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Clinical decisions made in the delivery setting are often made under high pressure and great uncertainty, and have serious consequences for mother and baby. Theories of decision-making suggest that individuals in such settings may resort to using heuristics, or simplified decision rules, to aid complex decision-making. This study investigates whether physicians’ delivery mode decisions (i.e., when to perform a vaginal versus a cesarean delivery) are influenced by such a heuristic. Electronic health records spanning 86,000 deliveries suggest that if the prior patient had complications in one delivery mode, the physician will be more likely to switch to the other—and likely inappropriate—delivery mode for the subsequent patient, regardless of patient indications. There is evidence that this heuristic has small, suboptimal effects on patient health.

BACKGROUND Decreased availability of pediatric residents in neonatal intensive care units (NICUs) has created demand for other neonatal medical care providers. No recent publications exist about how to approach the organization of tasks involved in that care. PURPOSE The purpose of this article is to present a structure and resources to guide the organization of tasks in the care of sick and premature infants in the NICU. METHODS The methods included a literature review to develop evidenced-based practice resources. The literature was reviewed regarding the relevant history and resources to support task organization during patient rounds and care in the NICU, and for delivery attendance by skilled providers. The goal, to establish a reference to support education about these approaches, is based upon evidence, which appears to be rooted in tradition. FINDINGS Evidence-based resources include documentation templates, problem list in order of systems, and provider tasks for NICU and delivery attendance. IMPLICATION FOR RESEARCH Future studies can measure mentor or learner perceptions of the value of these resources, critical thinking improvement, safety, and clinical outcomes. IMPLICATION FOR PRACTICE These resources may provide structure for learners and providers who have studied the physiology, pathophysiology, and problem management concepts, but need to learn how to execute their responsibilities in these busy environments.

Objective Current delivery room (DR) resuscitation utilizes pressure-limited devices without tidal volume (TV) measurements. Clinicians use chest expansion as a surrogate, which is a poor indicator of TV. TV in early life can be highly variable due to rapidly changing lung compliance. Our objectives were to assess feasibility of measuring TV in DR, and to report the generated TV in intubated patients. Study design Prospective, observational, feasibility study in infants 6 ml/kg) provided 47.7% of times. Conclusion TV measurement in DR is feasible. It is associated with high intra and inter-patient variability.

The neonatal resuscitation program recommends a wide dose range of epinephrine for newborns who receive chest compressions (endotracheal tube [ET] dose of 0.05-0.1 mg/kg or intravenous [IV] dose of 0.01-0.03 mg/kg), which presents a challenge to neonatal care providers when attempting to determine the optimal initial dose. Dosing errors are common when preparing epinephrine for neonatal resuscitation. Based on animal data, we suggest preparing 0.1 mg/kg or 1 ml/kg of 1 mg/10 ml epinephrine in a 5 ml syringe for ET administration. For IV epinephrine, we suggest preparing an initial dose of 0.02 mg/kg or 0.2 ml/kg of 1 mg/10 ml epinephrine in a 1 ml syringe. A dose of 0.02 mg/kg enables use of a 1 ml syringe for a wide range of birth weights from 500 g to 5 kg. The use of a color-coded syringe may decrease errors in dose preparation.

Background Respiratory distress syndrome (RDS) is the most common cause of respiratory failure in preterm infants. Treatment consists of respiratory support and exogenous surfactant administration. Commonly, surfactant is administered intratracheally. However, this requires airway instrumentation and subsequent fluid instillation which may be harmful. Surfactant nebulization (SN) may offer a safe and effective alternative for surfactant administration, but the clinical efficacy is not yet established. Thus, this systematic review and meta-analysis of randomized controlled trials will summarize the available evidence to determine the effectiveness and safety of SN for the prevention of intubation and subsequent mechanical ventilation at 72 h after birth. Methods A systematic literature search in Medline, Embase, and The Cochrane Library will be performed, and all randomized controlled trials (RCTs) and quasi-RCTs from published articles, presentations, and trial registries will be included in this meta-analysis. Titles and abstracts of all records identified in the search will be screened by two reviewers independently. Data on preterm infants (≤ 37 weeks) receiving nebulized surfactant in the first 72 h after birth for the treatment or prevention of RDS will be evaluated. Primary outcome is the intubation rate by 72 h after birth, and secondary outcomes include peridosing safety effects as well as major neonatal morbidities. Risk of bias will be assessed using the revised Cochrane ROB tool, and subgroup analyses will be performed to evaluate potential confounding factors. Publication bias will be assessed by examining a funnel plot. The meta-analysis will be performed using a fixed-effects model. Discussion This review will provide an evidence-based tool for information about surfactant nebulization, illustrating the current knowledge and hopefully revealing potential novel avenues for researchers and clinicians alike. Systematic review registration This review is registered with the publicly available resource PROSPERO (CRD42020175625).

