Conference Coverage

Two changes are made to resuscitation practice in delivery room


 

EXPERT ANALYSIS FROM AAP 2017

CHICAGOTwo changes have occurred in guidance related to resuscitation of newborns in the delivery room, according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.

One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.

Dr. Gary M. Weiner
Dr. Gary M. Weiner
He began his discussion of newborn delivery practices with an emphasis on risk factors, using tools such as checklists, and simply being prepared for resuscitation because delay isn’t an option.

About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.

Situations in which there is the highest risk for advanced resuscitation include the following:

  • Fetal bradycardia: 24-fold greater odds.
  • Intrauterine growth restriction (IUGR): 20-fold greater odds.
  • Clinical chorioamnionitis: 17-fold greater odds.
  • Forceps or vacuum: 17-fold greater odds.
  • Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
  • Gestational diabetes: 16-fold greater odds.
  • Abruption: 12-fold greater odds.
  • General anesthesia: 11-fold greater odds.

These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).

Assembling a team and using checklists

Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.

He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.

“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.

It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.

He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.

In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).

Brand New Baby. Newborn baby girl getting checked by the doctor stockce/Thinkstock
Similarly, in a study at Children’s Hospital of Philadelphia, clinicians implemented evidence-based guidelines to improve a specific set of outcomes among very low birth weight infants requiring resuscitation, including routine use of a checklist and frequent feedback to clinicians. The intervention led to less hypothermia among infants, less oxygen exposure in the first 10 minutes of birth, and reduced median durations of invasive ventilation and hospitalization (Pediatrics 2013;132:e1018–e1025).

Delayed cord clamping

Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).

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