Evidence-Based Practices for the Fetal to Newborn Transition

Judith S. Mercer, CNM, DNSc; Debra A. Erickson-Owens, CNM, MS, ; Barbara Graves, CNM, MN, MPH; Mary Mumford Haley, CNM, MS

Disclosures

J Midwifery Womens Health. 2007;52(3):262-272.

Conclusion

An important tenet of practice for all health care personnel is to first do no harm. This idea takes on additional importance when dealing with newborns, as there is almost no long-term data on the safety of many procedures. No clear conclusions can be drawn from studies on maternal analgesia effects on the newborn; thus, judicious use of medications in labor is recommended with further study of better biobehavioral assessment tools to differentiate outcomes. Delaying clamping of the umbilical cord appears to offer protection from anemia without harmful effects. The practice of immediate clamping, especially with a nuchal cord, should be discontinued. The evidence suggests that skin-to-skin care of the newborn after birth and during the first hour of life should be the mainstay of newborn thermoregulation and care. Routine suctioning of the infant at birth should be abandoned. Meconium-stained babies should not be suctioned on the perineum and vigorous infants should not be intubated and suctioned. There is no evidence that amnioinfusion prevents meconium aspiration syndrome. The mounting evidence suggests that use of 100% oxygen at birth to resuscitate newborns may cause harmful effects. Room air is permissible for the first 90 seconds with oxygen available if there is not an appropriate response in that time.

Routine interventions, such as suctioning the airway or stomach or using 100% oxygen for resuscitation, or immediate clamping of the umbilical cord, have never based on any clear evidence that they improve newborn care or outcomes. Yet some of these practices are so firmly entrenched that it will take a large body of research to change the standard. We must continue to build a body of knowledge that supports the evidence: more often than not, less intervention is better.

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Reprint Address

Judith S. Mercer, CNM, DNSc, FACNM, Nurse-Midwifery Program, University of Rhode Island College of Nursing, 2 Heathman Road, Kingston, RI 02881-2021.

Cite this: Evidence-Based Practices for the Fetal to Newborn Transition - Medscape - May 01, 2007.

Randomized, Controlled Trials on Cord Clamping in Full-Term Infants
Authors, Year, Location	Study Population	Cord Management Placement of Infant	Significant Results	Comments
Chaparro et al. (2006)^[32]; Mexico	Women 37-42 wks; singleton pregnancy, vaginal birth, normal pregnancies, plan to breastfeed for 6 mo, no smokers; no IUGR or major anomalies (excluded after birth); 358 infants randomized	EC: CC at 10 s (mean = 16.5 s); DC: CC at 2 minutes (mean = 94 s); Level: held at the level of the uterus	POV: At 6 mo, DC infants had higher MCV (81 vs. 79.5 fL; P = .001), ferritin (51 vs. 34 mL; P = .0002), and total body iron (48 vs. 44 \0x03BCg/dL, P = .0003) than EC infants. Diff HCT in NB period: 62% vs. 60%; P = .003. After birth, HCT > 70%: DC 13% vs. EC 8%; P < .15. Jaundice: DC 17% vs. EC 14%; P ≤ .36	Largest study to date to look at any long-term outcomes. Conservative in that they used only a 2-min delay. No significant differences in HGB or HCT at 6 mo, but iron stores increased by 27-47 mg in infants with DC. No harmful effects noted.
Cernadas et al. (2006)^[33]; Argentina	276 term infants; vaginal and cesarean birth, no complications, normal pregnancies	EC: CC at 15 s (n = 93); IC: CC at 1 min (n = 91); DC: CC 3 min (n = 92)	POV: Venous HCT at 6 hrs: EC 54% vs. IC 57% vs. DC 59%. HCT < 45% highest with EC at 6 and 24 hrs. HCT > 65% was highest in DC at 6 and 24 hrs without clinical symptoms	No harmful effects were seen. At 24-48 hrs, 16.9% of infants with EC had HCT < 45%. No increase in maternal postpartum hemorrhage. Authors recommend DC.
Emhamed, van Rheenen, and Brabin (2004)^[35]; Libya	Women 37-42 wks; singletons; excluded for major congenital anomalies, maternal complications; tight nuchal cord, need for resuscitation; 102 infants > 2500 gms	EC: immediate (n = 45); DC: after cord stopped pulsating (n = 57); oxytocic after CC	DC infants had significantly higher HCT (53% vs. 49%; P = .004) and Hgb 17.1 vs. 18.5 g/dL (P = .0005) at 24 hrs. Three DC infants had polycythemia with no symptoms; two EC infants needed phototherapy	No perinatal complications from DC in this study. Authors recommend DC as a safe, simple intervention to increase red cell mass.
Gupta and Ramji (2002)^[34]; India	Term infants (n = 102) born to anemic mothers (HGB < 10 g/dL); vaginal birth, no resuscitation needed at birth; no major congenital anomalies	EC: immediate (n = 53); LC: when placenta in vagina (n = 49); Infant held 0-10 cm below introitus	At 3 mos of age (n = 58), infants with LC had higher serum ferritin levels (118 vs. 73; P = .001). Odds risk for anemia at 3 mos was 7.7 times higher for the EC group (95% CI, 1.84-34.9)	EC Infants weighed 2707 gms, LC infants 2743 g. Iron stores in neonates born to anemic mothers can be improved by LC (jaundice and polycythemia not addressed)