Aim Following extreme preterm birth, there has traditionally been felt an imperative to rush baby to the neonatal unit for ongoing intensive care. Immediate needs of parents to bond with their babies through direct early physical contact have often been overlooked; many weeks can pass before parents get to hold their babies for the first time. Recognition of the importance of early contact is growing. We aimed to review the safety and value of routinely practising delivery room cuddles for extremely preterm babies. Methods We reviewed delivery room cuddles in babies born

To evaluate the Doppler changes in the intracranial arteries of neonates exposed to perinatal hypoxic insult and compare it with normal neonates.Color Doppler of bilateral anterior and middle cerebral arteries was performed within 6 h of birth in 26 healthy neonates and 50 neonates who received delivery room resuscitation (DRR) for perinatal depression and had a 5 min Apgar score7. Comparisons of resistive index (RI) and peak systolic velocity (PSV) were made between the (a) control group (b) patients with low 5 min Apgar score7 who without clinical features of neonatal encephalopathy at 24 h (c) neonates with perinatal depression with a clinical evidence of disturbed neurological function at 24 h of birth and examination consistent with mild, moderate, or severe encephalopathy using modified Sarnat and Sarnat's classification.Significantly higher RI was observed in the neonates with to perinatal depression compared to the normal neonates. Significantly higher RI was seen in the patients with clinical features of neonatal encephalopathy (Group C) compared to group B. RI0.6 and0.82 was associated with severe neonatal encephalopathy. Differences in PSV were not statistically significant in the various groups.The study presents the changes in early cerebral Doppler parameters observed in neonates with low 5 min Apgar score following DRR compared to the normal neonates. We also present the relations of Doppler parameters with increasing severity of neonatal encephalopathy according to Sarnat classification.

ObjectiveInformed consent is standard in research. International guidelines allow for research without prior consent in emergent situations, such as neonatal resuscitation. Research without prior consent was incorporated in the Vermont Oxford Network Heat Loss Prevention Trial. We evaluated whether significant differences in outcomes exist based on the consent method.DesignSubgroup analysis of infants enrolled in a randomised controlled trial conducted from 2004 to 2010.SettingA multicentre trial with 38 participating centres.ParticipantsInfants born 24–27 weeks of gestation. 3048 infants assessed, 2231 excluded due to fetal congenital anomalies, failure to obtain consent or gestation less than 24 weeks. 817 randomised, 4 withdrew consent, total of 813 analysed.Main outcome measureThe difference in mortality between consent groups.ResultsNo significant differences were found in mortality at 36 weeks (80.2%, 77.4%, p=0.492) or 6 months corrected gestational age (80.7%, 79.7%, p=0.765). Infants enrolled after informed consent were more likely to have mothers who had received antenatal steroids (95.2%, 84.0%, pConclusions and relevanceResearch without prior consent resulted in the inclusion of infants with different baseline characteristics than those enrolled after informed consent. There were no significant differences in mortality. Significantly higher Apgar scores in the informed consent group suggest that some of the sicker infants would have been excluded from enrolment under informed consent. Research without prior consent should be considered in neonatal resuscitation research.

Establishing effective respiration is vital in the transition from fetal to neonatal life. Respiratory support mainly facilitates and creates functional residual capacity and maintains adequate gas exchange. Sustained inflation (SI) delivers prolonged inflation and rapidly creates and establishes the functional residual capacity. The use of SI in preterm infants in the delivery room is still controversial. The optimum settings of SI remain unknown. Animal studies and clinical reports have demonstrated the advantages and disadvantages of SI. In this article, the current literature was reviewed to examine the efficacy of SI in infants.

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.

