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Although electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants. Neonates

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

Background: Advances in neonatal intensive care have improved outcomes for term and preterm infants. Delivery room (DR) management of newborn infants remains basic although recent advances include the use of air for resuscitation, plastic wraps/bags for temperature preservation, DR CPAP and pulse oximetry. No data exist on DR management of newborns in the UK. Aim: Establish current DR management of newborn infants in the UK. Methods: A telephone/email/postal survey of DR management in UK neonatal units during 2009. 192 units were surveyed and 171 (89%) responded (65 Level III and 106 Level II/I units). Comparisons were made between level III (intensive care) and level II/I units (high dependency/special care). Results: There were differences in DR management with level III units using significantly more ventilation devices with PEEP (95% vs 88%, P< 0.05) and delivery room CPAP (43% vs 16%, P< 0.0001). Significantly more level III units commenced resuscitation in air (49% vs 30%, P=0.01) and fewer used 100% oxygen (12% vs 40%, P< 0.0001). The use of pulse oximeters (III=23% vs II/I=12%), plastic wraps/bags (III=97% vs II/I=96%), DR surfactant (III=92% vs II/I=83%) and elective intubation of preterm infants (III=83% vs II/I=73%) were not statistically different. Conclusions: These important data highlight significant variance of DR management for newborn infants in the UK with level III units adopting a more evidence-based practice. Furthermore, these data differ markedly from those reported in other developed countries. These discrepancies between resuscitation guidelines, DR management and poor evidence-base need urgent attention. Funded by Action Medical Research.

Background: Supplemental oxygen is often given to infants in the delivery room. Clinicians adjust oxygen concentration (FiO2) in order to prevent hypoxia and hyperoxia. Using an animal model, we aimed to measure the delivered FiO2 when using a T-piece and a self-inflating bag (SIB) and oxygen via a blender.

Background and Aims: To be useful in the delivery room, pulse oximeters must provide clinicians with accurate data in the first minutes after birth. This study aimed to identify the sensor application technique which gave the fastest display of accurate data using the Nellcor N-600x Oximax Pulse Oximeter (PO). Method: Stable infants from our Neonatal Intensive and Special Care nurseries with electrocardiograph (ECG) monitoring were included. Three sensor application techniques were studied: The order of techniques was randomised. Time taken to apply PO sensor, to display any data, and to display accurate data (HRPO = HRECG ± 3 bpm) were recorded using a stopwatch. Means were compared using paired t tests. Results: Forty infants were studied [mean(SD) birth weight 1455(872) g, gestational age 31(4) weeks, postnatal age 34(4) weeks]. Time to acquire any data mean(SD): method 1: 15(13) s; method 2: 13(6) s; method 3: 9(7) s. Method 3 acquired data significantly faster than methods 1 (p=0.013) and 2 (p=0.004). Time to acquire accurate data mean(SD): method 1 17(13) s; method 2 14(7) s; method 3 11(9) s. Method 3 acquired accurate data significantly faster than method 1 (p=0.016), but not method 2 (p=0.15). Conclusions: Applying the N-600x PO sensor to the infant before connecting it to the cable yields fastest acquisition of accurate data.

Background: A large percentage of LPIs are hypothermic in NICU. Due to decreased subcutaneous tissue, LPIs are at increased risk for hypothermia in the Delivery and Operating Room (DR/OR). Hypothermia is cited as the primary reason for NICU admission in 5.2% of all LPIs and associated with prolonged Length of Stay (LOS).

The Effect of Two Second and Sixteen Second Averaging on Pulse Oximetry Measurements in the Delivery Room (DR)

For the past 50 years, the practice of neonatal resuscitation has been based largely on expert opinion and evidence from animal models. The 2010 International Liaison Committee on Resuscitation (ILCOR) guidelines contain recommendations derived from an accumulating body of higher quality evidence. This presentation will summarise some of the studies underpinning changes to the guidelines. Changes include: Mask ventilation remains the cornerstone of neonatal resuscitation. Clinical signs, including chest wall movement poorly measure the effectiveness of ventilation. Mask leak and airway obstruction are common, often unrecognized factors that lead to ineffective ventilation. Respiratory function monitoring is a potentially useful way of improving treatment in the delivery room. The strengths and limitations of novel monitoring techniques will be discussed. Evidence emerging since publication of the 2010 guidelines will be presented and the most important gaps in our knowledge outlined.

Transferring Infants < 32 Weeks' Gestation from the Delivery Room to the NICU. How Vigilant are we in Avoiding Hypoxia/Hyperoxia During the First “Golden Hour”?

