy often have neurological damage at birth and the use of physical therapy or speech therapy enhances their outcome.

Resources

BOOKS

Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Tappero, Ellen, and Mary Honeyfield. Physical Assessment of the Newborn, 3rd ed. Santa Rosa, CA: NICU Ink Book Publishers, 2003.

PERIODICALS

Casey, B. M., et al. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants." New England Journal of Medicine 334 (February 15, 2000): 467–71.

ORGANIZATIONS

Association of Women's Health, Obstetric, and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: <www.awhonn.org>.

National Association of Neonatal Nurses. 4700 W. Lake Avenue, Glenview, IL 60025–1485. Web site: <www.nann.org>.

WEB SITES

"APGAR Scoring for Newborns." Available online at <www.childbirth.org/articles/apgar.html> (accessed November 28, 2004).

"What is the Apgar Score?" KidsHealth. Available online at <http://kidshealth.org/parent/pregnancy_newborn/medical_care/apgar.html> (accessed November 28, 2004).

Linda K. Bennington, RNC, MSN, CNS

Apgar Testing

Definition

Apgar testing is the assessment of the neonate rating color, heart rate, stimulus response, muscle tone, and respirations on a scale of zero to two, for a maximum possible score of 10. It is performed twice, first at one minute and then again at five minutes after birth.

Purpose

Apgar scoring was originally developed in the 1950s by the anesthesiologist Virginia Apgar to assist practitioners attending a birth in deciding whether or not a newborn was in need of resuscitation. Using a scoring method fosters consistency and standardization among different practitioners.

Precautions

When the neonate needs immediate intervention or resuscitation, time is not taken away from these actions in order to perform the test. The interventions (such as suctioning to remove mucus and thereby improve breathing) are begun, while simultaneously noting the scoring of the five specific areas.

Description

The five areas are scored as follows:

• Appearance, or color: 2 if the skin is pink all over; 1 for acrocyanosis, where the trunk and head are pink, but the arms and legs are blue; and 0 if the whole body is blue. Newborns with naturally darker skin color will not be pink. However, pallor is still noticeable, especially in the soles and palms. Color is related to the neonate's ability to oxygenate its body and extremities, and is dependent on heart rate and respirations. A perfectly healthy newborn will often receive a score of 9 because of some blueness in the hands and feet.
• Pulse (heart rate): 2 for a pulse of 100+ beats per minute (bpm); 1 for a pulse below 100 bpm; 0 for no pulse. Heart rate is assessed by listening with a stethoscope to the newborn's heart and counting the number of beats.
• Grimace, or reflex irritability: 2 if the neonate coughs, sneezes, or vigorously cries in response to a stimulus (such as the use of nasal suctioning, stroking the back to assess for spinal abnormalities, or having the foot tapped); 1 for a slight cry or grimace in response to the stimulus; 0 for no response.
• Activity, or muscle tone: 2 for vigorous movements of arms and legs; 1 for some movement; 0 for no movement, limpness.
• Respirations: 2 for visible breathing and crying; 1 for slow, weak, irregular breathing; 0 for apnea, or no breathing. A crying newborn can adequately oxygenate its lungs. Respirations are best assessed by watching the rise and fall of the neonate's abdomen, as infants are diaphragmatic breathers.

The combined first letters in these five areas spell Apgar.

Preparation

No preparation is needed to perform the test. However, while being born the neonate may receive nasal and oral suctioning to remove mucus and amniotic fluid. This may be done when the head of the newborn is safely out, while the mother rests before she continues to push.

Aftercare

Since the test is primarily observational in nature, no aftercare is needed. However, the test may flag the need for immediate intervention or prolonged observation.

Complications

There are no complications from the test itself, just the possible complications if intervention is required but not initiated.