Objective Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period. Study Design Retrospective, single-center study of infants delivered Results The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula. Conclusion When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished. Key Points

Objective: It has been suggested that desaturations and bradycardia precede acute life-threatening events (ALTE) and that ALTE is more common in the delivery room than later in life. However, frequency, duration and severity of desaturations in the first hours of life and additional risk factors have not readily been studied. Methods: Term neonates (n = 100) were monitored for the first two hours after birth by pulse oximetry. The impact of maternal and perinatal factors on the frequency and severity of desaturations (Results: Desaturations were detected in 30%, prolonged desaturations in 25% of infants. Desaturations were observed significantly more often in infants born by planned Cesarean section (pCs) compared to other modes of delivery (pCs 20/49; others 10/51; p = .029). Desaturations were also more frequent in infants diagnosed with neonatal infection (NI) or infants born to a mother with gestational diabetes (GDM), although not significantly. No bradycardia Conclusions: In our collective 4% of healthy term neonates had prolonged, clinically relevant desaturations in the first hours after birth. The mode of delivery and maternal risk factors may increase the risk for these events. However, our cohort was too small to detect any ALTE or SIDS and determine potential risk factors for these events. Our data lay ground for a large-scale prospective trial to investigate whether the mode of delivery could be an indication for general pulse oximetry monitoring of newborn in the delivery room.

AIM: Flow Disruptions (FDs) are deviations from the progression of care that compromise safety and efficiency of a specific process. The study aim was to identify the impact of FDs during neonatal resuscitation and determine their association with key process and outcome measures. METHODS: Prospective observational study of video recorded delivery room resuscitations of neonates

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.

Congenital diaphragmatic hernia (CDH) is associated with high mortality rates and significant pulmonary morbidity, mainly due to disrupted lung development related to herniation of abdominal organs into the chest. Pulmonary hypertension is a major contributor to both mortality and morbidity, however, treatment modalities are limited. Novel prenatal and postnatal interventions, such as fetal surgery and medical treatments, are currently under investigation. Until now, the perinatal stabilisation period immediately after birth has been relatively overlooked, although optimising support in these early stages may be vital in improving outcomes. Moreover, physiological parameters obtained from the perinatal stabilisation period could serve as early predictors of adverse outcomes, thereby facilitating both prevention and early treatment of these conditions. In this review, we focus on the perinatal stabilisation period by discussing the current delivery room guidelines in infants born with CDH, the physiological changes occurring during the fetal-to-neonatal transition in CDH, novel delivery room strategies and early predictors of adverse outcomes. The combination of improvements in the perinatal stabilisation period and early prediction of adverse outcomes may mitigate the need for specific postnatal management strategies.

Background: We aimed to evaluate the policies and practices about neonatal resuscitation in a large sample of European hospitals. Methods: This was a cross-sectional electronic survey. A 91-item questionnaire focusing on the current delivery room practices in neonatal resuscitation domains was individually sent to the directors of 730 European neonatal facilities or (in 5 countries) made available as a Web-based link. A comparison was made between hospitals with ≤2,000 and those with >2,000 births/year and between hospitals in 5 European areas (Eastern Europe, Italy, Mediterranean countries, Turkey, and Western Europe). Results: The response rate was 57% and included participants from 33 European countries. In 2018, approximately 1.27 million births occurred at the participating hospitals, with a median of 1,900 births/center (interquartile range: 1,400–3,000). Routine antenatal counseling (p < 0.05), the presence of a resuscitation team at all deliveries (p < 0.01), umbilical cord management (p < 0.01), practices for thermal management (p < 0.05), and heart rate monitoring (p < 0.01) were significantly different between hospitals with ≤2,000 births/year and those with >2,000 births/year. Ethical and educational aspects were similar between hospitals with low and high birth volumes. Significant variance in practice, ethical decision-making, and training programs were found between hospitals in 5 different European areas. Conclusions: Several recommendations about available equipment and clinical practices recommended by the international guidelines are already implemented by centers in Europe, but a large variance still persists. Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs.

The care of infants born at the lowest extreme of gestation requires dedication, skill, and experience. Most centers apply a selective approach where intensive care at these gestational ages is being offered to a varying proportion of infants depending on the views and experiences of the medical community, the individual physician, and the parents. Consequently, the outcomes differ dramatically with survival rates at 22-23 weeks ranging from 0 to greater than 50%. This paper presents the approach in a center with a long tradition of providing a comprehensive and uniformly active care to all mother-infant dyads from 22+0 weeks of gestation. Important features outlined include prenatal maternal referral and transfer, delivery room management, and initial intensive care.

