Delivery Room Guidelines Improve Outcomes for Preemies

Steven Fox

September 16, 2013

Use of new evidence-based delivery room guidelines was associated with significantly improved outcomes for very low birth weight infants, according to the results of a single-institution study published online September 16 in Pediatrics.

The authors, led by Sara B. DeMauro, MD, MSCE, from the Department of Pediatrics, the Children's Hospital of Philadelphia, Pennsylvania, note that events during the first moments of an infant's life can have lasting effect, especially for those born very prematurely. "Specifically, 3 aspects of newborn care that require prompt attention in the delivery room are thermoregulation, respiratory management, and oxygen delivery," they write.

Therefore, the researchers assembled a multidisciplinary team to develop evidence-based guidelines that focus on preventing heat loss, reducing exposure to supplemental oxygen, and increasing use of noninvasive respiratory support.

To implement the guidelines, the researchers used several complementary strategies: staging multidisciplinary conferences, establishing routine use of checklists, adding dedicated resuscitation nurses to delivery room teams, and making sure clinicians receive adequate feedback on the care they provide.

In the current study, designed to gauge the effect of the guidelines on care, the researchers compared outcomes of 2 groups, each with 80 infants who had been born at Children's Hospital of Philadelphia.

The first was a cohort born before the launch of the new guidelines; the second was a prospective group born after the guidelines were instituted in mid-2010. All infants included in the study had been born with birth weights no greater than 1250 g.

The authors found that once the guidelines were introduced, average admission temperatures increased (36.4°C vs 36.7° C; P < .001) and the proportion of infants admitted with moderate or severe hypothermia decreased (14% vs 1%; P = .003).

In addition, infants were exposed to less oxygen during the first 10 minutes of life (P < .001), yet exhibited similar oxygen saturations.

The researchers note, however, that even though more patients received trial therapy with continuous positive airway pressure after the guidelines were established (40% vs 61%; P = .007), they did not see a difference in intubation rates (64% vs 54%; P = .20).

The investigators also report that median duration of invasive ventilation procedures (5 vs 1 days; P = .008), and the duration of hospital stay decreased after the guidelines were in place. (80 vs 60 days; P = .02).

The authors list specific steps they took to get their positive results. For example, to help prevent heat loss, they readied several bedding options to which infants could be shifted, depending on clinical factors. They also wrapped the infant in plastic without drying, placed a stocking cap on the infant's head, and used an overhead warmer. To cut down on infant exposure to oxygen, they started resuscitation with 30% oxygen and titrated every minute by 10%. They note that goal saturations should be 75% by 5 minutes of life and 85% to 92% by 10 minutes, as measured by a pulse oximeter on the infant's hand.

To promote use of noninvasive respiratory support, they recommend beginning resuscitation using routine bulb suction, stimulation, and bag-mask ventilation for infants who are not breathing spontaneously. Next, they immediately initiate continuous positive air pressure, starting at 5 cm of water and titrating that rate up to 8 cm as needed. The guidelines also specify when to use intubation and surfactant.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 16, 2013.

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