Neonatal Resuscitation Practices in Portuguese Delivery Rooms: A Cross-Sectional Study.

INTRODUCTION: Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of this study was to assess the quality of newborn healthcare and resuscitation practices in Portuguese delivery rooms, comparing current practices with the 2021 European Resuscitation Council guidelines. The secondary aim was to compare the consistency of practices between tertiary and non-tertiary centers across Portugal. METHODS: An 87-question survey concerning neonatal care was sent to all physicians registered with the Portuguese Neonatal Society via email. In order to compare practices between centers, participants were divided into two groups: Group A (level III and level IIb centers) and Group B (level IIa and I centers). A descriptive analysis of variables was performed in order to compare the two groups. RESULTS: In total, 130 physicians responded to the survey. Group A included 91 (70%) and Group B 39 (30%) respondents. More than 80% of participants reported the presence of a healthcare professional with basic newborn resuscitation training in all deliveries, essential equipment in the delivery room, such as a resuscitator with a light and heat source, a pulse oximeter, and an O2 blender, and performing delayed cord clamping for all neonates born without complications. Less than 60% reported performing team briefing before deliveries, the presence of electrocardiogram sensors, end-tidal CO2 detector, and continuous positive airway pressure in the delivery room, and monitoring the neonate's temperature. Major differences between groups were found regarding staff attending deliveries, education, equipment, thermal control, umbilical cord management, vital signs monitoring, prophylactic surfactant administration, and the neonate's transportation out of the delivery room. CONCLUSION: Overall, adherence to neonatal resuscitation international guidelines was high among Portuguese physicians. However, differences between guidelines and current practices, as well as between centers with different levels of care, were identified. Areas for improvement include team briefing, ethics, education, available equipment in delivery rooms, temperature control, and airway management. The authors emphasize the importance of continuous education to ensure compliance with the most recent guidelines and ultimately improve neonatal health outcomes.

Quality improvement efforts directed at optimal umbilical cord management in delivery room.

Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study.

BACKGROUND: Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility -based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants. METHODS: This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours. RESULTS: Birth attendants' compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants' qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives' hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception. CONCLUSION: The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants' hand hygiene compliance in our study settings.

Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis.

Importance: Prevention of hypothermia in the delivery room is a cost-effective, high-impact intervention to reduce neonatal mortality, especially in preterm neonates. Several interventions for preventing hypothermia in the delivery room exist, of which the most beneficial is currently unknown. Objective: To identify the delivery room thermal care intervention that can best reduce neonatal hypothermia and improve clinical outcomes for preterm neonates born at 36 weeks' gestation or less. Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL databases were searched from inception to November 5, 2020. Study Selection: Randomized and quasi-randomized clinical trials of thermal care interventions in the delivery room for preterm neonates were included. Peer-reviewed abstracts and studies published in non-English language were also included. Data Extraction and Synthesis: Data from the included trials were extracted in duplicate using a structured proforma. A network meta-analysis with bayesian random-effects model was used for data synthesis. Main Outcomes and Measures: Primary outcomes were core body temperature and incidence of moderate to severe hypothermia on admission or within the first 2 hours of life. Secondary outcomes were incidence of hyperthermia, major brain injury, and mortality before discharge. The 9 thermal interventions evaluated were (1) plastic bag or plastic wrap covering the torso and limbs with the head uncovered or covered with a cloth cap; (2) plastic cap covering the head; (3) skin-to-skin contact; (4) thermal mattress; (5) plastic bag or plastic wrap with a plastic cap; (6) plastic bag or plastic wrap along with use of a thermal mattress; (7) plastic bag or plastic wrap along with heated humidified gas for resuscitation or for initiating respiratory support in the delivery room; (8) plastic bag or plastic wrap along with an incubator for transporting from the delivery room; and (9) routine care, including drying and covering the body with warm blankets, with or without a cloth cap. Results: Of the 6154 titles and abstracts screened, 34 studies that enrolled 3688 neonates were analyzed. Compared with routine care alone, plastic bag or wrap with a thermal mattress (mean difference [MD], 0.98 °C; 95% credible interval [CrI], 0.60-1.36 °C), plastic cap (MD, 0.83 °C; 95% CrI, 0.28-1.38 °C), plastic bag or wrap with heated humidified respiratory gas (MD, 0.76 °C; 95% CrI, 0.38-1.15 °C), plastic bag or wrap with a plastic cap (MD, 0.62 °C; 95% CrI, 0.37-0.88 °C), thermal mattress (MD, 0.62 °C; 95% CrI, 0.33-0.93 °C), and plastic bag or wrap (MD, 0.56 °C; 95% CrI, 0.44-0.69 °C) were associated with greater core body temperature. Certainty of evidence was moderate for 5 interventions and low for plastic bag or wrap with a thermal mattress. When compared with routine care alone, a plastic bag or wrap with heated humidified respiratory gas was associated with less risk of major brain injury (risk ratio, 0.23; 95% CrI, 0.03-0.67; moderate certainty of evidence) and a plastic bag or wrap with a plastic cap was associated with decreased risk of mortality (risk ratio, 0.19; 95% CrI, 0.02-0.66; low certainty of evidence). Conclusions and Relevance: Results of this study indicate that most thermal care interventions in the delivery room for preterm neonates were associated with improved core body temperature (with moderate certainty of evidence). Specifically, use of a plastic bag or wrap with a plastic cap or with heated humidified gas was associated with lower risk of major brain injury and mortality (with low to moderate certainty of evidence).