Background Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room. Objective To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation. Content Covered Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed. Discussion Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

BACKGROUND Preterm infants are commonly supported with 4-8 cm H2O continuous positive airway pressures (CPAP), although higher CPAP levels may improve functional residual capacity (FRC). METHODS Preterm rabbits delivered at 29/32 days (~26-28 weeks human) gestation received 0, 5, 8, 12, 15 cm H2O of CPAP or variable CPAP of 15 to 5 or 15 to 8 cm H2O (decreasing ~2 cm H2O/min) for up to 10 min after birth. RESULTS FRC was lower in the 0 (6.8 (1.0-11.2) mL/kg) and 5 (10.1 (1.1-16.8) mL/kg) compared to the 15 (18.8 (10.9-22.4) mL/kg) cm H2O groups (p = 0.003). Fewer kittens achieved FRC > 15 mL/kg in the 0 (20%), compared to 8 (36%), 12 (60%) and 15 (73%) cm H2O groups (p = 0.008). While breathing rates were not different (p = 0.096), apnoea tended to occur more often with CPAP

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).

Background: Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized. Objective: The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes. Design: This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes. Results: There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06–2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26–0.71). Conclusion: Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.

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.

Point of care ultrasound has emerged as useful tool in cardiac arrest situations in adult population. Despite of these, there is not a protocol for cardiopulmonary resuscitation in the delivery room for newborns. We describe two case were ultrasound helped to rule out the cardiopulmonary arrest case and we propose and algorithm were ultrasound is integrated in the newborn resuscitation and may help to diagnose the cardiac arrest cause.

Objective Identify clinical factors, transport characteristics and transport time intervals associated with clinical deterioration during neonatal transport in California. Study design Population-based database was used to evaluate 47,794 infants transported before 7 days after birth from 2007 to 2016. Log binomial regression was used to estimate relative risks. Results 30.8% of infants had clinical deterioration. Clinical deterioration was associated with prematurity, delivery room resuscitation, severe birth defects, emergent transports, transports by helicopter and requests for delivery room attendance. When evaluating transport time intervals, time required for evaluation by the transport team was associated with increased risk of clinical deterioration. Modifiable transport intervals were not associated with increased risk. Conclusion Our results suggest that high-risk infants are more likely to be unstable during transport. Coordination and timing of neonatal transport in California appears to be effective and does not seem to contribute to clinical deterioration despite variation in the duration of these processes.

The assessment of newborns' heart rate (HR) in the delivery room is one of the important steps to ascertain the need for initiation and continuation of resuscitation. At present, ECG is the "gold standard" to monitor neonatal HR in the delivery room. However, various limitations with the use of ECG exist. Furthermore, in developing countries, ECG may not be universally available in delivery rooms.To compare the accuracy and HR acquisition time of portable Doppler ultrasound (PDU) versus electrocardiogram (ECG) in newborns.This multicenter, prospective, observational study across five centers in India between January and September 2017 included neonates more than 34 weeks of gestation (Mean (±SD) gestational age and birthweight were 37.7 (±1.2) weeks and 2954 (±457) g, respectively. The mean (±SD) visible HRPortable Doppler has similar accuracy to ECG and is faster in acquiring the signal.

