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Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches.

Aim To investigate the effects of 60 minutes delivery room skin-to-skin contact (DR-SSC) compared with 5 minutes visual contact (VC) on mother-child interaction (MCI), salivary cortisol, maternal depression, stress and bonding at 6 months corrected age. Methods A single-centre randomized controlled trial conducted in a German level III NICU. Eighty-eight preterm infants (25-32 weeks of gestational age) were randomized after initial stabilization to either 60 minutes DR-SSC or 5 minutes VC. Forty-five infants were allocated to DR-SSC, 43 to VC. Results Delivery room skin-to-skin contact dyads showed a higher quantity of maternal motoric (18 vs 15, P = .030), infant's vocal (7 vs 5, P = .044) and motoric (20 vs 15, P = .032) responses. Moreover, the combined score of maternal and infant responsive behaviour was higher (86 vs 71, P = .041) in DR-SSC dyads. DR-SSC mothers had lower risk of both, early postpartum depression (15% vs 45%, P = .003) and impaired bonding (Score 3 vs 5, P = .031). Conclusion In addition to regular intermittent kangaroo mother care, DR-SSC promotes MCI and decreases risk of maternal depression and bonding problems. Thus, DR-SSC may have positive effects on preterm development.

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).

Treatment with mechanical ventilation is associated with chronic lung disease and poor neurologic outcomes in very premature neonates. Surfactant replacement in patients with respiratory distress syndrome reduces need for mechanical ventilation and may be most beneficial when performed early.

Advances in perinatal science over the past five decades have reduced the practical ‘threshold of viability’ by approximately one week every 10 years such that survivors are expected as early as 22 weeks. Ethical standards regarding treatment of this periviable patient population remain enigmatic. Conclusion We review limitations in the current ethical rationale for caring for these infants in the delivery room and introduce an alternative utilising a delivery room hospice care approach involving the administration of opioids.

OBJECTIVE To analyze the usefulness of rapid HIV testing in pregnant patients in the delivery room. METHODS This prospective study compared a rapid test and a fourth-generation enzyme-linked immunoassay (ELISA) for HIV screening among pregnant patients admitted in labor with an unknown HIV status at a university hospital in Mexico between July 2015 and February 2016. Pearson correlation analysis was performed, and the diagnostic accuracy of the two tests was assessed with HIV RNA polymerase chain reaction (PCR) as the reference method. RESULTS Overall, 534 patients were included. With a signal-to-cutoff (S/CO) value of 1.0 or more as a diagnostic criterion, 6 (1.1%) patients had a positive ELISA result. Three had a negative rapid test and three had a positive test (r=0.705). With an S/CO value of 2.0 or more as cutoff, 4 (0.7%) patients had a positive ELISA result. Three had a positive rapid test and one had a negative test (r=0.865). Only three of six patients with an S/CO of 1.0 or more were confirmed to have HIV by RNA PCR. CONCLUSION The rapid test showed a strong correlation with the fourth-generation ELISA. Therefore, rapid testing is a useful tool in the delivery room for patients with unknown HIV status.

This study investigated whether continuous improvements to neonatal care and the legalisation of newborn euthanasia in 2005 had changed end-of-life decisions by Dutch neonatologists.We carried out a retrospective study of foetuses and neonates of more than 22 weeks' gestation that died in the delivery room or in the neonatal intensive care unit (NICU) of a tertiary referral hospital in the Netherlands, comparing end-of-life decisions and mortality in 2001-2003 and 2008-2010, before and after euthanasia legislation was introduced.In 2008-2010, there were more deaths in the delivery room due to termination of pregnancy than in 2001-2003 (17% versus 29%, p = 0.031), and fewer infants received comfort medication (12% versus 20%, p = 0.078). The main mode of death in the NICU was the withdrawal of life-sustaining therapy. The number of days that infants lived increased significantly between 2001-2003 (11.5 days) and 2008-2010 (18.4 days, p 0.006). Most infants received comfort medication, and neuromuscular blocking agents were administered incidentally.Terminations increased after changes in healthcare regulations. Modes of death in the NICU remained similar over 10 years. The increased duration of NICU treatment before dying suggests a more interventionist approach to treatment in 2008-2010.