Cardiorespiratory monitoring in the delivery room using transcutaneous electromyography.

OBJECTIVE: To assess feasibility of transcutaneous electromyography of the diaphragm (dEMG) as a monitoring tool for vital signs and diaphragm activity in the delivery room (DR). DESIGN: Prospective observational study. SETTING: Delivery room. PATIENTS: Newborn infants requiring respiratory stabilisation after birth. INTERVENTIONS: In addition to pulse oximetry (PO) and ECG, dEMG was measured with skin electrodes for 30 min after birth. OUTCOME MEASURES: We assessed signal quality of dEMG and ECG recording, agreement between heart rate (HR) measured by dEMG and ECG or PO, time between sensor application and first HR read-out and agreement between respiratory rate (RR) measured with dEMG and ECG, compared with airway flow. Furthermore, we analysed peak, tonic and amplitude diaphragmatic activity from the dEMG-based respiratory waveform. RESULTS: Thirty-three infants (gestational age: 31.7±2.8 weeks, birth weight: 1525±661 g) were included.18%±14% and 22%±21% of dEMG and ECG data showed poor quality, respectively. Monitoring HR with dEMG was fast (median 10 (IQR 10-11) s) and accurate (intraclass correlation coefficient (ICC) 0.92 and 0.82 compared with ECG and PO, respectively). RR monitoring with dEMG showed moderate (ICC 0.49) and ECG low (ICC 0.25) agreement with airway flow. Diaphragm activity started high with a decreasing trend in the first 15 min and subsequent stabilisation. CONCLUSION: Monitoring vital signs with dEMG in the DR is feasible and fast. Diaphragm activity can be detected and described with dEMG, making dEMG promising for future DR studies.

Fatores associados às práticas assistenciais ao recém-nascido na sala de parto / Factors associated with care practices for newborns in the delivery room

RESUMO Objetivo identificar os fatores associados às práticas assistenciais ao recém-nascido adotadas na sala de parto de uma maternidade na baixada litorânea do Rio de Janeiro. Método estudo transversal, realizado em instituição pública no estado Rio de Janeiro, mediante coleta de dados em prontuários de nascimentos entre 2015 e 2017. Na associação entre variáveis, adotou-se o Teste Qui-Quadrado e a regressão logística. Resultados entre 351 (100,0%) prontuários, constituíram-se como práticas realizadas na sala de parto: contato pele a pele e aleitamento materno precoce (28,0%); secagem (92,3%); aspiração oronasofaríngea (82,1%); aspiração gástrica (52,7%); aspiração traqueal (12,2%); oxigênio inalatório (7,7%); e encaminhamento ao Alojamento Conjunto (91,1%). O contato precoce com o seio materno esteve associado ao tipo de parto (p=0,043) e às alterações no exame físico (p=0,001). Possuir alterações no exame físico ao nascimento diminuiu significativamente as chances de o bebê ser colocado nessa posição ainda na sala de parto (p=0,001) assim como os recém-nascidos de parto cesáreo (p=0,045). Nascer de cesárea aumentou duas vezes as chances de o recém-nascido ser submetido à aspiração gástrica (p=0,002). Conclusão e implicações para a prática é premente organizar as rotinas dos serviços, de modo a evitar intervenções desnecessárias visando uma atenção obstétrica e neonatal humanizada e de qualidade.