Background Sudden unexpected postnatal collapse of presumably healthy neonates during early skin-to-skin contact is a rare, yet recognized occurrence, associated with a high risk of mortality and morbidity. A survey was conducted in 2012 in 30 delivery wards throughout Piedmont and the Aosta Valley to evaluate the environmental and logistical aspects that could be linked to SUPC. The survey was again conducted in 2016 in 28 delivery wards in Piedmont and the Aosta Valley in order to evaluate organizational improvements introduced after ministerial indications and recommendations by the Italian Society of Neonatology were published in 2014, in light of new findings regarding the phenomenon. Methods A questionnaire specifically asking about the organization of delivery wards, and surveillance or supervision during early skin-to-skin contact, was sent to all of the hospitals taking part in the survey in both 2012 and 2016. The collected data were elaborated anonymously and the statistical analysis was performed by using the two by two table. Results In 2012, 28 out of 30 delivery wards in Piedmont and Aosta, with a total of 31,074 newborns out of 35,435, were evaluated in all of the environmental and logistical aspects that might be cause for SUPC to occur. An identical survey was taken again in 2016; 26 out of 28 wards participated with a total of 27,484 newborns out of 30,339. In 2012, early skin-to-skin contact took place immediately in all the delivery rooms in 27 wards, and soon after in the post-partum room in one; in 11 out of 28 wards there was early skin-to-skin contact in the operating theater itself, following caesarean sections (11/26 in 2016). Routine newborn care was given after 3 h in 8 delivery wards (7/26 in 2016); after 2 h in 12 (7/26 in 2016); after 1 h in 2 (4/26 in 2016); after 30 min in 3 (2/26 in 2016); after 10 min in 1 (0/26 in 2016); after 1 or 2 min in 1 (0/26 in 2016) and at any time in one ward (6/26 in 2016). Conclusion Periodic surveys of delivery wards are useful for the assessment of all the aspects and risk factors that need to be changed in order to implement safe early skin-to-skin contact. Electronic supplementary material The online version of this article (10.1186/s13052-019-0688-9) contains supplementary material, which is available to authorized users.

ObjectiveTo compare neonatal outcomes in singletons versus multiples, first-born versus second-born multiples and monochorionic versus dichorionic/trichorionic multiples DesignRetrospective, observational study of 529 preterm infants receiving ≥30 s DCC. Generalised estimating equations and mixed effects models were used to compare outcomes in singletons versus multiples and monochorionic versus dichorionic/trichorionic multiples. Wilcoxon signed-rank and McNemar tests were used to compare first-born versus second-born multiples.SettingLevel III neonatal intensive care unit, California, USA.Patients433 singletons and 96 multiples Results86% of multiples and 83% of singletons received DCC. Multiples had higher GA (31.0 weeks vs 30.6 weeks), more caesarean sections (91% vs 54%), fewer males (48% vs 62%) and higher 12–24 hour haematocrits (54.3 vs 50.5) than singletons. Haematocrit difference remained significant after adjusting for birth weight, delivery type and sex. Compared with first-born multiples, second-born multiples were smaller (1550 g vs 1438 g) and had lower survival without major morbidity (91% vs 77%). Survival without major morbidity was not significant after adjusting for birth weight. Compared with dichorionic/trichorionic multiples, monochorionic multiples had slightly lower admission temperatures (37.0°C vs 36.8°C), although this difference was not clinically significant. There were no other differences in delivery room, respiratory, haematological or neonatal outcomes between singletons and multiples or between multiples’ subgroups.ConclusionsNeonatal outcomes in preterm infants receiving DCC were comparable between singletons and multiples, first and second order multiples and monochorionic and dichorionic/trichorionic multiples.

Objective To investigate if the use of a visible respiratory function monitor (RFM) to use lower tidal volumes (Vts) during positive pressure ventilation (PPV) in the delivery room (DR) reduces the need of surfactant administration and invasive mechanical ventilation during the first 72 hours after birth of preterm infants Study Design Infants Results Median expiratory Vts during inflations were greater in the masked group (7 mL/kg) than in the visible group (5.8 mL/kg; p = 0.001) same as peak inflation pressure (PIP) administered (21.5 vs. 19.7 cmH2O; p Conclusion Using a RFM in the DR prevents the use of large Vt and PIP during respiratory support inflations, mostly in the more immature newborn infants, but with no other short-term benefits.

Objective To determine the frequency, type, and severity of adverse events (AEs) during intrahospital transport of newborn infants and to identify associated factors. Study design We conducted a prospective observational study in a tertiary care academic neonatal unit. All patients hospitalized in the neonatal unit and undergoing intrahospital transport between June 1, 2015, and May 31, 2017 were included. Transports from other hospitals and the delivery room were not included. Results Data from 990 intrahospital transports performed in 293 newborn infants were analyzed. The median postnatal age at transport was 13 days (Q1-Q3, 5-44). Adverse events occurred in 25% of transports (248/990) and were mainly related to instability of cardiovascular and respiratory systems, agitation, and temperature control. Adverse events were associated with no harm in 207 transports (207/990, 21%), mild harm in 37 transports (37/990, 4%), and moderate harm in 4 transports (4/990, 0.4%). There was no severe or lethal adverse event. Hemodynamic support with catecholamines, the presence of a central venous catheter, and a longer duration of transport were independent predictors for the occurrence of adverse events during transport. Conclusions Intrahospital transports of newborns are associated with a substantial proportion of adverse events of low-to-moderate severity. Our data have implications to inform clinical practice, for benchmarking and quality improvement initiatives, and for the development of specific guidelines.