CC = cord clamping; DC = delayed cord clamping; EC = early cord clamping; HCT = hematocrit; HGB = hemoglobin; IC = intermediate cord clamping; IUGR = intrauterine growth restriction; MCV = mean corpuscular volume; NB = newborn; LC = late cord clamping; POV = primary outcome variable.

Randomized, Controlled Trials on Cord Clamping in Full-Term Infants
Authors, Year, Location	Study Population	Cord Management Placement of Infant	Significant Results	Comments
Chaparro et al. (2006)^[32]; Mexico	Women 37-42 wks; singleton pregnancy, vaginal birth, normal pregnancies, plan to breastfeed for 6 mo, no smokers; no IUGR or major anomalies (excluded after birth); 358 infants randomized	EC: CC at 10 s (mean = 16.5 s); DC: CC at 2 minutes (mean = 94 s); Level: held at the level of the uterus	POV: At 6 mo, DC infants had higher MCV (81 vs. 79.5 fL; P = .001), ferritin (51 vs. 34 mL; P = .0002), and total body iron (48 vs. 44 \0x03BCg/dL, P = .0003) than EC infants. Diff HCT in NB period: 62% vs. 60%; P = .003. After birth, HCT > 70%: DC 13% vs. EC 8%; P < .15. Jaundice: DC 17% vs. EC 14%; P ≤ .36	Largest study to date to look at any long-term outcomes. Conservative in that they used only a 2-min delay. No significant differences in HGB or HCT at 6 mo, but iron stores increased by 27-47 mg in infants with DC. No harmful effects noted.
Cernadas et al. (2006)^[33]; Argentina	276 term infants; vaginal and cesarean birth, no complications, normal pregnancies	EC: CC at 15 s (n = 93); IC: CC at 1 min (n = 91); DC: CC 3 min (n = 92)	POV: Venous HCT at 6 hrs: EC 54% vs. IC 57% vs. DC 59%. HCT < 45% highest with EC at 6 and 24 hrs. HCT > 65% was highest in DC at 6 and 24 hrs without clinical symptoms	No harmful effects were seen. At 24-48 hrs, 16.9% of infants with EC had HCT < 45%. No increase in maternal postpartum hemorrhage. Authors recommend DC.
Emhamed, van Rheenen, and Brabin (2004)^[35]; Libya	Women 37-42 wks; singletons; excluded for major congenital anomalies, maternal complications; tight nuchal cord, need for resuscitation; 102 infants > 2500 gms	EC: immediate (n = 45); DC: after cord stopped pulsating (n = 57); oxytocic after CC	DC infants had significantly higher HCT (53% vs. 49%; P = .004) and Hgb 17.1 vs. 18.5 g/dL (P = .0005) at 24 hrs. Three DC infants had polycythemia with no symptoms; two EC infants needed phototherapy	No perinatal complications from DC in this study. Authors recommend DC as a safe, simple intervention to increase red cell mass.
Gupta and Ramji (2002)^[34]; India	Term infants (n = 102) born to anemic mothers (HGB < 10 g/dL); vaginal birth, no resuscitation needed at birth; no major congenital anomalies	EC: immediate (n = 53); LC: when placenta in vagina (n = 49); Infant held 0-10 cm below introitus	At 3 mos of age (n = 58), infants with LC had higher serum ferritin levels (118 vs. 73; P = .001). Odds risk for anemia at 3 mos was 7.7 times higher for the EC group (95% CI, 1.84-34.9)	EC Infants weighed 2707 gms, LC infants 2743 g. Iron stores in neonates born to anemic mothers can be improved by LC (jaundice and polycythemia not addressed)

