Novel technologies for heart rate assessment during neonatal resuscitation at birth – A systematic review

Fast and accurate newborn heart rate monitoring at birth: A systematic review

Aim

To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth.

Methods

A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.

Results

Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes.

Limitations

Certainty of evidence was low or very low for most comparisons.

Conclusion

If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

Electronic Heart (ECG) Monitoring at Birth and Newborn Resuscitation

BACKGROUND

Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations.

METHODS

This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit.

RESULTS

An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality.

CONCLUSIONS

Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.

Contactless assessment of heart rate in neonates within a clinical environment using imaging photoplethysmography

Introduction

In neonatology, the accurate determination of vital parameters plays a pivotal role in monitoring critically ill newborns and premature infants, as well as aiding in disease diagnosis. In response to the limitations associated with contact-based measurement methods, substantial efforts have been directed toward developing contactless measurement techniques, particularly over the past decade.

Methods

Building upon the insights gained from our pilot study, we realized a new investigation to assess the precision of our imaging photoplethysmography-based system within a clinical environment of the neonatal intermediate care unit. We conducted measurements in 20 preterm infants or newborns requiring therapeutic interventions. As a point of reference, we employed a conventional pulse oximeter. To analytically predict measurement artifacts, we analyzed the potential influence of confounding factors, such as motion artifacts, illumination fluctuations (under- and overexposure), and loss of region of interest prior to heart rate evaluation. This reduced the amount of data we evaluated for heart rate to 56.1% of its original volume.

Results

In artifact-free time segments, the mean difference between the pulse oximetry and the imaging photoplethysmography-based system for 1 s sampling intervals resulted in -0.2 bpm (95% CI -0.8 to 0.4, LOA ± 12.2). For the clinical standard of 8 s averaging time, the mean difference resulted in -0.09 bpm (95% CI -0.7 to 0.6, LOA ± 10.1). These results match the medical standards.

Discussion

While further research is needed to increase the range of measurable vital parameters and more diverse patient collectives need to be considered in the future, we could demonstrate very high accuracy for non-contact heart rate measurement in newborn infants in the clinical setting, provided artifacts are excluded. In particular, performing a priori signal assessment helps make clinical measurements safer by identifying unreliable readings.

The critical role of technologies in neonatal care

Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.

Use of Pulse Oximetry during Resuscitation of 230 Newborns-A Video Analysis

BACKGROUND

European guidelines recommend the use of pulse oximetry (PO) during newborn resuscitation, especially when there is a need for positive pressure ventilation or supplemental oxygen. The objective was to evaluate (i) to what extent PO was used, (ii) the time and resources spent on the application of PO, and (iii) the proportion of time with a useful PO signal during newborn resuscitation.

METHODS

A prospective observational study was conducted at Stavanger University Hospital, Norway, between 6 June 2019 and 16 November 2021. Newborn resuscitations were video recorded, and the use of PO during the first ten minutes of resuscitation was recorded and analysed.

RESULTS

Of 7466 enrolled newborns, 289 (3.9%) received ventilation at birth. The resuscitation was captured on video in 230 cases, and these newborns were included in the analysis. PO was applied in 222 of 230 (97%) newborns, median (quartiles) 60 (24, 58) seconds after placement on the resuscitation table. The proportion of time used on application and adjustments of PO during ongoing ventilation and during the first ten minutes on the resuscitation table was 30% and 17%, respectively. Median two healthcare providers were involved in the PO application. Video of the PO monitor signal was available in 118 (53%) of the 222 newborns. The proportion of time with a useful PO signal during ventilation and during the first ten minutes on the resuscitation table was 5% and 35%, respectively.

CONCLUSION

In total, 97% of resuscitated newborns had PO applied, in line with resuscitation guidelines. However, the application of PO was time-consuming, and a PO signal was only obtained 5% of the time during positive pressure ventilation.

Comparing pulse rate measurement in newborns using conventional and dry-electrode ECG monitors

Aim

Heart rate (HR) is the most important parameter to evaluate newborns’ clinical condition and to guide intervention during resuscitation at birth. The present study aims to compare the accuracy of NeoBeat dry‐electrode ECG for HR measurement with conventional ECG and pulse oximetry (PO).

Methods

Newborns with a gestational age ≥32 weeks and/or birth weight ≥1.5 kg were included when HR evaluation was needed. HR was simultaneously measured for 10 min with NeoBeat, PO and conventional ECG.

Results

A total of 18 infants were included (median (IQR) gestational age 39 (36–39) weeks and birth weight 3 150 (2 288–3 859) grams). Mean (SD) duration until NeoBeat obtained a reliable signal was 2.5 (9.0) s versus 58.5 (171.0) s for PO. Mean difference between NeoBeat and ECG was 1.74 bpm (LoA −4.987–8.459 and correlation coefficient 0.98). Paired HR measurements over 30‐s intervals revealed no significant difference between NeoBeat and ECG. The positive predictive value of a detected HR <100 bpm by NeoBeat compared with ECG was 54.84%, negative predictive value 99.99%, sensitivity 94.44%, specificity 99.99% and accuracy 99.85%.