Background The Apgar score is the most common score used to quantify neonatal status after birth. It is routinely used in clinical practice and research. However, since its introduction there have been significant changes in peripartum and neonatal management, our understanding of neonatal physiology, and changes in data analysis capabilities. Purpose To assess the Apgar score's reliability and validity in the context of today's clinical and research environments. Method PubMed was searched using the term "Apgar." Just over 22,000 titles were identified. Full-text articles were obtained if they addressed the Apgar score's use, reliability, and validity, or if the score was a primary outcome measure. This was followed by a hand search using the same criteria. The 505 identified articles build the basis for this discussion of the Apgar score's reliability and validity. Findings Multiple positive and negative aspects of the Apgar score's reliability and validity were identified. Some facets needed to evaluate reliability and validity do not seem to have been addressed in the literature. Overall, the identified concerns can introduce bias into outcomes obtained via the use of the Apgar score in both clinical practice and research. Implications for practice The Apgar score is no longer used to determine neonatal management in the delivery room. Implications for research The use of the Apgar score in research may introduce bias into outcomes. As discussed in the Video Abstract, researchers need to address and improve the score's weaknesses or consider developing a new tool better suited to today's research needs. Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Delivery complications can influence later decision-making

Background Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting. Methods A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation. Results Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96–1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference −11 seconds, 95% confidence interval −39 to 18). Conclusions In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers. Clinical trials registration clinicalTrial.gov: NCT04056091.

Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.

Background Quality care during childbirth requires that health care providers have not only excellent skills but also appropriate and considerate attitudes and behavior. Few studies have examined the proportion of women in Western countries expressing dissatisfaction with such inappropriate or inconsiderate behavior. This study evaluated this proportion in a sample presumably representative of French maternity units. Methods This prospective multicenter study, using data from a selfadministered questionnaire, took place in 25 French maternity units during one week in September 2018. The primary outcome measure was mothers' self-reported dissatisfaction with blatantly inappropriate behavior (ie, inappropriate attitude, inadequate respect for privacy, insufficient gentleness of care, and/or inappropriate language) by health care workers in the delivery room. The secondary outcome was their self-reported dissatisfaction with these workers' inconsiderate behavior (ie, unclear and inappropriate information, insufficient participation in decision-making, or deficient consideration of pain). Results Of 803 potentially eligible women, 627 completed the questionnaire after childbirth; 5.62% (35/623, 95% CI: 3.94-7.73) reported dissatisfaction with blatantly inappropriate behaviors and 9.79% (61/623, 95% CI: 7.57-12.40) with inconsiderate behaviors. The main causes of dissatisfaction reported by women in this survey were the inadequate consideration of their pain and the failure to share decision-making. Conclusions Most of the women were satisfied with how health care workers behaved towards them in the delivery room. Nonetheless, health care staff must be aware of women's demands for greater consideration of their expressions of pain and of their voice in decisions.

This study was aimed to explore the attitude of Argentinean neonatologists in the delivery room on resuscitating infants with trisomies.An anonymous questionnaire was completed by neonatologists staffing level-III neonatal intensive care units (NICUs) on resuscitation of children with trisomies 21, 18, and 13. Potential sociocultural factors influencing the decision to resuscitate were included.Overall, 314 neonatologists in 34 units in the Buenos Aires region participated (response rate of 54%). The position of neonatologists regarding the resuscitation in the delivery room was that 98% would resuscitate newborns with trisomy 21, and 47% with trisomy 18 or trisomy 13. Resuscitation of newborns with trisomy 18 or trisomy 13 by neonatologists was significantly associated with working in the public sector, religious beliefs, and legal framework.With improvement in the management and treatment of infants with trisomies 18 and 13, Argentinean neonatologists showed a favorable attitude toward resuscitating them in the delivery room.· We explored the attitudes of Argentinean neonatologists on resuscitation of children with trisomies.. · Half of neonatologists would resuscitate newborns with trisomies18 and 13.. · These results suggest an ongoing paradigm shift of the most severe trisomies..