Literature Overview on Infant Placement at Birth and Skin-to-Skin Care
Authors, Year, Study Type	Study Population	Style of Thermoregulation	Results	Comments
Carfoot, Williamson, and Dickson (2005)^[43]; RCT	204 term mother-baby pairs randomized to either group	Early SSC compared with RNC	Higher temps 1 hr after birth (P < .02); no difference in # breastfeeding at 4 mos, mothers more satisfied with SSC (90% vs. 50%)	Largest trial to date; supports no harm with SSC; found warmer infants and high maternal satisfaction with SSC
Vaidya, Sharma, and Dhungel (2005)^[44]; RCT	92 lactating mother-baby pairs followed up to 6 mos	Randomized to 15 min of SSC in the first hrs vs. RNC (babies dressed and given to mother)	Significantly more mothers in the SCC group were breastfeeding at 6 mos of age (77% vs. 38%)	Large study from a resource-poor country; well done; cultural differences may play a role
Fransson, Karlsson, and Nilsson (2005)^[45]; physiologic study	27 healthy term babies during first 2 days of life	Determine normal temperature patterns and variations and the influence of external factors	Skin temperature of baby was higher when with the mother, even if not skin-to-skin	Highest temperatures were recorded when baby was in close contact with mother, lowest when baby was in the cot
Anderson et al. (2003)^[1]; Cochrane review	Cochrane review of 806 participants in 17 studies	Early skin-to-skin contact, baby naked and prone on mother's bare chest versus routine hospital care	Increased scores for maternal love/touch/affection, increased maternal attachment behavior	Safety and breastfeeding success; editors recommended improving methodological and statistical integrity
Ferber and Makhoul (2004)^[46]; RCT	47 healthy mother-baby pairs	All infants had SSC for first 5-10 min. The SSC group had SSC from 15 min to 1 hr of life; control group had routine care in the nursery	At 4 hrs, infants in the SSC group slept longer (P = .02) with more quiet sleep time (P = .01) and had better flexion (P = .03) and less extension of limbs (P = .05)	SSC appears to influence state organization and motor coordination

RCT = randomized, controlled trial; RNC = routine newborn care; SSC = skin-to-skin.

Literature Overview on Infant Placement at Birth and Skin-to-Skin Care
Authors, Year, Study Type	Study Population	Style of Thermoregulation	Results	Comments
Carfoot, Williamson, and Dickson (2005)^[43]; RCT	204 term mother-baby pairs randomized to either group	Early SSC compared with RNC	Higher temps 1 hr after birth (P < .02); no difference in # breastfeeding at 4 mos, mothers more satisfied with SSC (90% vs. 50%)	Largest trial to date; supports no harm with SSC; found warmer infants and high maternal satisfaction with SSC
Vaidya, Sharma, and Dhungel (2005)^[44]; RCT	92 lactating mother-baby pairs followed up to 6 mos	Randomized to 15 min of SSC in the first hrs vs. RNC (babies dressed and given to mother)	Significantly more mothers in the SCC group were breastfeeding at 6 mos of age (77% vs. 38%)	Large study from a resource-poor country; well done; cultural differences may play a role
Fransson, Karlsson, and Nilsson (2005)^[45]; physiologic study	27 healthy term babies during first 2 days of life	Determine normal temperature patterns and variations and the influence of external factors	Skin temperature of baby was higher when with the mother, even if not skin-to-skin	Highest temperatures were recorded when baby was in close contact with mother, lowest when baby was in the cot
Anderson et al. (2003)^[1]; Cochrane review	Cochrane review of 806 participants in 17 studies	Early skin-to-skin contact, baby naked and prone on mother's bare chest versus routine hospital care	Increased scores for maternal love/touch/affection, increased maternal attachment behavior	Safety and breastfeeding success; editors recommended improving methodological and statistical integrity
Ferber and Makhoul (2004)^[46]; RCT	47 healthy mother-baby pairs	All infants had SSC for first 5-10 min. The SSC group had SSC from 15 min to 1 hr of life; control group had routine care in the nursery	At 4 hrs, infants in the SSC group slept longer (P = .02) with more quiet sleep time (P = .01) and had better flexion (P = .03) and less extension of limbs (P = .05)	SSC appears to influence state organization and motor coordination

RCT = randomized, controlled trial; RNC = routine newborn care; SSC = skin-to-skin.