Aim: Neonatal resuscitation requires minimal equipment, but the immediate availability of expert staff accounts for the largest proportion of the costs. Despite this, staff requirements and timetables are currently planned without comprehensive epidemiologic data. The aim of this study was to evaluate the staffing required for neonatal resuscitations in the delivery room. Methods: We measured attendance for each specific role in a tertiary university-affiliated hospital and for four possible intervention levels: preparation time, basic paediatric care, moderate resuscitation and extended resuscitation. Results: Between 2005 and 2012, resuscitation staff attended 11 561 of the 32 799 births: 27.2% for preparation time, 17.7% for basic paediatric care, 6.4% for moderate resuscitation and 3.5% for extended resuscitation. Moderate and extended resuscitations occurred in roughly 10% of births and evenly during 24-h periods. Basic paediatric care levels were higher during weekday mornings, and extended resuscitations were uniformly distributed. However, there was a drop in all types of interventions around 7 a.m. to 8 a.m., when staff were changing shifts. Conclusion: Moderate and extended resuscitations occurred evenly over 24 h in roughly 10% of births, stressing the importance of having a highly competent neonatal team constantly available. All activities associated with resuscitation were lower during morning shift changes.

Aim: Neonatal resuscitation surveys have showed practice variations between countries, centres and levels of care. We evaluated delivery room practices after a nationwide neonatal resuscitation training programme focused on nontertiary centres. Methods: A 2012 survey sent to all Spanish hospitals handling deliveries covered staff availability and training, equipment and practices in the delivery room and during transfers to neonatal intensive care units. The results from 98 centres that had completed a previous survey in 2007 were analysed by levels of care. Pearson's chi-square test was used to compare the proportions. Results: The following had significantly improved in 2012 compared to 2007: the availability of T-piece resuscitators (71.4% vs. 41.8%), plastic wraps (69.4% vs. 31.6%), gas blenders (79.6% vs. 40.8%), pulse oximetry (92.9% vs. 61.2%), use of continuous positive airway pressure (82.7% vs. 43.9%) (all p < 0.01), the availability of instructors (55.6% vs. 83.3%, p < 0.05) and neonatal resuscitation courses (40.8% vs. 79.6%, p < 0.05) in nontertiary centres. In 2012, the use of exhaled carbon dioxide detectors was < 7% and endotracheal administration of adrenaline was >90%. Conclusion: Neonatal resuscitation equipment and practices improved over time, but several aspects needed to be reinforced in training programmes, namely preterm infants' management, monitoring and adrenaline administration.

Background The aim of this study was to determine the current neonatal resuscitation practices for term infants in Japan, immediately before the 2010 publication of the international neonatal resuscitation consensus. Methods In January 2010, a 26-question survey was mailed to neonatal department directors. Results A total of 287 neonatal departments were identified. Four surveys were returned as undeliverable. A total of 191 surveys were returned completed, but four departments had no labor and delivery rooms (66.6% response rate, 65.2% survey available response rate). Flow-inflating bags were most commonly used (63.2%), followed by self-inflating bags (35.8%), and T-piece resuscitators (1.0%). Among the participants, 42.1% used oxygen blenders, 56.2% used pure oxygen for initial resuscitation, and 79.5% used a pulse oximeter to change the fraction of inspired oxygen. Among the participants, 45.3% used carbon dioxide detectors to confirm intubation, 42.5% routinely used the detectors, and 55.2% used them when confirming a difficult intubation. In addition, 42.5% of the participants used continuous positive airway pressure to treat breathing problems, most commonly with flow-inflating bags (93.2%). Conclusions The equipment and techniques used in Japanese perinatal center delivery room resuscitation practices are highly varied. Further research is required to determine which devices and techniques are appropriate for this important and common intervention.