Background and objective Healthcare providers should use personal protective equipment (PPE) when performing aerosol-generating medical procedures during highly infectious respiratory pandemics. We aimed to compare the timing of neonatal resuscitation procedures in a manikin model with or without PPE for prevention of SARS-COVID-19 transmission. Methods A randomised controlled cross-over (AB/BA) trial of resuscitation with or without PPE in a neonatal resuscitation scenario. Forty-eight participants were divided in 12 consultant–nurse teams and 12 resident–nurse teams. The primary outcome measure was the time of positive pressure ventilation (PPV) initiation. The secondary outcome measures were duration of tracheal intubation procedure, time of initiation of chest compressions, correct use of PPE and discomfort/limitations using PPE. Results There were significant differences in timing of PPV initiation (consultant–nurse teams: mean difference (MD) 6.0 s, 95% CI 1.1 to 10.9 s; resident–nurse teams: MD 11.0 s, 95% CI 1.9 to 20.0 s), duration of tracheal intubation (consultant–nurse teams: MD 22.0 s, 95% CI 7.0 to 36.9 s; resident–nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s) and chest compressions (consultant–nurse teams: MD 32.3 s, 95% CI 14.4 to 50.1 s; resident–nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s). Twelve participants completed the dressing after entering the delivery room. PPE was associated with visual limitations (43/48 participants), discomfort in movements (42/48), limitations in communication (32/48) and thermal discomfort (29/48). Conclusions In a manikin model, using PPE delayed neonatal resuscitation procedures with potential clinical impact. Healthcare workers reported limitations and discomfort when wearing PPE. Trial registration number NCT04666233., Unique study of neonatal resuscitation in PPE using a simulation model which identified small but potentially important differences in timings of key resus events. Also shows the inevitable discomfort and inconvenience of PPE in this scenario.

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).

Precise characterization of cardiac anatomy and physiology through fetal echocardiography can predict early postnatal clinical course. Some neonates with prenatally defined critical congenital heart disease have anticipated precipitous compromise during perinatal transition for which specialized, diagnosis-specific delivery room care can be arranged to expeditiously stabilize cardiopulmonary hemodynamics. In this article, we describe our institutional approach to the delivery room care of neonates with prenatally diagnosed congenital heart disease, emphasizing our diagnosis-specific care pathways for newborns with critical disease.

OBJECTIVES: To assess infection rates predischarge and postdischarge in breast milk–fed newborns with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive mothers who were separated postdelivery from their mothers and discharged from the hospital. Also, we aim to evaluate breastfeeding rates predischarge and postdischarge. METHODS: Nasopharyngeal swabs for SARS-CoV-2 were obtained from symptomatic and high-risk women in the delivery room. Mothers with positive SARS-CoV-2 test results were separated from the newborns. Newborns were screened within 48 hours of delivery, and anti-infectious guidelines were imparted to the mothers before discharge. Rescreening took place ≥14 days postdischarge. Data regarding SARS-CoV-2–positive household members and breastfeeding were obtained by follow-up phone calls. RESULTS: A total of 73 newborns of SARS-CoV-2–positive mothers were born in Israel during the ∼3-month period under study. Overall, 55 participated in this study. All neonates tested negative for the virus postdelivery. A total 74.5% of the neonates were fed unpasteurized expressed breast milk during the postpartum separation until discharge. Eighty-nine percent of the neonates were discharged from the hospital after their mothers were instructed in anti-infection measures. In 40% of the households, there were additional SARS-CoV-2–positive residents. A total of 85% of the newborns were breastfed postdischarge. Results for all 60% of the newborns retested for SARS-CoV-2 postdischarge were negative. CONCLUSIONS: No viral infection was identified in neonates born to and separated from their SARS-CoV-2–positive mothers at birth and subsequently fed unpasteurized breast milk. All infants breastfed at home remained SARS-CoV-2 negative. These findings may provide insights regarding the redundancy of postpartum mother-newborn separation in SARS-CoV-2–positive women and, assuming precautions are adhered to, support the safety of breast milk.