Results

The maximum possible score is 10, the minimum is zero. It is rare to receive a true 10, as some acrocyanosis in the neonate is considered normal, and therefore not a cause for concern. Most infants score between 7 and 10. These infants are expected to have an excellent outcome. A score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance, or perhaps just suctioning if breathing has been obstructed by mucus. While suctioning is being done, a source of oxygen may be placed near, but not over the newborn's nose and mouth. This form of oxygen is referred to as "blowby." A score in the 4-6 range indicates that the neonate is having some difficulty adapting to extrauterine life. This may be due to medications given to the mother during a difficult labor, or at the very end of labor, when these medications have an exaggerated effect on the neonate. With a score of 0-3 the neonate is unresponsive, apneic, pale, limp and may not have a pulse. Interventions to resuscitate will begin immediately. The test is repeated at 5 minutes after birth and both scores are documented. Should the resuscitation effort continue into the five-minute time period, interventions will not stop in order to perform the test. The one-minute score indicates the need for intervention at birth. It addresses survival and prevention of birth-related complications resulting from inadequate oxygen supply. Poor oxygenation may be due to inadequate neurological and/or chemical control of respiration. The five-minute score appears to have a more predictive value for morbidity and normal development, although research studies on this are inconsistent in their conclusions.

A February 2001 study published in the New England Journal of Medicine investigated whether Apgar scoring continues to be relevant. Researchers concluded that "The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago."

Health care team roles

In an uncomplicated delivery, the attending labor and delivery nurse, the obstetrician, or the midwife usually performs the test. If a problem birth has been anticipated, there may be a nurse from the neonatal intensive care unit or a neonatologist in attendance at the birth. One or all of these individuals may make a mental score and provide input regarding their observations, if there appears to be a discrepancy in the score to be noted on the official delivery and nursery forms.

The first question asked by new parents after the birth of their child is usually "Is s/he all right?". Reassuring the parents is an important nursing role. Explaining to new parents what is being done to their newborn keeps them informed, without interfering with the nurse's actions. The brief time spent suctioning and stimulating the neonate to take its first breath can seem like an eternity to the waiting parent, especially for the first-time parent for whom all this is a new experience. The ability to attend to the neonate's needs while simultaneously addressing the parents' needs becomes smoother as the nurse gains experience.

KEY TERMS

Acrocyanosis— A slight cyanosis, or blueness of the hands and feet of the neonate is considered normal. This impaired ability to fully oxygenate the extremities is due to an immature circulatory system which is still in flux.

Amniotic fluid— The protective bag of fluid that surrounds the fetus while growing in the uterus.

Neonate— A term referring to the newborn infant, from birth until one month of age.

Neonatologist— A physician who specializes in problems of newborn infants.

Pallor— Extreme paleness in the color of the skin.

Resources

BOOKS

Doenges, Marilynn E., and Mary Frances Moorhouse. Maternal/Newborn Plans of Care; Guidelines for Individualizing Care. 3rd Edition. New York: F. A. Davis Company, 1999.

Feinbloom, Richard I. Pregnancy, Birth and the Early Months. Cambridge, MA: Perseus Publishing, 2000.

Pillitteri, Adele. Maternal & Child Nursing; Care of the Childbearing and Childrearing Family. 3rd Edition. Philadelphia: Lippincott, 1999.

Spencer, Paula. Parenting: Guide to Pregnancy and Childbirth. New York: Ballantine Books, 1998.

PERIODICALS

Casey, B. M., D. D. McIntire, and K. J. Leveno. "The Continuing Value of Apgar Score for the Assessment of Newborn Infants." New England Journal of Medicine 344 (February 15, 2000): 467-71.

OTHER

Apgar, Virginia. A Proposal for a New Method of Evaluation of the Newborn Infant. 〈http://www.apgarfamily.com/Apgar_Paper.html〉.

The National Childbirth Trust. 〈http://www.nctpregnancyandbabycare.com〉.

PregnancyWeekly.com. 〈http://www.pregnancyweekly.com〉.

Apgar score

The Apgar Score is a rating system used to evaluate the health of newborn infants. The test is administered one minute after birth and again five minutes after birth. A rating of zero, one, or two is given in each of these five categories: color, breathing, heart rate (pulse), muscle tone, and response to stimulation. A total score of three or lower is a signal that the baby's condition is critical and requires immediate attention. A score of seven or higher means that the baby's initial vital statistics are good. Studies of the extended Apgar Score (the five-minute recheck) have shown the test to be a fairly reliable indicator that the subject infant has a good chance for survival. Because the Apgar Score does not check for all possible complications (such as chromosonal damage), however, a high number does not guarantee that a child's long-term outlook is completely positive.