Conclusions

HR measurement with NeoBeat dry‐electrode ECG at birth is reliable and accurate.

A Pilot Randomized Trial of Heart Rate Monitoring Using Conventional Versus a New Electrocardiogram Algorithm during Neonatal Resuscitation at Birth

Current guidelines support the use of a cardiac monitor during neonatal resuscitation. Infants born preterm randomized to a novel electrocardiogram algorithm displayed a heart rate sooner than the conventional electrocardiogram algorithm. Although resuscitation outcomes were not different, the availability of an earlier heart rate may benefit neonatal providers during high-risk resuscitations. TRIAL REGISTRATION: ClinicalTrials.govNCT04587934.

Contactless heart rate measurement in newborn infants using a multimodal 3D camera system

Newborns and preterm infants require accurate and continuous monitoring of their vital parameters. Contact-based methods of monitoring have several disadvantages, thus, contactless systems have increasingly attracted the neonatal communities' attention. Camera-based photoplethysmography is an emerging method of contactless heart rate monitoring. We conducted a pilot study in 42 healthy newborn and near-term preterm infants for assessing the feasibility and accuracy of a multimodal 3D camera system on heart rates (HR) in beats per min (bpm) compared to conventional pulse oximetry. Simultaneously, we compared the accuracy of 2D and 3D vision on HR measurements. The mean difference in HR between pulse oximetry and 2D-technique added up to + 3.0 bpm [CI-3.7 - 9.7; p = 0.359, limits of agreement (LOA) ± 36.6]. In contrast, 3D-technique represented a mean difference in HR of + 8.6 bpm (CI 2.0-14.9; p = 0.010, LOA ± 44.7) compared to pulse oximetry HR. Both, intra- and interindividual variance of patient characteristics could be eliminated as a source for the results and the measuring accuracy achieved. Additionally, we proved the feasibility of this emerging method. Camera-based photoplethysmography seems to be a promising approach for HR measurement of newborns with adequate precision; however, further research is warranted.

Comparison of Heart Rate Feedback from Dry-Electrode ECG, 3-Lead ECG, and Pulse Oximetry during Newborn Resuscitation

Background: Assessment of heart rate (HR) is essential during newborn resuscitation, and comparison of dry-electrode ECG technology to standard monitoring by 3-lead ECG and Pulse Oximetry (PO) is lacking. Methods: NeoBeat, ECG, and PO were applied to newborns resuscitated at birth. Resuscitations were video recorded, and HR was registered every second. Results: Device placement time from birth was median (quartiles) 6 (4, 18) seconds for NeoBeat versus 138 (97, 181) seconds for ECG and 152 (103, 216) seconds for PO. Time to first HR presentation from birth was 22 (13, 45) seconds for NeoBeat versus 171 (129, 239) seconds for ECG and 270 (185, 357) seconds for PO. Proportion of time with HR feedback from NeoBeat during resuscitation from birth was 85 (69, 93)%, from arrival at the resuscitation table 98 (85, 100)%, and during positive pressure ventilation 100 (95, 100)%. For ECG, these proportions were, 25 (0, 43)%, 28 (0, 56)%, and 33 (0, 66)% and for PO, 0 (0, 16)%, 0 (0, 16)%, and 0 (0, 18)%. All p < 0.0001. Conclusions: NeoBeat was faster to place, presented HR more rapidly, and provided feedback on HR for a larger proportion of time during ongoing resuscitation compared to 3-lead ECG and PO.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Characterisation of Textile Embedded Electrodes for Use in a Neonatal Smart Mattress Electrocardiography System

Heart rate monitoring is the predominant quantitative health indicator of a newborn in the delivery room. A rapid and accurate heart rate measurement is vital during the first minutes after birth. Clinical recommendations suggest that electrocardiogram (ECG) monitoring should be widely adopted in the neonatal intensive care unit to reduce infant mortality and improve long term health outcomes in births that require intervention. Novel non-contact electrocardiogram sensors can reduce the time from birth to heart rate reading as well as providing unobtrusive and continuous monitoring during intervention. In this work we report the design and development of a solution to provide high resolution, real time electrocardiogram data to the clinicians within the delivery room using non-contact electric potential sensors embedded in a neonatal intensive care unit mattress. A real-time high-resolution electrocardiogram acquisition solution based on a low power embedded system was developed and textile embedded electrodes were fabricated and characterised. Proof of concept tests were carried out on simulated and human cardiac signals, producing electrocardiograms suitable for the calculation of heart rate having an accuracy within ±1 beat per minute using a test ECG signal, ECG recordings from a human volunteer with a correlation coefficient of ~ 87% proved accurate beat to beat morphology reproduction of the waveform without morphological alterations and a time from application to heart rate display below 6 s. This provides evidence that flexible non-contact textile-based electrodes can be embedded in wearable devices for assisting births through heart rate monitoring and serves as a proof of concept for a complete neonate electrocardiogram monitoring system.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Heart Rate Determination in Newborns at Risk for Resuscitation in a Low-Resource Setting: A Randomized Controlled Trial

OBJECTIVE

To compare 2 different methods (auscultation with a stethoscope and umbilical cord palpation) of heart rate (HR) estimation in newborns at risk for resuscitation in a low-resource setting.