Oropharyngeal Suctioning at Birth*
Author, Year, Study Type*	Intervention and Sample Size	Significant Results	Comments
Cordero and Hon (1971)^[53]; non-randomized	Bulb suction (n = 41) vs. catheter suction (n = 46)	The catheter group developed severe arrhythmia (n = 7) and became apneic (n = 5)	First study to show that suctioning disrupted infant transition
Estol et al. (1992)^[51]; prospective, non-random trial (assigned by hour of birth)	Bulb suction (n = 20) vs. no suction (n = 20)	Respiratory resistance and lung compliance were not different at 10, 30, or 120 min	No significant differences between infants with and without suctioning; no advantage to infants from suctioning
Carrasco, Martell, and Estol (1997)^[50]; RCT	Immediate suction with catheter (n = 15) vs. no suctioning (n = 15)	Suctioned group had lower SaO2 between 1-6 min of life (P < .05); time to reach 86%-92% SaO2 shorter in nonsuctioned group	No respiratory distress in either group; no advantage to infants from suctioning
Waltman et al. (2004)^[52]; RCT	Bulb suction on perineum and just after birth (n = 10) vs. no suction (n = 10)	No difference in Apgar scores at 1, 5, or 10 min; higher heart rate [166-173 (n = 10) bpm] in no suction group compared to suction group (150-166 bpm); lower SaO2 from 10-20 min in non-suctioned group (although > 90%)	No benefits to the infants from suctioning demonstrated

Bpm = beats per minute.
*Study populations: All infants were vigorous term infants.

Current Evidence for Practices Related to Management of Infants Born With Meconium-Stained Amniotic Fluid
Treatment	Recommendation	Reference	Study Details
Amnioinfusion	No benefit to infants found for the prevention of MAS	Fraser et al. (2005)^[54]	Multicenter RCT, women (n = 1998) in labor at term with MSAF stratified by presence of variable decelerations and randomly assigned to amnioinfusion or standard care. Amnioinfusion did not reduce risk of MAS, or perinatal death.
Intrapartum suctioning before delivery of shoulders	No benefit to any infants including high risk infants; suctioning of infant before delivery is not indicated	Vain et al. (2004)^[55]	RCT, blinded, infants (n = 1176) suctioned on perineum compared with infants (n = 1225) not suctioned. No difference in Apgar scores, respiratory distress, use of oxygen, need for ventilation, MAS (4% in each group), or death.
Endotracheal intubation and suctioning after birth of vigorous infants	No benefits to any infants; not recommended for vigorous infants	Wiswell et al. (2000)^[56]	RCT, vigorous term infants (n = 2094) with MSAF randomly assigned to intubation and suctioning or to expectant management. Intubation and suctioning did not result in lower incidence of MAS or other respiratory disorders.

MAS = meconium aspiration syndrome; MSAF= meconium-stained amniotic fluid; RCT = randomized, controlled trial.

Current Evidence for Practices Related to Management of Infants Born With Meconium-Stained Amniotic Fluid
Treatment	Recommendation	Reference	Study Details
Amnioinfusion	No benefit to infants found for the prevention of MAS	Fraser et al. (2005)^[54]	Multicenter RCT, women (n = 1998) in labor at term with MSAF stratified by presence of variable decelerations and randomly assigned to amnioinfusion or standard care. Amnioinfusion did not reduce risk of MAS, or perinatal death.
Intrapartum suctioning before delivery of shoulders	No benefit to any infants including high risk infants; suctioning of infant before delivery is not indicated	Vain et al. (2004)^[55]	RCT, blinded, infants (n = 1176) suctioned on perineum compared with infants (n = 1225) not suctioned. No difference in Apgar scores, respiratory distress, use of oxygen, need for ventilation, MAS (4% in each group), or death.
Endotracheal intubation and suctioning after birth of vigorous infants	No benefits to any infants; not recommended for vigorous infants	Wiswell et al. (2000)^[56]	RCT, vigorous term infants (n = 2094) with MSAF randomly assigned to intubation and suctioning or to expectant management. Intubation and suctioning did not result in lower incidence of MAS or other respiratory disorders.

MAS = meconium aspiration syndrome; MSAF= meconium-stained amniotic fluid; RCT = randomized, controlled trial.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

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Evidence-Based Practices for the Fetal to Newborn Transition

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