Background Delivery of a macrosomic fetus can be linked with significant maternal and perinatal morbidity. Detection of the macrosomic fetus prior to delivery could have a significant impact on reducing that morbidity. Aims The purpose of this study was to determine the likelihood of detection of macrosomia at the time of labour and delivery admission using ultrasound. Methods Retrospective review using the electronic medical record and delivery room logs to identify women admitted to labour and delivery with a birthweight of ≥4000 g. Results There were 272 macrosomic neonates delivered between January 2010 and December 2012, of which, 91 (33.46%) were identified as macrosomic by ultrasound. Using Spearman correlation, the association between the estimated fetal weight by ultrasound and birthweight was r = 0.214 (95% CI: 0.098–0.325; P = 0.0004). In bivariate analyses, only White race was significant for macrosomia detection with 59 of 149 (39.6%) identified compared with 32 of 123 (26.02%) (P = 0.020) non-White people. In the multivariate model, race remained significant. The odds of being labelled macrosomia for White people was 2.051 (95% CI: 1.188–3.542) compared with non-White people (P = 0.010). Conclusions Only 33% of fetuses whose birthweight was ≥4000 g were identified by a labour and delivery ultrasound. White race was the only significant factor that increased the odds of having a correct diagnosis of macrosomia by ultrasound.

Background Expertise in neonatal resuscitation is essential for personnel involved in the care of newborns. In this observational cohort study the skills of 52 midwives in a simulated scenario were assessed. Methods A total of 52 midwives in a low-risk unit and five specialist nurses in a high-risk unit were tested to establish their competence in newborn resuscitation. The 52 midwives were divided into groups 1 (n = 39; no pretest training) and 2 (n = 13; 1 day training prior to study). The video-recorded test scenario was a newborn with asphyxia. Thirty items were graded by a neonatologist and nursing team in real time. Using the Angoff method, a pass score was 18.71 for skills that were graded 0 or 1. Results The average score of specialist nurses was 26 (range, 23–29). A total of 49% of midwives in group 1 and 92% in group 2 passed the test. The average score was 17.7 (range, 9–25) in group 1 and 21.9 (range, 17–27) in group 2. A total of 27% and 77% of midwives in groups 1 and 2, respectively, carried out ventilation at a frequency as per the algorithm. Mask leakage was higher in group 1 (44%) versus group 2 (23%). Five and three midwives in groups 1 and 2, respectively, overexpanded the lungs. Conclusion Many midwives had imperfect resuscitation skills. A 1 day course improved such skills. The standard scenario is an objective and useful performance marker in assessing and documenting improvements in competence in delivery room resuscitation.

Aim: To describe decisions made for babies who died in the delivery room as a result of clinical practice of non-resuscitation or unsuccessful resuscitation.

Background: Delivery room resuscitation of hypoxic newborn infants with pure or 100% oxygen causes oxidative toxicity and increases mortality. Current international resuscitation guidelines therefore recommend that oxygen be used judiciously. However, this requires staff education and special equipment that may not be available in non-tertiary maternity hospitals where the majority of births occur. Aim: To determine current attitudes, practices and available equipment for the use of air and blended oxygen for newborn delivery room resuscitation in non-tertiary maternity hospitals of Australia and New Zealand (ANZ). Methods: Structured questionnaires sent by mail and e-mail after personal phone contact. A total of 203 eligible hospitals in ANZ were identified. A second mailing was conducted a month later for non-responders. Responders: Final response rate was 64% (n= 130: 70% physicians, 30% midwives). The majority (121, 93%) of respondents were aware of Australian Resuscitation Council recommendations, but only one in five hospitals had the capacity to deliver blended oxygen and 38% used pulse oximeters at delivery. Only 24 (18.5%) hospitals had guidelines. Air would be used by 68 (57%) hospitals to resuscitate term infants compared to 35 (31%) for preterm infants. Most (111, 91%) advocated the use of blended oxygen despite the lack of facilities. Conclusion: Only one in five ANZ non-tertiary maternity hospitals had the capacity to resuscitate newborn infants with air or blended oxygen. Most are aware of current recommendations and agreed that the use of less oxygen would be beneficial for this purpose. Further study into the necessary infrastructure required to implement these guidelines are recommended.

Resuscitation of newborns has been described since ancient times and is among the most commonly performed emergency medical interventions. The International Liaison Committee on Resuscitation first made recommendations on resuscitation in newborns in 1999. Over the last decade, new research and careful review of the available evidence have resulted in substantial changes to these recommendations - in particular, regarding the assessment of colour, giving supplemental oxygen, suctioning infants born through meconium-stained liquor, confirming endotracheal tube position, the use of pulse oximetry, giving CPAP to premature infants, keeping preterm infants warm using polyethylene wrapping and cooling term infants with encephalopathy. This process has also highlighted the paucity of evidence to support much of the care given to infants in the delivery room and the need for research to refine our techniques.