962 Heartlight - Delivery Room Acquisition Time for a Novel Forehead Heart Rate Sensor for Newborn Resuscitation

341 Using Centile Charts Derived From Pulse Oximetry Measurements to Inform Oxygen Treatment in the Delivery Room

Objective: At birth, infants needing neonatal resuscitation are positioned under a radiant infant warmer (RIW) at 37°C. We aimed to evaluate the performance of three different RIWs in a delivery room setting. Methods: Temperatures were measured (Incu Fluke Biomedical, Bio-Tek Instruments, Everett, WA, USA) under 3 RIWs: (a) GE Healthcare PANDA i-RES, (b) Draeger Babytherm 8010 and (c) Fisher & Paykel IW 930. Measurements were obtained at baseline, at 10 and 20 minutes after switching the power from 0 to 100% and maintaining the setting temperature constant at 24°C. Results: Table 1 Conclusions: Temperature under RIW is significantly influenced by the utilized device. This aspect would be considered for management of neonates at birth.

Background: Current guidelines suggest a role for clinical assessment of chest rise in determining adequacy of positive pressure ventilation (PPV). However, these guidelines do not state how chest rise should be assessed. We compared the clinical assessment of chest rise from the infant's head and infant's side with measured tidal volume during PPV in the delivery room. Methods: Airway pressures and expiratory tidal volume (VTe) were measured during PPV using a respiratory function monitor. After 60 seconds of PPV, resuscitators at the infants' head and infants' side were asked to assess chest rise and estimate delivered VTe. These estimates were compared with measurements taken during the previous 30 seconds. Result: Twenty infants receiving PPV were included. A total of 433 inflations with a mean of (SD) of 23 (4) inflations per infant during the 30 seconds baseline. Six resuscitators were unable to assess tidal volume from their position at the infant's head versus three from the infant's side. Figure 1 (Tidal volume assessment at the infant's head) and Figure 2 (Tidal volume assessment at the infant's side) illustrate the poor agreement between estimated and delivered VTe. Assessment from the infants side was somewhat better than from the head. Conclusion: During mask ventilation most resuscitators were unable to accurately assess chest wall movement in either of two positions.

332 Use of a Respiratory Function Monitor During Positive Pressure Ventilation in the Delivery Room -A Randomized Trial

330 Prevalence of Airway Obstruction and Mask Leak During Face Mask Ventilation of Preterm Infants in the Delivery Room

Background/Aims: We questioned whether extremely low birth weight (ELWB) infants who undergo cardiopulmonary resuscitation (CPR) at delivery room present poorer survival and short-term outcomes than those who do not.

Background/aims: There is a lack of information regarding the delivery room management of the extremely low birth weight infants (ELBWI). We aimed to survey the practice and the approach to the neonatal resuscitation of the ELBWIs in Italian tertiary centres.

Effect of Mental Stress on Heart Rate Variability: Validation of Simulated Operating and Delivery Room Training Modules

Endotracheal Intubation (EOT) in the Delivery room : Should It Be a Routine Procedure for the Extreme Low Birth Weight Infant?

Favorable Neurological Outcomes in ≤750g Recipients of Delivery Room Cardiopulmonary Resuscitation (CPR). 1031

Current neonatal delivery room (DR) resuscitation teaching includes the use of chest compressions and/or intratracheal epinephrine (CPR) for infants with a heart rate 750 gm birthweight. Methods: We evaluated the outcome of all inborn infants whose birthweights (BW) were 750gm(15/98). Surviving infants were followed up to 36 months adjusted age (AA) using standardized neurodevelopmental (ND) assessments including the Amiel-Tison Neurologic Screen and the Gesell Developmental Screening Inventory. Results: Overall, 21 infants required CPR in the DR, of whom 13 were < 750 gm. Three infants, all < 750 gm, have normal neurodevelopmental outcome at 6, 19,& 26 months AA. These preliminary results indicate that intact survival is possible for infants of < 750 gm BW following CPR in the DR as defined above. Further information is required regarding the indications for CPR, the use of the individual components(compressions and epinephrine) and the duration of CPR from retrospective and prospective evaluation of larger data sets. In addition, we require more complete neurodevelopmental follow-up in order to develop recommendations for the use of CPR in the DR resuscitation of the < 1000 gm birthweight infant. Table