Apgar Develops System

Until the early 1950s, physicians had no reliable way to assess the health of newborns in the critical first minutes of life. Because of delays in diagnosis, conditions that might have been corrected sometimes proved fatal. In 1952 Virginia Apgar (1909-1974), a physician at the Columbia-Presbyterian Medical Center in New York City, developed a scoring system that became the standard tool for evaluation of newborns. Apgar was one of the first female graduates of Columbia University's College of Physicians and Surgeons; she was also the first woman ever to hold a full professorship at the college. She invented her scoring system after years of studying the effects of anesthesia in childbirth.

Apgar Scoring

The Apgar Score has five important components, each with its own set of acceptable standards. The individual categories and their ranges are listed below:

• Color: A baby who possesses a healthy pink skin tone receives two points, while a pale or bluish infant receives zero points. Most newborns have pink bodies and lips but bluish hands and feet. This coloring receives one point. An all-over bluish color can mean the baby has problems with his heart or lungs, has something blocking his airway, or has inhaled amniotic fluid.
• Breathing: A newborn should gasp and begin to breathe at birth. Regular breathing gets a score of two, while irregular breathing gets a score of one. A score of zero is given to a newborn who makes no effort to breathe. Irregular breathing can mean the infant lacks oxygen in his body, has an infection, has central nervous system damage, or has a depressed respiratory drive because of anesthesia given the mother during birth.
• Pulse: The normal heart rate at birth is between 120 and 160 beats per minute. A newborn with no detectable heartbeat is scored at zero; a heart rate of less than 100 beats per minute is scored one, and a two is given for a heart rate of 100 beats per minute or more.
• Muscle tone: An infant should move his arms and legs at birth. Limpness or poor muscle tone are usually caused by lack of oxygen, central nervous system trauma, or drugs given the mother during birth. A limp newborn is scored at zero. Some movement gets a score of one, and active movement gets a score of two.
• Response to stimulation: A newborn is stimulated at birth by inserting a tube through a nostril into the throat. This should cause the infant to grimace, cough, or sneeze. If he does not respond he is scored at zero; a grimace alone gets a one, and a grimace with a cough or sneeze is scored at two.

The highest possible total Apgar Score is ten. It is not unusual for infants to score a seven at one minute of age and nine or ten at five minutes of age. By this later time, babies generally have a healthier skin tone and are breathing better. With information provided by the Apgar Score, medical personnel can take immediate measures if needed to assure a new-born's survival.

Apgar score

The Apgar score is the assessment of a newborn baby’s physical condition that was established by Dr. Virginia Apgar. The score is based on skin color, heart rate, response to stimulation, muscle tone, and respiratory effort. Apgar has become an acronym for Appearance, Pulse, Grimace, Activity, and Respiration.

Each criteria of the Apgar score is rated from zero to two with a total score of 10 signifying the best possible physical condition. The assessment determines the need for immediate emergency treatment, helps prevent unnecessary emergency intervention, and indicates possible brain damage. Because the score corresponds closely to an infant’s life expectancy, it is used as a guideline to advise parents on their baby’s chances of survival.

A newborns’ appearance scores two if the baby’s skin is a healthy tone such as pink; one if extremities are bluish; and zero if the entire body is blue. Pulse (heart rate) scores two for higher than 100 per minute; one for below 100; and zero if absent. Grimace scores two for an energetic cry (with or without the traditional slap on the bottom or soles of the feet); one for a slight wail; and zero for no response. Actively moving babies score two for muscle tone; one for some effort at movement; and zero if limp. Respiration scores two for strong efforts to breathe; one for irregular breathing; and zero for no effort. With a total five-minute score of seven to 10, the infant’s chances of surviving the first month are almost 100%, approximately 80% with a score of four, and 50% with a score of zero to one.

Dr. Apgar published her scoring system in 1953 during her tenure as professor of anesthesiology at Columbia-Presbyterian Medical Center, New York, where she was involved in the birth of more than 17,000 babies. She observed the need for a quick, accurate, scientific evaluation of the newborn, primarily to aid in diagnosing asphyxiation (suffocation) and to determine the need for resuscitation (aided breathing). The evaluations, which were made and recorded one, five, and ten minutes after birth, quickly became the global standard by which the health of the newborn infant was measured and, despite contentions that diagnostic and treatment advancements have made the Apgar evaluation outmoded, it remains a standard practice.