Use of Suctioning during Newborn Resuscitation and Its Effects on Heart Rate in a Low-Resource Setting, Tanzania.

Suctioning of newborns immediately after birth, as part of delivery room resuscitation, is only recommended if the airway is obstructed. The aim of this study was to describe the use of suctioning during newborn resuscitation among survivors versus those who died within 3 days and potential suction-related heart rate responses and associations to newborn characteristics. This was a retrospective observational study from July 2013 to July 2016 in a referral hospital in rural Tanzania. Research assistants observed and documented all deliveries, newborn resuscitations were video-recorded, and newborn heart rates were captured with a dry-electrode electrocardiogram. Liveborn infants ≥34 weeks gestation who received ventilation and with complete datasets were eligible. All 30 newborns who died were included, and a total of 46 survivors were selected as controls. Videos were annotated and heart rate patterns were observed before and after the suction events. Suctioning was performed more frequently than recommended. No differences were found in suctioning characteristics between newborns who died versus those who survived. In 13% of suction events, a significant heart rate change (i.e., arrhythmia or brief/sustained >15% fall in heart rate) was observed in relation to suctioning. This represents a potential additional harm to already depressed newborns undergoing resuscitation.

Delayed and Interrupted Ventilation with Excess Suctioning after Helping Babies Breathe with Congolese Birth Attendants.

There is a substantial gap in our understanding of resuscitation practices following Helping Babies Breathe (HBB) training. We sought to address this gap through an analysis of observed resuscitations following HBB 2nd edition training in the Democratic Republic of the Congo. This is a secondary analysis of a clinical trial evaluating the effect of resuscitation training and electronic heart rate monitoring on stillbirths. We included in-born, liveborn neonates ≥28 weeks gestation whose resuscitation care was directly observed and documented. For the 2592 births observed, providers dried/stimulated before suctioning in 97% of cases and suctioned before ventilating in 100%. Only 19.7% of newborns not breathing well by 60 s (s) after birth ever received ventilation. Providers initiated ventilation at a median 347 s (>five minutes) after birth; no cases were initiated within the Golden Minute. During 81 resuscitations involving ventilation, stimulation and suction both delayed and interrupted ventilation with a median 132 s spent drying/stimulating and 98 s suctioning. This study demonstrates that HBB-trained providers followed the correct order of resuscitation steps. Providers frequently failed to initiate ventilation. When ventilation was initiated, it was delayed and interrupted by stimulation and suctioning. Innovative strategies targeting early and continuous ventilation are needed to maximize the impact of HBB.

Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings.

Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of "local motivators" in a rural Tanzanian hospital with 4000-5000 deliveries annually. Midwives (n = 15-27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as "well done" feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance.

Effect of resuscitation training and implementation of continuous electronic heart rate monitoring on identification of stillbirth.

AIM: To evaluate the effect of resuscitation training and continuous electronic heart rate (HR) monitoring of non-breathing newborns on identification of stillbirth. METHODS: We conducted a pre-post interventional trial in three health facilities in the Democratic Republic of the Congo. We collected data on a retrospective control group of newborns that reflected usual resuscitation practice (Epoch 1). In the prospective, interventional group, skilled birth attendants received resuscitation training in Helping Babies Breathe and implemented continuous electronic HR monitoring of non-breathing newborns (Epoch 2). Our primary outcome was the incidence of stillbirth with secondary outcomes of fresh or macerated stillbirth, neonatal death before discharge and perinatal death. Among a subset, we conducted expert review of electronic HR data to estimate misclassification of stillbirth in Epoch 2. We used a generalized estimating equation, adjusted for variation within-facility, to compare risks between EPOCHs. RESULTS: There was no change in total stillbirths following resuscitation training and continuous electronic HR monitoring of non-breathing newborns (aRR 1.15 [0.95, 1.39]). We observed an increased rate of macerated stillbirth (aRR 1.58 [1.24, 2.02]), death before discharge (aRR 3.31 [2.41, 4.54]), and perinatal death (aRR 1.61 [1.38, 1.89]) during the intervention period. In expert review, 20% of newborns with electronic HR data that were classified by SBAs as stillborn were liveborn. CONCLUSION: Resuscitation training and use of continuous electronic HR monitoring did not reduce stillbirths nor eliminate misclassification.

Improving Newborn Resuscitation by Making Every Birth a Learning Event.

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

Automatic identification of stimulation activities during newborn resuscitation using ECG and accelerometer signals.

BACKGROUND AND OBJECTIVE: Early neonatal death is a worldwide challenge with 1 million newborn deaths every year. The primary cause of these deaths are complications during labour and birth asphyxia. The majority of these newborns could have been saved with adequate resuscitation at birth. Newborn resuscitation guidelines recommend immediate drying, stimulation, suctioning if indicated, and ventilation of non-breathing newborns. A system that will automatically detect and extract time periods where different resuscitation activities are performed, would be highly beneficial to evaluate what resuscitation activities that are improving the state of the newborn, and if current guidelines are good and if they are followed. The potential effects of especially stimulation are not very well documented as it has been difficult to investigate through observations. In this paper the main objective is to identify stimulation activities, regardless if the state of the newborn is changed or not, and produce timelines of the resuscitation episode with the identified stimulations. METHODS: Data is collected by utilizing a new heart rate device, NeoBeat, with dry-electrode ECG and accelerometer sensors placed on the abdomen of the newborn. We propose a method, NBstim, based on time domain and frequency domain features from the accelerometer signals and ECG signals from NeoBeat, to detect time periods of stimulation. NBstim use causal features from a gliding window of the signals, thus it can potentially be used in future realtime systems. A high performing feature subset is found using feature selection. System performance is computed using a leave-one-out cross-validation and compared with manual annotations. RESULTS: The system achieves an overall accuracy of 90.3% when identifying regions with stimulation activities. CONCLUSION: The performance indicates that the proposed NBstim, used with signals from the NeoBeat can be used to determine when stimulation is performed. The provided activity timelines, in combination with the status of the newborn, for example the heart rate, at different time points, can be studied further to investigate both the time spent and the effect of different newborn resuscitation parameters.