We surveyed parents attitudes about the level of support provided to their borderline viable baby in the delivery room and NICU and how these decisions were made. Surveys were sent to parents of all livebirths born at our hospital from 1990 through 1995 at 23-25 wks of gestation. All babies were initially provided respiratory support in the delivery room and 140/142 were intubated. If the baby survived the delivery room and neonatal intensive care was initiated, consideration for withdrawing support was presented to the parents when the attending neonatologists considered the prognosis hopeless. Separate surveys were sent to each parent at least 1 year after the death of discharge of their baby. Sixty-eight surveys (40 mothers, 28 fathers) were returned representing 40 babies. The birthweight, gestational age, and rate of major morbidities were similar for babies whose parents returned surveys compared with those who did not, however, survival was higher for the group returning the surveys (78% vs 57%; p

Determining the limits of viability and long term outcome of ELBW infants are foremost concerns for perinatal medicine and society. We documented improved survival of ELBW infants following the introduction of surfactant(Pediatrics, 1996). We now compare outcomes of ELBW for three time periods: 1982-88, pre-surfactant; 1990-92, surfactant; 1993-95, surfactant plus increased use of antenatal steroids. Between `90-'92 and `93-'95 antenatal steroid use among survivors increased from 10% to 53% (p

The use of cardiopulmonary resuscitation in the delivery room (CPR) has been associated with very poor outcomes in the very low birth weight infant, especially < 750 grams. However, all of the literature to date involves very small numbers of infants with the largest reviewing 156 infants from a single institution (Davis, D Pediatr 1993;92:447) We reviewed the Vermont Oxford Network database to determine the utilization of delivery room CPR(cardiac compressions, epinephrine or both) and the neonatal outcomes of inborn infants of 501 to 1500 grams at birth without congenital malformations. The data were collected from 196 inborn neonatal units participating in the Network in 1994 - 1996. Information was available for 27,196 infants, 23,889 of whom survived (87.8%). Overall, 989 of 1591 infants with CPR survived(62.1%) compared with 89.4% of the 25,580 infants without CPR, p

Delivery Room Management of The Apparently Vigorous Meconium-Stained Neonate: Results Of The Multicenter Collaborative Trial • 1185

Recent observational studies suggest a relationship between low Paco2 values in the mechanically ventilated VLBW infants and neonatal morbidity, i.e., chronic lung disease. Permissive hypercapnia has been advocated as one approach to minimize such lung injury. However, the time of initiating such a strategy and factor (s) that influence postnatal Paco2 values are not well characterized. The study objective was to determine the effect of delivery room resuscitation on early Paco2 levels and the relation to O2 requirement at 28 days in VLBW infants 40 (n=42, 43%) (m=46.8±6.3mmHg), ≥45(n=23, 24%) (m=50.6±6.4mmHg). 19 patients (20%) had Paco2 0.05) respectively. The lowest Paco2 values were following abruption(m=23±7mmHg) and multiple gestation (m=32±12mmHg). Of infants with Paco2

Background. Criteria for intubation (I) of ELBWI after birth are not established. Intervention. Change of delivery room strategy: strategy 1 (1994): primary I; strategy 2 (1996). prolonged inflation(15s,20cmH2O) by pharyngeal tube and CPAP in all infants, secondary I only when respiratory failure had occurred. Hypothesis: Mechanical ventilation of ELBWI can be avoided by strategy 2. Subjects. All inborn ELBWI born 1994 and 1996 were grouped: A: I in the delivery room, B: secondary I (RDS); C: no I Statistics: Fisher's exact, Mann-Whitney U test. Results. Group A: n=45(1994)/27(1996); B: 4/14, C: 4/17. When the bias of GA and retardation were eliminated (matched pairs), ventilatory data and outcome did not significantly differ in A (1994) vs A or B(1996). The outcome of C(1996) was the best of all groups .Conclusion. Strategy 2 resulted in a decreased I rate (83 vs 40%). The group of infants who were never ventilated increased (7 vs 27%). Our data do not indicate an impaired outcome in B.Table

The standard model of physician staffing of neonatal care units (attending, resident, fellow) remains undefined. Recent changes in reimbursement and resident training have led to changes in NICU coverage. We postulated that in-house attending coverage in our NICU would improve patient outcome. We compared data from 1995 (control group with on-call coverage) to NICU data from 1996 (study group with in-house 24 hr coverage). Data from inborn NICU admissions were retrospectively collected and grouped by calendar year. There were no changes in nurse staffing, resident staffing, NICU attendings, delivery room policies or OB referral patterns during the years studied. Pediatric teams attended approximately the same number of deliveries in each group (46%). The infant populations were similar in number (total births and NICU admissions), birth weight and gestational age. The number of infants with 1 and 5 minute APGAR scores 1500 gm infants a similar reduction was noted; 53 in 1995 to 30 in 1996 and 7 in 1995 to 5 in 1996 for the 1 and 5 minute APGARs respectively. The use of CPR in the delivery room also showed a significant decline with the change in NICU coverage. In the 1500 gm birthweight. We conclude that the change from an on-call NICU attending coverage to an in-house attending coverage model appears to have resulted in a significant improvement in outcome.