Coronavirus disease 2019 (COVID‐19) has spread worldwide within a short period, and there is still no sign of an end to the pandemic. Management of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐infected pregnant women at the time of delivery presents a unique challenge. To fulfill the goal of providing adequate management of such women and their infants, and to decrease the risk of exposure of the healthcare providers, tentative guidelines are needed until more evidence is collected. Practical preventative action is required that takes into account the following infection routes: (i) aerosol transmission from mothers to healthcare providers, (ii) horizontal transmission to healthcare providers from infants infected by their mothers, and (iii) horizontal transmission from mothers to infants. To develop standard operating procedures, briefings/training simulations should be carried out, taking into account the latest information. Briefings should be carefully conducted to clarify the role and procedures. Healthcare providers should wear personal protective equipment. If it is physically possible, neonatal resuscitation should be performed in a separate area next to the delivery room. If a separate area is not available, the infant warmer should be placed at least 2 m away from the delivery table, or partitioned off in the same room. A minimum number of skilled personnel should participate in resuscitation using the latest neonatal resuscitation algorithms.

The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection.To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department.A retrospective cohort study in one medical center. The population was women20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department.During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6,The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Objective This study aimed to use real-time safety audits to establish whether preparation of the equipment required for the stabilization and resuscitation of newborns in the delivery room areas is adequate. Study Design This was a descriptive, multicenter study performed at five-level III-A neonatal units in Madrid, Spain. For 1 year, one researcher from each center performed random real-time safety audits (RRTSAs), on different days and during different shifts, of at least three neonatal stabilization areas, either in the delivery room or in the operating room used for caesarean sections. Three factors in each area were reviewed: the set-up of the radiant warmer, the materials, and medication available. The global audit was considered without defect when no errors were detected in any of the audited factors. Possible differences in the results were analyzed as a function of the study month, day of the week, or shift during which the audit had been performed. Results A total of 852 audits were performed. No defects were detected in any of the three factors analyzed in the 534 (62.7%, 95% confidence interval [CI]: 59.3–65.9) cases. Slight defects were detected in 98 (11.5%, 95% CI: 9.4–13.8) cases and serious defects capable of producing adverse events in the newborn during resuscitation were found in 220 (25.8%, 95% CI: 22.9–28.9) cases. No statistically significant differences in the results were found according to the day of the week or time during which the audits were performed. However, the percentage of RRTSAs without defect increased as the study period progressed (first quarter 38.1% vs. the last quarter 84.2%; p Conclusion The percentage of adequately prepared resuscitation areas was low. RRTSAs made it possible to detect errors in the correct availability of the neonatal stabilization areas and improved their preparation by preventing errors from being perpetuated over time. Key Points

ObjectiveTo compare rectal and axillary temperatures in preterm newborns on admission to the neonatal intensive care unit (NICU).DesignSecondary analysis of data collected in a randomised controlled trial (RCT).SettingMaternity hospital, level 3 NICU.PatientsSeventy-two newborns ISRCTN31707342).InterventionsNewborns were placed in polyethylene bags and were randomised to placement on exothermic mattresses, or not in the delivery room. All infants had rectal and axillary temperatures measured in immediate succession using a digital thermometer on NICU admission.Outcome measuresAdmission rectal and axillary temperatures.ResultsMean (SD) gestational age was 28 (2) weeks and birth weight was 1138 (374) g. Mean rectal-axillary temperature difference was 0.1 (0.5°C) (range −1.4°C to +1.5°C). Rectal and axillary temperatures differed by ≥0.5°C in 18/72 (25%) infants; axillary temperature was higher than rectal in 6 (8%) and lower in 12 (17%). There was a positive linear relationship between rectal and axillary measurements (Pearson’s correlation R=0.84). Applying the Bland-Altman technique, the width of 95% prediction interval was 1.8°C (−0.8°C to 1.0°C) implying that rectal and axillary measurements may vary by up to 1.0°C. Axillary temperature had a sensitivity of 65% when used to detect rectal hyperthermia and 100% sensitivity for hypothermia.ConclusionPaired rectal and axillary temperature measurements in preterm newborns on NICU admission vary significantly. Axillary temperature was sensitive at detecting rectal hypothermia but not hyperthermia. Axillary temperature may not be an accurate proxy for rectal temperature measurement in all preterm newborns on NICU admission.