Delivery Room Guidelines Improve Premature Infant Outcomes CME/CE

Particularly for very preterm infants, events occurring in the first moments of life may have far-reaching implications for subsequent outcomes. Management of thermoregulation, respiration, and oxygen delivery is especially critical.Clinical Context

Poor outcomes linked to hypothermia in the newborn include hypoglycemia, respiratory distress, hypoxia, metabolic acidosis, and mortality. Although normal postnatal transition is associated with a slow increase in oxygen saturation for the first 5 to 10 minutes, it is common practice to give supplemental oxygen, often without monitoring or specific saturation goals, despite potential complications associated with oxygen exposure. Evidence suggests lower rates of death or bronchopulmonary dysplasia in infants initially treated with continuous positive airway pressure (CPAP).

Study Synopsis and Perspective

Evidence-based delivery room guidelines significantly improved delivery room care for very preterm infants, according to a cohort studypublished online September 16 in Pediatrics.

"At the Hospital of the University of Pennsylvania, we were inconsistently using a warmer mattress or plastic wrap to prevent hypothermia, initiating resuscitation with 80% oxygen, and intubating all infants with birth weight <750 g or gestational age ≤26 weeks," write Sara B. DeMauro, MD, MSCE, Department of Pediatrics, Children's Hospital of Philadelphia. "Given the current literature, we designed an intervention to prevent heat loss, reduce exposure to supplemental oxygen, and increase the use of CPAP during delivery room resuscitation of infants with birth weights ≤1250 g. Our goal was to use quality improvement (QI) [principles] to standardize and improve the quality and safety of delivery room care for very preterm infants."

Delivery Room Guidelines for Infants with Birth Weight Less Than 1250 g

The following interventions were used to prevent hypothermia:

• Making available several bedding options most suited to specific clinical factors, such as a warmer bed, a warm blanket, and a prewarmed transwarmer mattress.
• Wrapping the newborn's body and head in plastic without drying.
• Using a stocking cap over the plastic and overhead warmer in servo mode.

The following interventions were used to lower infant exposure to oxygen:

• Oxygen at 30% for initial resuscitation, with titration by 10% increments every minute as needed.
• Goal oxygen saturations of 75% by 5 minutes of life and 85% to 92% by 10 minutes, as measured by a pulse oximeter on the infant's right hand.

The following interventions were used to encourage use of noninvasive respiratory support:

• Routine bulb suction and stimulation for initial resuscitation, as first-line therapy for all infants.
• Bag-mask ventilation for infants who fail to breathe spontaneously.
• CPAP immediately after bag-mask ventilation, initially at 5 cm of water with titration as needed up to 8 cm.
• Reliance on specific criteria for intubation and use of surfactant.

Use of Guidelines Linked to Better Outcomes

Multidisciplinary conferences, routine use of a checklist, involvement of a dedicated resuscitation nurse, and frequent feedback to clinicians facilitated guidelines implementation. The investigators compared the primary outcome of axillary temperature at admission to the intensive care nursery and various secondary outcomes in a historical group (n = 80) and a prospective group after guidelines implementation (n = 80).

At baseline, both groups had similar clinical characteristics. Average admission temperatures increased in the prospective group (36.7°C vs 36.4°C in the historical group; P < .001), and the proportion of infants admitted with moderate to severe hypothermia decreased (14% vs 1%; P = .003).

In the prospective group, infants with similar oxygen saturations were exposed to less oxygen during the first 10 minutes (P < .001), and CPAP was attempted on more infants (61% vs 40%; P = .007). However, the groups did not differ significantly in intubation rate (54% vs 64%; P = .20). After guidelines implementation, there was a reduction in median duration of invasive ventilation (1 vs 5 days; P = .008) and of hospitalization (60 vs 80 days; P = .02).

Limitations of this study include sample size insufficient to draw causal inferences or conclusions regarding relationships between the quality improvement initiative and less common patient outcomes.

"We have demonstrated significantly improved quality of delivery room care for very preterm infants after introduction of evidence-based delivery room guidelines," the study authors write. "Multidisciplinary involvement and continuous education and reinforcement of the guidelines permitted sustained change."

This study received no external funding. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 16, 2013.

Study Highlights

• For improved delivery room care of very preterm infants, room temperature should be set at 25°C to prevent heat loss.
• The warmer bed should be preheated to maximal temperature, manual mode.
• The newborn should be weighed on a warm blanket on a warmed scale and transferred to the warmer bed.
• The newborn should be immediately transferred to a prewarmed transwarmer mattress and the body and head wrapped in plastic without drying.
• The overhead warmer should be in servo mode and a stocking cap placed on the newborn's head, over the plastic.
• Axillary temperature should be checked every 15 minutes.
• During transport to the nursery, the infant should be covered with warm blankets and the bed covered with plastic.
• Readings from a pulse oximeter on the infant's right hand should guide oxygen administration.
• Initial resuscitation should be with 30% oxygen, with titration by 10% every minute as needed.
• Goal oxygen saturations should be 75% by 5 minutes of life and 85% to 92% by 10 minutes.
• Infants with prolonged bradycardia (< 100 bpm) should have oxygen increased to 100% and titrated from there after bradycardia is resolved.
• Noninvasive respiratory support should be first-line therapy for all infants.
• Infants who fail to breathe spontaneously should receive routine bulb suction, stimulation, and bag-mask ventilation.
• CPAP should then be started immediately at 5 cm of water, with titration as needed up to 8 cm.
• Intubation criteria are a heart rate of less than 100 bpm or hemodynamic instability, CO₂ of more than 65 mm Hg, more than 60% oxygen needed to maintain target saturations, apnea, or severe distress.
• All infants intubated in the first 48 hours of life should receive at least 1 dose of surfactant.
• Implementation of these guidelines was associated with an increase in average hospital admission temperatures from 36.4°C to 36.7°C (P < .001) and a decline in the proportion of infants admitted with moderate to severe hypothermia (1% from 14%; P = .003).
• After guidelines implementation, infants with similar oxygen saturations were exposed to less oxygen during the first 10 minutes (P < .001), and CPAP was attempted on more infants (61% vs 40%; P = .007), but the intubation rate was similar in both groups (54% vs 64%; P = .20).
• After guidelines implementation, median duration of invasive ventilation decreased from 5 to 1 days (P = .008), and median length of hospitalization decreased from 80 to 60 days (P = .02).
• Study limitations include sample size insufficient to draw causal inferences or conclusions regarding relationships between the quality improvement initiative and less common patient outcomes.
• On the basis of their findings, the study authors concluded that the quality of delivery room care for very preterm infants improved significantly after introduction of evidence-based delivery room guidelines.
• They also noted that multidisciplinary involvement and continuous education and reinforcement of the guidelines allowed sustained change.

Clinical Implications

• Evidence-based delivery room guidelines for delivery room care of very preterm infants address prevention of heat loss, reduction of oxygen exposure, and respiratory management. Noninvasive respiratory support should be first-line therapy for all infants.
• A cohort study showed significant improvements in these areas after implementation of evidence-based delivery room guidelines for delivery room care of very preterm infants. Multidisciplinary involvement and continuous education and reinforcement of the guidelines allowed sustained change.