Physician decisions to resuscitate ELBW infants in the delivery room (DR) and antenatal parent counseling have been poorly studied. To assess current neonatal practices of initiating life-support in the DR for ELBW infants, we surveyed 447 neonatologists in California, 263 (59%) returned completed surveys; they were typically white (61%), male (65%), parents (83%), 46(± 1, SEM) yrs old, 13 (± 1, SEM) yrs in practice, board-certified (83%), and on-service 8 mo/yr. 34% had made life-support decisions for family members, 18% for their own premature infants.

Delivery Room Management of Newborns with Prenatal Diagnosis of Hypoplastic Left Heart Syndrome. 1104

Beginning with the housestaff who started July 1993, the NRP became mandatory for all incoming residents. In order to assess if there was any positive impact of having trained personnel in attendance at high risk deliveries, we compared the outcome in delivery room survival in asphyxiated newborns and in short term morbidity in meconium aspiration syndrome (MAS) in two groups. Group I consisted of all births in the five year period prior to the institution of the NRP and Group II consisted of all births in the three year period following the institution of the NRP.

Decisions about delivery-room resuscitation for extremely premature infants: Whatever happened to baby autonomy? • 157

Maternal Fever (MF) (T>38°C) an Unanticipated but Important Associated Clinical Variable in Term Infants with Depressed Apgar Scores Requiring Resuscitation in the Delivery Room (DR). † 566

Adverse Outcome After Delivery Room Cardiovascular Resuscitation of Extremely Premature Infants. † 1167

The survival of extremely low birth weight newborns (ELBW) [≤ 1000 grams] has dramatically and significantly improved since 1990. This has been attributed to Surfactant, maternal steroids and new forms of neonatal ventilation. Over a 10 year period at our institution, we evaluated neonatal survival (alive at Day 28 of life) based on birthweight (BW) and gestational age (GA). Small for GA newborns, as well as those who expired in the delivery room (DR) and beyond 28 days of life, were excluded. Newborns < 500 grams at birth with a GA ≤ 23 weeks are not routinely resuscitated.Table

CHEMICAL RESUSCITATION (CR) IN THE DELIVERY ROOM AND THE RISK FOR INTRACRANIAL HEMORRHAGE (ICH). 1567

PURPOSE: To explore the degree of variation in routine management of infants born through meconium-stained amniotic fluid (MSAF) in New Hampshire. METHODS: In spring 1994 a survey was sent to one pediatrician or family practitioner (FP), one obstetrician, and one labor nurse manager at each of the 26 hospitals in the state providing delivery services. Questions dealt with usual practices regarding attendance at these deliveries by pediatricians/FPs, routine intubation and tracheal suction, major influences on practice, and Neonatal Resuscitation Program (NRP) certification. Responses were received from 20 obstetricians, 23 pediatricians/FPs, and 26 nurse managers; overall response rate was 90% including at least one response from each hospital. RESULTS: Ten percent of respondents stated that no deliveries were attended routinely by a pediatrician or FP, while 7% said that no infants were intubated routinely. Many practitioners do not routinely provide tracheal suction for depressed infants born through thin meconium, or for vigorous infants with thick MSAF (TABLE). Several different sources were cited as the most important influence on practice: NRP (46%). AAP/ACOG Perinatal Guidelines (11%), local experience (11%), and the medical literature (7%) were most frequent. While 97% of nurses, 65% of obstetricians, and 71% of pediatricians/FPs were NRP certified, hospitals with higher rates of physician NRP certification did not have different practices regarding airway management or attendance at deliveries when compared with those with lower rates. CONCLUSION: Management of infants born through MSAF is not uniform among the hospitals surveyed. Variations in practice are particularly common with depressed infants born through thin meconium, or for vigorous infants with thickly stained fluid. We speculate that this may be due to a lack of concensus regarding these issues among major references and organizations.