ABSTRACT Objective to identify the factors associated with newborn care practices adopted in the delivery room of a maternity hospital in the coastal lowlands of Rio de Janeiro. Method a cross-sectional was study carried out in a public institution in the state of Rio de Janeiro using data collected from birth records between 2015 and 2017. The chi-square test and logistic regression were adopted to associate the variables. Results among 351 (100.0%) medical records, the following constituted practices performed in the delivery room: skin-to-skin contact and early breastfeeding (28.0%); drying (92.3%); oronasopharyngeal aspiration (82.1%); gastric aspiration (52.7%); tracheal aspiration (12.2%); inhaled oxygen (7.7%); and rooming-in referral (91.1%). Early breastfeeding was associated with the type of delivery (p=0.043) and changes in physical examination (p=0.001). Changes in the physical examination at birth significantly decreased the chances of babies being placed in this position while still in the delivery room (p=0.001), as well as newborns delivered by cesarean section (p=0.045). Being born by cesarean section increased the chances of newborns being submitted to gastric aspiration twice (p=0.002). Conclusion and implications for practice it is urgent to organize the routines of services in order to avoid unnecessary interventions aiming at humanized and quality obstetric and neonatal care.

Analysis of the Sound Environment and the Sound Level in the Delivery Room in the First Hour of a Newborn's Life.

OBJECTIVE: The aim of the study was to analyse the sound environment and the range of sound levels recorded in the delivery room immediately after the birth of a newborn. MATERIALS AND METHODS: The research method was open observation combined with recording measurements of the sound intensity levels. The material was collected by means of an observation questionnaire. The research was conducted in 11 maternity hospitals in Warsaw. A total of 304 vaginal labours were analysed. RESULTS: The average sound level in the delivery room after the birth of a newborn was 58.03 ± 7.66 dB, and the sound intensity ranged from 40.30 dB to 78.0 dB. Staff conversations were the most common sources of noise. A statistically significant relationship between the number of people in the delivery room and sound intensity was observed. The number of people positively correlated with the average sound level (R=0.520, p<0.001). CONCLUSIONS: Based on the tests, it was found that the average sound level in the delivery room exceeded the recommended standards. The noise was mainly caused by the activity of staff. The present study indicates the need for staff education and the use of noise reduction procedures.

Management of the mother-infant dyad with suspected or confirmed SARS-CoV-2 infection in a highly epidemic context.

In the context of SARS-CoV-2 pandemic, the hospital management of mother-infant pairs poses to obstetricians and neonatologists previously unmet challenges. In Lombardy, Northern Italy, 59 maternity wards networked to organise the medical assistance of mothers and neonates with suspected or confirmed SARS-CoV-2 infection. Six "COVID-19 maternity centres" were identified, the architecture and activity of obstetric and neonatal wards of each centre was reorganised, and common assistance protocols for the management of suspected and proven cases were formulated. Here, we present the key features of this reorganization effort, and our current management of the mother-infant dyad before and after birth, including our approach to rooming-in practice, breastfeeding and neonatal follow-up, based on the currently available scientific evidence. Considered the rapid diffusion of COVID-19 all over the world, we believe that preparedness is fundamental to assist mother-infant dyads, minimising the risk of propagation of the infection through maternity and neonatal wards.

Optimizing oxygen therapy for preterm infants at birth: Are we there yet?

Premature infants undergo a complex postnatal adaptation at birth. For last two centuries, oxygen has been integral to respiratory support of preterm infants at birth. Excess oxygen can cause oxidative stress and tissue injury. Preterm infants due to lung immaturity may need oxygen for successful transition at birth. Although, considerable progress has been made in the last 3 decades, optimum oxygen therapy for preterm delivery room resuscitation remains unknown. In this review, we discuss the history and physiology behind oxygen therapy in the delivery room, evaluate current literature, provide practice points and point out knowledge gaps of oxygen therapy in preterm infant at birth.

Effects of Birthing Room Design on Maternal and Neonate Outcomes: A Systematic Review.

AIM: To summarize, categorize, and describe published research on how birthing room design influences maternal and neonate physical and emotional outcomes. BACKGROUND: The physical healthcare environment has significant effects on health and well-being. Research indicates that birthing environments can impact women during labor and birth. However, summaries of the effects of different environments around birth are scarce. METHODS: We conducted a systematic review, searching 10 databases in 2016 and 2017 for published research from their inception dates, on how birthing room design influences maternal and neonate physical and emotional outcomes, using a protocol agreed a priori. The quality of selected studies was assessed, and data were extracted independently by pairs of authors and described in a narrative analysis. RESULTS: In total, 3,373 records were identified and screened by title and abstract; 2,063 were excluded and the full text of 278 assessed for analysis. Another 241 were excluded, leaving 15 articles presenting qualitative and quantitative data from six different countries on four continents. The results of the analysis reveal four prominent physical themes in birthing rooms that positively influence on maternal and neonate physical and emotional outcomes: (1) means of distraction, comfort, and relaxation; (2) raising the birthing room temperature; (3) features of familiarity; and (4) diminishing a technocratic environment. CONCLUSIONS: The evidence on how birthing environments affect outcomes of labor and birth is incomplete. There is a crucial need for more research in this field.