Aim: The aim of this study was to determine the frequency, risk factors and anthropometric measurements of fetally malnourished, liveborn singleton term neonates. Methods: The computed delivery room data of 11.741 liveborn singleton term neonates was used to compare malnourished and nourished newborns. Results: Of the total subjects, 577 (4.9%) were malnourished. There were no differences between the groups with regard to gender distribution, Apgar scores, maternal parity, smoking during pregnancy and type of delivery. Maternal age and neonatal gestational age (GA) were significantly lower in malnourished newborns (P < 0.001). Birthweight (BW), birth length (BL) and head circumference (HC) were significantly lower in the malnourished group compared with well-nourished group (P < 0.001). Mean BW (g) was 2724.7 ± 17.0 in the malnourished group versus 3234.3 ± 3.8 in the well-nourished group; BL (cm) was 47.8 ± 0.1 in malnourished versus 49.5 ± 0.0 in well-nourished neonates; HC (cm) was 33.25 ± 0.1 in the malnourished versus 34.3 ± 0.0 in the well-nourished group. Between the groups, there were significant differences in the ratio of small, appropriate and large for GA (P < 0.001). Of the malnourished newborns, 35.5% were small for GA, 63.3% were appropriate for GA and 1.2% were large for GA. Conclusion: Fetal malnutrition (FM) still exists despite the advances in current obstetric care. Neonates of adolescent mothers and of low GA are particularly at risk for FM. The BW, BL and HC of fetally malnourished neonates are lower than that of well-nourished neonates. Like term singleton appropriate and small for GA neonates, term singleton large for GA neonates could also have been fetally malnourished.

Aims: To compare the admission temperature of infants treated with polyethylene bags alone to infants treated with exothermic mattresses in addition to bags in the delivery room. Methods: We prospectively studied infants born at

Aim: The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self-inflating bag with a positive end expiratory pressure (PEEP) valve, a T-piece resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and PEEP. Methods: Participants were asked to use each device to give positive pressure ventilation to a modified neonatal mannequin via a face mask to achieve 40–60 inflations per minute, aiming for a PIP/PEEP of 30/5 cm H2O. A manometer was visible to participants with each device. PIP, PEEP, percentage leak at the face mask and expired tidal volume were measured using a hot-wire anemometer. We analysed 20 inflations from each participant for each device. Results: Fifty participants provided PIP and PEEP with each device. The T-piece was the most accurate and consistent. The flow-inflating bag had the most variation. The leak was lowest with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide variation. Conclusion: Each device was able to provide PIP and PEEP when used appropriately. When compared with other resuscitation devices, the T-piece provided the most accurate and consistent PIP and PEEP.

Dr Jennifer Dawson, Neonatal Services, NewbornResearch, 7th Floor, The Royal Women’s Hospital, 20 Flemington Road,Parkville, Vic. 3052, Australia. Fax: 0011 61 38345 3789; email:jennifer.dawson@thewomens.org.auConflictofinterest:Masimoprovidedthepulseoximeterandprobesforthisstudy; however, they had no involvement in the study design, data collec-tion or interpretation, or the decision to present or publish the results.Accepted for publication 29 November 2010.

Aim To assess the time to obtain reliable oxygen saturation readings by different pulse oximeters during neonatal resuscitation in the delivery room or NICU.

