Feasibility of pulse oximetry for assessment of infants born in community based midwifery care.

OBJECTIVE: to evaluate the feasibility of using pulse oximetry (PO) for evaluating infants born in community-based midwifery care. DESIGN: a prospective, observational study of infants born after midwifery supervised (home) births. SETTING: 27 midwives from seven practices providing primary care in (home) births used PO at birth or the early puerperal period over a ten-month period. Data were obtained on the effect of PO on outcome, interventions and decision-making. Midwives were surveyed about applicability and usefulness of PO. PARTICIPANTS: 153 infants born in primary midwifery care. FINDINGS: all births were uncomplicated except for one infant receiving supplemental oxygen and another was mask ventilated. In 138/153 (90%) infants PO was successfully used and 88% of midwives found PO easy to use. In 148/153 (97%) infants PO did not influence midwives' clinical judgment and referral policy. In 5/153 (3%) infants, midwives were uncertain of the infant's condition, but PO measurements were reassuring. In case of suboptimal neonatal condition or resuscitation, 100% of midwives declared they would use PO again. KEY CONCLUSIONS: it is feasible to use PO in community based midwifery care, but not considered an important contribution to routine evaluation of infants. Midwives would like to have PO available during suboptimal neonatal condition or when resuscitation is required. IMPLICATIONS FOR PRACTICE: PO can be applied in community based midwifery care; it does not lead to insecurity or extra referral. Further research on a larger group of infants must show the effect of PO on neonatal outcomes.

Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation.

AIM: Clinical assessment and end-tidal CO(2) (ETCO(2)) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO(2) detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO(2) detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement. METHODS: We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO(2) detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not. RESULTS: Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement. CONCLUSION: Colorimetric CO(2) detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases.

Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room.

AIM: The aim was to compare resuscitators' estimates of tidal volume (V(T)) and face mask leak with measured values during positive pressure ventilation (PPV) of newborn infants in the delivery room. PATIENTS AND METHODS: The authors measured inflating pressures and V(T) delivered using a respiratory function monitor, and calculated face mask leak. After 60 s of PPV, resuscitators were asked to estimate V(T) and face mask leak. These estimates were compared with measurements taken during the previous 30 s. RESULTS: The authors studied 20 infants who received a mean (SD) of 21 (6) inflations during the 30 s. The median (IQR) expired tidal volume (V(Te)) delivered was 8.7 ml/kg (5.3-11.3). V(Te) varied widely during each resuscitation and between resuscitators. Five resuscitators could not estimate V(Te), one overestimated and 14 underestimated their median delivered V(Te). The median (IQR) face mask leak was 29% (16-63%). Leak also varied widely during each resuscitation and between resuscitators. One resuscitator could not estimate mask leak, four overestimated leak and 15 underestimated leak. CONCLUSION: During face mask ventilation in the delivery room, V(T) and face mask leak were large and variable. The resuscitators were unable to accurately assess their face mask leak or delivered V(T).

Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival.

BACKGROUND: Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis. OBJECTIVE: To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth. METHODS: We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve. RESULTS: Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival. CONCLUSION: Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.

Financial costs for parents with a baby in a neonatal nursery.

AIM: To determine the additional financial cost to families of babies admitted to the nurseries of The Royal Women's Hospital, Melbourne, Australia. METHODS: Prospective case series of consecutive babies admitted to the Special and Intensive Care Nurseries at The Royal Women's Hospital, Melbourne, Australia. Data were collected from diaries completed by parents who recorded expenses related to having their baby in hospital. Fifty nine families of babies born <34 weeks' gestation who were hospitalised for at least 2 weeks. RESULTS: The median expenditure per family per week was Australian (A) $243 and the median length of stay in the nurseries was 7 weeks. The major costs were related to food and transport. Expenses related to the expression/storage of breast milk and accommodation were also considerable consuming 11% and 14%, respectively of the weekly amount spent. Of the 23 families who reported lost or reduced income, the median amount lost per week per family was A$324. CONCLUSION: The financial burden on families with babies admitted to a tertiary neonatal unit is substantial. The median cost per week was approximately one quarter of the average gross weekly income and included lost income as well as additional expenses. It is important that institutions and health-care systems recognise the magnitude of this additional burden on vulnerable families.