Placental Transfusion, Timing of Plastic Wrap or Bag Placement, and Preterm Neonates.

OBJECTIVE: Compare delivery room practices and outcomes of infants born at less than 32 weeks' gestation or less than 1,500 g who have plastic wrap/bag placement simultaneously during placental transfusion to those receiving plastic wrap/bag placement sequentially following placental transfusion. STUDY DESIGN: Retrospective analysis of data from a multisite quality improvement initiative to refine stabilization procedures pertaining to placental transfusion and thermoregulation using a plastic wrap/bag. Delivery room practices and outcome data in 590 total cases receiving placental transfusion were controlled for propensity score matching and hospital of birth. RESULTS: The simultaneous and sequential groups were similar in demographic and most outcome metrics. The simultaneous group had longer duration of delayed cord clamping compared with the sequential group (42.3 ± 14.8 vs. 34.1 ± 10.3 seconds, p < 0.001), and fewer number of times cord milking was performed (0.41 ± 1.26 vs. 0.86 ± 1.92 seconds, p < 0.001). The time to initiate respiratory support was also significantly shorter in the simultaneous group (97.2 ± 100.6 vs. 125.2 ± 177.6 seconds, p = 0.02). The combined outcome of death or necrotizing enterocolitis in the simultaneous group was more frequent than in the sequential group (15.3 vs. 9.3%, p = 0.038); all other outcomes measured were similar. CONCLUSION: Timing of plastic wrap/bag placement during placental transfusion did affect duration of delayed cord clamping, number of times cord milking was performed, and time to initiate respiratory support in the delivery room but did not alter birth hospital outcomes or respiratory care practices other than the combined outcome of death or necrotizing enterocolitis. KEY POINTS: · Plastic bag placement during placental transfusion is effective in stabilization of preterms.. · Plastic bag placement after placental transfusion is effective in stabilization of preterms.. · Plastic bag placement during placental transfusion and risk of death or necrotizing enterocolitis needs additional study..

Using the Eat Sleep Console Model to Promote Optimal Care and Outcomes for Infants With Neonatal Abstinence Syndrome: A Nurse-Driven, Multidisciplinary Initiative.

BACKGROUND: A nurse led a team of providers in a quality improvement (QI) project to positively impact inpatient care and outcomes for infants with neonatal abstinence syndrome (NAS). The Eat Sleep Console (ESC) model was implemented to promote rooming-in and family-centered care as part of a nonpharmacological treatment approach. PURPOSE: To compare the ESC model with the traditional Finnegan treatment approach to describe differences in infants' pharmacotherapy use (morphine), length of stay (LOS), weight loss, consumption of mother's own milk by any feeding method within 24 hours of discharge, Neonatal Intensive Care Unit (NICU) use, and Pediatric Unit utilization. METHODS: The QI project was conducted at a single hospital site with more than 1700 deliveries per year in the Midwestern United States. A comparative effectiveness study design was used to evaluate the ESC model. RESULTS: The ESC model impacted care and outcomes for infants with NAS, contributing to a significant reduction in morphine treatment, decrease in LOS among morphine-treated infants, increase in weight loss in infants who did not require morphine treatment, less NICU use, and greater Pediatric Unit utilization. A nonsignificant increase was found in the number of infants who consumed their mother's own milk by any feeding method in the 24-hour period prior to discharge. IMPLICATIONS FOR PRACTICE AND RESEARCH: Results may be helpful for hospitals striving to optimize care for infants exposed to opioids, using assessments of eating, sleeping, and consoling to guide individualized treatment decisions and to reduce morphine use.

Place of delivery and perinatal mortality in Kenya.

BACKGROUND: Increasing access to skilled birth attendants is a key goal in reducing perinatal mortality. In Kenya, where 40% of births occur at home, efforts toward this goal have focused on providing free maternity services in government facilities and discouraging home births. PURPOSE: To identify trends in facility deliveries and determine the association between delivery location and PM in Kenya. METHODS: We utilized data on 36,375 deliveries from the Kenya site of the Global Network for Women's and Children's Health Research, which maintains a prospective, population-based observational study of pregnancy and neonatal outcomes. We identified temporal trends in facility utilization and perinatal mortality. We then assessed associations between delivery location and PM using generalized linear mixed equations. RESULTS: The percentage of facility births increased from 38.4% in 2009 to 47.6% in 2013, with no change in perinatal mortality. Infants delivered in a facility had a higher risk of perinatal mortality than infants delivered at home (aOR = 1.41, p = 0.005). In stratified analyses, hospital deliveries had a higher adjusted odds of perinatal mortality than home and health center deliveries, with no difference between health center and home deliveries. CONCLUSION: The increase in facility deliveries between 2009 and 2013 was not associated with a decline in perinatal mortality. Infants born in facilities had a 41% greater risk of perinatal mortality than infants born at home. Further research is needed to assess possible explanations for this finding, including delays in referring and caring for complicated pregnancies, higher risk infants delivering at facilities, and poor quality of care in facilities.

Influence of Maternal Factors in Neonatologists' Counseling for Periviable Pregnancies.

Background Neonatologists have varying counseling practices for women with threatened periviable pregnancies. Previous research has suggested this variability may be influenced by social and economic factors of the mother. Objective The objective of this study was to determine the relative influence of maternal factors in counseling recommendations for periviable pregnancies. Methods A national cohort of neonatologists was sent a web-based survey. Five maternal characteristics were varied across eight vignettes: age, education, race, parity, and pregnancy "intendedness." Following each vignette, participants reported their likelihood to recommend full resuscitation versus comfort care. Conjoint analysis was used to assess the relative influence of each factor on respondents' recommendations. Results Responses from 328 neonatologists were included. Of the five tested maternal characteristics, parity and intendedness had the highest importance scores (40.2 and 35.0), followed by race, education, and age. If parents requested resuscitation, respondents were highly likely to comply with preferences, with little variation across vignettes. Conclusion Fetal-specific factors such as gestational age and estimated weight are known to influence counseling and decision making for extremely preterm infants. Our results suggest that maternal factors may also influence counseling practices, although physicians are likely to comply with parental preferences regardless of maternal factors. Future research should identify how maternal characteristics impact actual counseling practices.