Background: In June 2014, the Argentinean Ministry of Health published guidelines for the management of neonates born at the limit of viability (≤25 weeks of gestation). We explored the opinion of neonatologists in Buenos Aires, Argentina, regarding the initiation of life‐sustaining treatment (LST) in critically ill neonates, focusing on the effect of sociocultural factors on their opinion. Methods: An anonymous survey was designed to explore the opinions of Argentinean neonatologists on whether or not to initiate LST in newborns born prematurely. Five hundred eighty neonatologists from 36 neonatal units were invited to participate, and 315 specialists from 34 neonatal units completed the survey (response rate 54%). The survey was conducted between June 2014 and February 2015. Results: At 22 weeks, 9.5% (30/315) of the neonatologists answered they would begin LST on neonates born, 42.5% (134/315) at 23 weeks, 37% (117/315) at 24 weeks, 7% (22/315) at 25 weeks, and 4% (12/315) at ≥26 weeks. Cumulatively, then 96% of participants stated they would start LST at 25 weeks of gestation or less. On multivariate analysis, a “transcendent” value of life and lack of consideration of the local legal framework for making medical decisions in the delivery room were statistically associated with an opinion in favor of initiation of LST in neonates born at the limit of viability. More than 50% of the Argentinean neonatologists surveyed answered they would initiate treatment at a gestational age of less than 23 weeks, despite the fact that the recommendations of the Argentinean Ministry of Health are to only give comfort care for these neonates. The opinion of most Argentinean neonatologists surveyed thus differs from that recommended by the guidelines of Argentina. Conclusion: The most frequent opinion of Argentinean neonatologists was to initiate LST in neonates at the limit of viability. Certain factors, in particular the sense of a transcendent meaning to life and lack of consideration of the local legal framework for making medical decisions in the delivery room, seem to influence the decision to start LST. Fil: Silberberg, Agustín. Universidad Austral. Facultad de Ciencias Biomédicas; Argentina Fil: Villar, Marcelo Jose. Universidad Austral. Facultad de Ciencias Biomédicas; Argentina. Universidad Austral. Facultad de Ciencias Biomédicas. Instituto de Investigaciones en Medicina Traslacional. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones en Medicina Traslacional; Argentina Fil: Torres, Silvio. Universidad Austral. Facultad de Ciencias Biomédicas; Argentina

Aim: Neonatal resuscitation is a common and important intervention. International consensus statements advise how newborns should be resuscitated and suggest equipment to be used. Use of equipment not specifically recommended in these guidelines has been advocated. We wished to determine how widely this supplementary equipment is used in a geographically defined region. Methods: Each of the 25 tertiary perinatal centres with on-site deliveries in Australia and New Zealand was surveyed. The questionnaire asked about the use of the following items during delivery room resuscitation: pulse oximetry, exhaled carbon dioxide detection, polyethylene wrapping, oxygen blenders, laryngeal mask and oropharyngeal airways. Results: Data were obtained from all centres. Pulse oximetry is used at 12 (48%) centres. Exhaled CO2detection is used to confirm endotracheal tube placement at three (12%) of the centres. Polyethylene wrapping is used to prevent heat loss in very-low-birthweight infants at delivery at 11 (44%) centres. Oxygen blenders are used to modify the amount of oxygen delivered at nine (36%) centres. Laryngeal mask airways are infrequently used at two (8%) centres. Oropharyngeal airways are infrequently used at five (20%) centres. Conclusion: There is considerable variation in the equipment and techniques used to resuscitate newly born infants. Use of equipment not specifically recommended in international consensus statements is widespread. These are potentially effective tools to improve resuscitation. The evidence supporting their use is, however, limited. Urgent evaluation of their efficacy and safety is required before even more widespread use occurs.

In many fields of education, there is a significant gap between theoretical study and practical apprenticeship, which training in virtual environments (VEs) can close. Recently, a standalone prototype for virtual reality (VR)-based training in neonatal decision-making, called Virtual Delivery Room (VIDERO) was developed. This prototype enables a simple and time-efficient simulation of the arbitrary postnatal critical situations. The purpose behind this paper is twofold: to outline the role of trainee's immersion into VIDERO environment and to addresses the need for assessment and upgrading of training scenarios. In particular, the distributed services enabling fine-tuning of both virtual patient's behavioral model and trainee's interventions through the practice and user interactions in shared VE are described. © 2007 wiley Periodicals, Inc. Comput Appl Eng Educ 15: 329–339, 2007; Published online in Wiley InterScience (www.interscience.wiley.com); DOI 10.1002/cae.20120

Background: The increase in neonatal survival in recent decades has been followed by an increase in later disabilities. This has given rise to many new ethical issues. In different countries, efforts are being made to define ethical guidelines regarding withholding or withdrawing intensive care and end-of-life decisions in critically ill newborn infants. These guidelines have to be differentiated from ethical decision-making models which structure the process of decision making for an individual child. Such a framework has been in existence in our clinic for 10 years. Aim: The aims of this study were to evaluate how end-of-life decisions are taken in our perinatal centre and to analyse whether these decisions are consistent with our framework for structured ethical decision making. Methods: 199 consecutive neonatal deaths over 5 y were evaluated. Results: In 157 cases (79%), end-of-life decisions were taken according to our ethical framework; in the remaining 42 cases (21%), the baby died before this could be done. In 92% of cases, parents were involved in the decision and, in all cases but one, agreed with the decision. A patient's life was never intentionally and actively terminated. Conclusion: In contrast to earlier years, in-hospital death in our clinic is nowadays usually preceded by structured and documented medical end-of-life decisions.