Suboptimal heart rate assessment and airway management in infants receiving delivery room chest compressions: a quality assurance project.

OBJECTIVE: In a previous audit, we demonstrated poor compliance with the neonatal resuscitation algorithm. Training can improve guideline compliance and performance. We aimed to prospectively collect detailed data on delivery room resuscitations to identify needs for educational interventions. DESIGN: Observational study using video recordings of neonatal resuscitations. We analysed episodes where chest compressions (CCs) were provided. SETTING: A Norwegian university hospital. PATIENTS: All delivery room resuscitations August 2014 to November 2016. INTERVENTIONS: The recordings were transcribed using Interact V.9 software (Mangold Int GmbH, Arnstorf, Germany). Supplementary information was collected from the patient electronic records. MAIN OUTCOME MEASURES: Heart rate (HR) assessment, provision of positive pressure ventilation (PPV) and CC, endotracheal intubation and team communication. RESULTS: Twenty-nine CC episodes were analysed. We identified team discordance in the decisions to perform CC and only 6 (21%) were retrospectively judged to be in need for CC: 8 (28%) infants had adequate spontaneous respiration, 18 (62%) infants received ineffective PPV and 5 (17%) had a HR >60 bpm. Only one infant was intubated before CC, and we could not identify a consistent pattern of ventilation corrective actions. One infant received CC without prior HR assessment. In some infants, CC duration was exceedingly short, and 11 (38%) of the infants that received CC were not admitted to the NICU. Six (21%) infants had no documentation of CPR in the delivery record. CONCLUSIONS: Education and training should focus on team function and communication, correct and timely HR assessment, effective PPV, and indications for endotracheal intubation.

Deferred consent for delivery room studies: the providers' perspective.

OBJECTIVE: To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios. METHODS: We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0. RESULTS: Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent. CONCLUSION: Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.

Accuracy of real-time delivery room resuscitation documentation.

OBJECTIVE: To assess the accuracy of real-time delivery room resuscitation documentation. DESIGN: Retrospective observational study. SETTING: Level 3 academic neonatal intensive care unit. PARTICIPANTS: Fifty infants with video recording of neonatal resuscitation. MAIN OUTCOME MEASURES: Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard. RESULTS: Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%-100%, procedures for 91%-100% and medications for 100% of events. CONCLUSION: Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments.

What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study.

BACKGROUND: In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres? METHODS: Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach. RESULTS: Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable. CONCLUSIONS: Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Delivery room interventions to prevent bronchopulmonary dysplasia in preterm infants: a protocol for a systematic review and network meta-analysis.

INTRODUCTION: As gestational age decreases, incidence of bronchopulmonary dysplasia (BPD) and chronic lung disease increases. There are many interventions used in the delivery room to prevent acute lung injury and consequently BPD in these patients. The availability of different treatment options often poses a practical challenge to the practicing neonatologist when it comes to making an evidence-based choice as the multitude of pairwise systematic reviews including Cochrane reviews that are currently available only provide a narrow perspective through head-to-head comparisons. METHODS AND ANALYSIS: We will conduct a systematic review of all randomised controlled trials evaluating delivery room interventions within the first golden hour after birth for prevention of BPD. The primary outcome includes BPD. Secondary outcomes include death at 36 weeks of postmenstrual age or before discharge; severe intraventricular haemorrhage (grade 3 or 4 based on the Papile criteria); any air leak syndromes (including pneumothorax or pulmonary interstitial emphysema); retinopathy of prematurity (any stage) and neurodevelopmental impairment at 18-24 months. We will search from their inception to August 2018, the following databases: Medline, EMBASE and Cochrane Central Register of Controlled Trials as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information and assess the risk of bias and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation approach). This review will use Bayesian network meta-analysis approach which allows the comparison of the multiple delivery room interventions for prevention of BPD. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, effectiveness and safety of delivery room interventions for prevention of BPD. ETHICS AND DISSEMINATION: The proposed protocol is a network meta-analysis, which has been registered on PROSPERO International prospective register of systematic reviews (CRD42018078648). The results will provide an evidence-based guide to choosing the right sequence of early postnatal interventions that will be associated with the least likelihood of inducing lung injury and BPD in preterm infants. Furthermore, we will identify knowledge gaps and will encourage further research for other therapeutic options. Therefore, its results will be disseminated through peer-reviewed publications and conference presentations. Due to the nature of the design, no ethics approval is necessary.