Mothers' ability to recognize their infants facies from a standardized Polaroid color photo was compared to nonparent subjects (students). Maternal visual exposure to infant was in immediate postpartum period in the delivery room. Students viewed infants on 1st day of life in nursery. Exposure time was limited to 10 minutes in each group. Positive result was defined as ability to distinguish specific infant photo from a group of 7 pictures. Fifty percent of mothers did not receive any medication, 43% received narcotic analgesia and 7% had an epidural. Only 37% (11/27) of the mothers could identify their infant as compared to the 73% (27/37) success rate in the nonparent group (p

We examined the relationship between AS and biochemical asph using 2 observers (obs). Obs 1 was aware of antepartum history, obs 2 exposed to the infant at the time of delivery. Obs changed roles after every 10th delivery. Independent AS's were assigned at 1 and 5 mins. Curing their 5 minute period of observation, obs predicted outcome as: normal; grade la asph (2 of pH 10); grade Ib (Ia + >5 mins to spontaneous respiration); grade II (Ib + clinical signs; seizures, lethargy, etc). Cord blood gas (CBG) was taken at delivery and later compared with AS and predicted outcome. Thirty five term deliveries were studied. Using the above criteria, 10 were Ia asph on subsequent CBG analysis; 3 were Ib; 22 were normal. The correlation coefficient for interobserver AS was r=.97 at 1 and 5 mins, and obs agreed on predicted outcome in 97% of cases. However, obs correctly predicted only 25% of asph and 62% of normals. The obs AS correlated with delivery room staff assessment of need for positive pressure resuscitation (PPR). All obs AS's of

This study is an analysis of the relationship of a number of variables to early maternal attachment behavior. Maternal responsive behavior was used as the measure of attachment. Observations were made in the delivery room, during a postpartum feeding and during a feeding four weeks following delivery. Forty primiparous mothers and newborns served as research subjects. The results show a shift over time in the factors which are most highly related to attachment behavior. In the delivery room the fathers' responsive behavior is the most significant factor (p ≥ .003). During the postpartum feeding the mothers' behavior in the delivery room is the most significant factor (p ≥ .001) . At four weeks postpartum the mothers' age is most highly related to her responsive behavior (p ≥ .001) and measures of social stability (p ≥ .001) have increased significance. Observations of behavior which have a high degree of correlation in the hospital setting, do not have the same degree of significance in a home setting at four weeks. At this time other factors, age and social stability, have an increased degree of significance. How these factors may reflect a mother's social support system and relate to her attachment behavior is discussed.

Apgar scores have been used to assess intrapartum asphyxia and to predict the association of perinatal insult with ultimate outcome. We tested the association of the one-minute Apgar Score and intrapartum asphyxia in LBW infants (n-38) by measuring umbilical artery pH and base excess (BE) from double clamped cord and by comparing infant survival with One- and Five-minute Apgar scores (n=153). There was no correlation between Apgar score and cord pH or BE. pH varied from 6.91 to 7.55 and BE from -18 to -3 in the LBW infants with one-minute Apgar scores of 3 or less. In infants with Apgars of 4-7, pH varied from 7.13 to 7.50 and BE from -13 to -4. No consistent effect of anesthesia was apparent Survival was not predicted by cord pH or BE. 85% of LBW infants with one minute Apgars of 7 or greater survived. 46% of LBW infants with Apgars of 3 or less survived. The 5 minute Apgar score was also imprecise in predicting survival, since 25% of LBW infants with Apgars 7 expired. The Apgar score is not a reliable reflection of the intrapartum condition in LBW infants and is an imprecise predictor of survival. Low Apgar scores in LBW infants should not be used, formally or informally, to decide intervention in the delivery room.

We could not find documented in the literature the commonly held belief that breast feeding is more common in upper and middle class than in the lower socioeconomic mothers. We retrospectively studied the incidence of breast feeding in our “private” and “clinic” newborn infants for a period of three years & nine months. The study comprised 7,284 newborns delivered from October, 1976 to June, 1980. 3,807 (52.2%) were admitted to the “private” service and 3,477 (47.9%) to the “clinic” service. All infants were born at Thomas Jefferson University Hospital. The mothers were questioned in the delivery room as to the type of nursing they had chosen. Three different answers were obtained: breast, bottle or undecided. The overall incidence of breast feeding was 55% in the private vs. 41% in the service group. Undecided mothers were 3.1% in the first group & 5.9% in the second. Each successive year of the study showed an increase in the incidence of breast feeding. In the private group the incidence increased from 49.4% in the first year to 60.2% in the last one. There was also a rise in the “clinic” group from 22.7% to 31.7% over the same dates. Our findings point to the need for better education regarding the importance of breast feeding for all women, especially those from lower socioeconomic backgrounds. For this purpose we recommend that human lactation should be introduced in the curriculum of all high schools and special emphasis should be given to breast feeding in all our maternity clinics.