Background and objectives. Collection strategy is the first step for collecting good quality cord blood (CB) units. There are two principal different techniques to collect CB from the umbilical vein: in the delivery room while the placenta is still in the uterus by midwives and obstetricians or in an adjacent room after placental delivery by CB-bank trained personnel. In this study, the benefits and disadvantages between two different CB collection strategies were evaluated in order to improve CB bank methodology. Design and methods. Valencia CB bank maintains the two different collection strategies aforementioned. Before processing CB units, volume was calculated and samples were drawn for cell counts. After processing and before cryopreservation, samples for cell counts, CD34 analysis, viability, clonogenic assays and microbiology were drawn directly from the bags. We compared the efficiency of the two collection techniques. Results. Obstetric date and umbilical CB was obtained from 848 vaginal (484 col...

Background: The aim of this study was to determine the usefulness of the three-lead electrocardiogram (ECG) during neonatal resuscitation. Methods: Both pulse oximetry (PO) and ECG were applied immediately after delivery to measure heart rate (HR). We reviewed video recordings of the respective monitors, and checked the time at which each monitor started to display reliable rate values. Results: In 20 deliveries, ECG showed HR much earlier than PO (median 38 s vs 122 s after delivery). ECG displayed reliable HR throughout resuscitation. We were able to confirm the effectiveness of the initial respiratory support from the elevation in HR. Conclusions: ECG was a safe and reliable method for showing HR, and was used to determine the initiation and the effectiveness of resuscitation in the delivery room.

Aim The optimal initial fraction of oxygen (iFiO2) for resuscitating/stabilising premature infants is not known. We aimed to study currently available information and provide guidelines regarding the iFiO2 levels needed to resuscitate/stabilise premature infants of ≤32 weeks' gestation. Methods Our systematic review and meta-analysis studied the effects of low and high iFiO2 during the resuscitation/stabilisation of 677 newborn babies ≤32 weeks' gestation. Results Ten randomised studies were identified covering 321 infants receiving low (0.21–0.30) iFiO2 levels and 356 receiving high (0.60–1.0) levels. Relative risk for mortality was 0.62 (95% CI: 0.37–1.04, I2 = 0%, pheterogeneity = 0.88) for low versus high iFiO2 ; for bronchopulmonary dysplasia, it was 1.11 (95% CI: 0.73–1.68, I2 = 46%, pheterogeneity = 0.06); and for intraventricular haemorrhage, it was 0.90 (95% CI: 0.53–1.53, I2 = 9%, pheterogeneity = 0.36). Conclusion These data show that reduced mortality approached significance when a low iFiO2 (0.21–0.30) was used for initial stabilisation, compared to a high iFiO2 (0.60–1.0). There was no significant association for bronchopulmonary dysplasia or intraventricular haemorrhage when comparing low and high iFiO2. Based on present data, premature babies ≤32 weeks' gestation in need of stabilisation in the delivery room should be given an iFiO2 of 0.21–0.30.

Objective: To study short- and long-term outcomes of infants ≤ 750 g birthweight who received cardiopulmonary resuscitation (CPR) in the delivery room. Methodology: A retrospective analysis of all inborn live births ≤ 750 g birthweight from 1990 to 1996. Cardiopulmonary resuscitation was defined as positive pressure ventilation via an endotracheal tube and chest compressions. Univariate analyses were conducted comparing patients according to the use of CPR or positive pressure ventilation alone. Results: Cardiopulmonary resuscitation was administered to 16 infants: four received chest compressions only and 12 also received adrenaline. Cardiopulmonary resuscitation recipients had significantly lower Apgar scores at both 1 and 5 min, and had delayed onset of spontaneous respiration (P < 0.01). Seven patients died, and eight of nine survivors were free of major neurodevelopmental abnormalities at follow up. All CPR recipients with a 5 min Apgar score of ≤ 5 and delayed onset of spontaneous respiration beyond 5 min had poor outcomes. Conclusion: Contrary to the majority of published evidence, delivery room CPR in our extremely small infants was not associated with a high risk of severe neurodevelopmental disability.

The care of infants born weighing less then 500 g is not only controversial but is also associated with medical uncertainties. We report the management of a growth retarded infant who weighed 280 g at birth after 26.9 weeks' gestation. The child not only survived but appears developmentally normal at two years of age. Although the infant is the smallest survivor reported, the case demonstrates the importance of gestational assessment in deciding delivery room management.

Summary. One hundred obstetricians and 50 paediatricians engaged in public antenatal and perinatal care in southern Italy were interviewed about the provision of care in their facilities: 93% of the obstetricians judged the coverage of the target population to be insufficient and 53% of them considered the use of the risk approach to be unsatisfactory in public clinics. For example, no initiative was taken by 60% of public clinics when a woman at high risk failed to attend a booked antenatal visit. Bed rest during labour was prescribed by 72% of the obstetricians, a supporting relative was admitted to only 18% of the births and routine episiotomy was performed in 77% of primigravidae. Only 56% of the paediatricians interviewed allowed early contact between mother and baby. In public hospitals, 80% of paediatricians were present in the delivery room for the births. Screening for congenital hypothyroidism and phenylketonuria was executed in only 37% of the public hospitals. Newborn transport system adequate to national standards was available in only 33% of the hospitals. Antenatal and perinatal care need to be rapidly improved to meet population needs in southern Italy.

The possible influence of the expectant mother's knowledge of childbirth on the outcome and experience of pregnancy and labour was investigated by means of a postpartum questionnaire in 1238 primiparae. The mothers were divided into two groups according to their basic childbirth knowledge. At birth, the conditions of newborns were equal in both groups when judged by Apgar scores. The low knowledge level group had small-for-gestational-age babies more frequently and these babies were also treated in the paediatric ward more frequently than those in the high knowledge group. The latter group was significantly more critical towards the staff of the delivery room and the postnatal ward; the fathers of this group were also present at delivery significantly more frequently. The low knowledge level group was significantly more unwilling to have another pregnancy in the near future or ever. The results indicate that low childbirth knowledge is associated with a poorer pregnancy outcome. It is a message to antenatal care staff of the need for support, supplementary education and careful obstetric surveillance. Low childbirth knowledge may imply a set of problems, including those in interparental relationship, socio-economic situation and need for close surveillance and improved education.

Background Modern fertilization techniques can lead to unexpected ABO phenotypes in newborn infants and can raise questions as to maternity, paternity, and infant misidentification. Ovum transplantation can result in an infant with an ABO phenotype that is unexpected, given the birth mother's ABO type. Study design and methods A group AB, Rh-positive female infant was born to a group O, Rh-positive woman as a result of ovum transplantation. The case report is provided. Results The birth mother typed group O, Rh-positive both before and after delivery. The infant typed group AB, Rh-positive on cord blood and heelstick specimens. Conclusion Ovum transplantation can result in newborns whose ABO phenotypes are unexpected, in relation to the birth mother's ABO type. To ensure patient privacy, such fertilization techniques may not be clearly documented in the delivery room chart. A complete obstetric history helps prevent repeat phlebotomies, expensive and unnecessary typing studies, and concern of the clinical staff with possible sample or infant misidentification.

Hammarlund, K. and Sedin, G. (Department of Paediatrics, University Hospital, Uppsala, Sweden). Water evaporation and heat exchange with the environment in newborn infants. Acta Paediatr Scand, Suppl. 305: 32–35, 1983.—The amount of water evaporated from the skin of newborn infants and the temperatures of the skin, the ambient air and the surfaces facing the infants were measured and used to calculate the evaporative, radiative and convective heat exchange between the infant and the environment in infants of varying gestational ages. Immediately after birth the evaporative heat exchange was very high but it then decreased gradually. The radiative heat exchange was very high in the delivery room but lower in the incubators. In incubators the evaporative heat exchange was high in the most pre-term infants, especially when nursed at a low ambient humidity. Different modes of heat exchange were interrelated, so that when the pre-term infants had a high evaporation rate, a high ambient temperature was needed and the heat exchange through radiation and convection decreased. Net heat exchange was lowest in very pre-term infants at an ambient humidity of 60%.