STUDY DESIGN

Sixty newborns at risk for resuscitation born at the St. Luke Catholic Hospital in Wolisso (Ethiopia) were randomized to HR assessment by auscultation using a stethoscope or umbilical cord palpation. HR was assessed at 60, 90, 120 seconds, and 5 minutes of life. The primary outcome was the agreement of HR obtained by auscultation or palpation compared with the HR determined by electrocardiogram.

RESULTS

Mean difference between auscultation using a stethoscope and electrocardiogram was -13 bpm, -4 bpm, -6 bpm, and -10 bpm at 60, 90, 120 seconds, and at 5 minutes of life. Mean difference between palpation and electrocardiogram of was -20 bpm, -25 bpm, -23 bpm, and -31 bpm at 60, 90, 120 seconds, and at 5 minutes of life. The magnitude of the difference between auscultation and electrocardiogram was lower than that between palpation and electrocardiogram over time (P = .007). HR range was correctly identified in 14 out of 16 measurements (87%) with HR <100 bpm.

CONCLUSION

HR assessment by auscultation was more accurate compared with cord palpation, but both may provide adequate clinical information to healthcare providers in terms of HR ranges. The clinical advantage of providing a stethoscope in low-resource settings remains to be established.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03854435.

Defining information needs in neonatal resuscitation with work domain analysis

OBJECTIVE

To gain a deeper understanding of the information requirements of clinicians conducting neonatal resuscitation in the first 10 min after birth.

BACKGROUND

During the resuscitation of a newborn infant in the first minutes after birth, clinicians must monitor crucial physiological adjustments that are relatively unobservable, unpredictable, and highly variable. Clinicians' access to information regarding the physiological status of the infant is also crucial to determining which interventions are most appropriate. To design displays to support clinicians during newborn resuscitation, we must first carefully consider the information requirements.

METHODS

We conducted a work domain analysis (WDA) for the neonatal transition in the first 10 min after birth. We split the work domain into two 'subdomains'; the physiology of the neonatal transition, and the clinical resources supporting the neonatal transition. A WDA can reveal information requirements that are not yet supported by resources.

RESULTS

The physiological WDA acted as a conceptual tool to model the exact processes and functions that clinicians must monitor and potentially support during the neonatal transition. Importantly, the clinical resources WDA revealed several capabilities and limitations of the physical objects in the work domain-ultimately revealing which physiological functions currently have no existing sensor to provide clinicians with information regarding their status.

CONCLUSION

We propose two potential approaches to improving the clinician's information environment: (1) developing new sensors for the information we lack, and (2) employing principles of ecological interface design to present currently available information to the clinician in a more effective way.

Heart Rate Assessment during Neonatal Resuscitation

Approximately 10% of newborn infants require some form of respiratory support to successfully complete the fetal-to-neonatal transition. Heart rate (HR) determination is essential at birth to assess a newborn’s wellbeing. Not only is it the most sensitive indicator to guide interventions during neonatal resuscitation, it is also valuable for assessing the infant’s clinical status. As such, HR assessment is a key step at birth and throughout resuscitation, according to recommendations by the Neonatal Resuscitation Program algorithm. It is essential that HR is accurate, reliable, and fast to ensure interventions are delivered without delay and not prolonged. Ineffective HR assessment significantly increases the risk of hypoxic injury and infant mortality. The aims of this review are to summarize current practice, recommended techniques, novel technologies, and considerations for HR assessment during neonatal resuscitation at birth.

Smartphone app for neonatal heart rate assessment: an observational study

BACKGROUND

Heart rate (HR) assessment is crucial in neonatal resuscitation, but pulse oximetry (PO) and electrocardiography (ECG) are rarely accessible in low-resource to middle-resource settings. This study evaluated a free-of-charge smartphone application, NeoTap, which records HR with a screen-tapping method bypassing mental arithmetic calculations.

METHODS

This observational study was carried out during three time periods between May 2015 and January 2019 in Uganda in three phases. In phase 1, a metronome rate (n=180) was recorded by low-end users (midwives) using NeoTap. In phase 2, HR (n=69) in breathing neonates was recorded by high-end users (paediatricians) using NeoTap versus PO. In phase 3, HR (n=235) in non-breathing neonates was recorded by low-end users using NeoTap versus ECG.

RESULTS

In high-end users the mean difference was 3 beats per minute (bpm) higher with NeoTap versus PO (95% agreement limits -14 to 19 bpm), with acquisition time of 5 seconds. In low-end users, the mean difference was 6 bpm lower with NeoTap versus metronome (95% agreement limits -26 to 14 bpm) and 3 bpm higher with NeoTap versus ECG in non-breathing neonates (95% agreement limits -48 to 53 bpm), with acquisition time of 2.7 seconds. The agreement between NeoTap and ECG was good in the HR categories of 60-99 bpm and ≥100 bpm; HR <60 bpm had few measurements (kappa index 0.71, 95% CI 0.63 to 0.79).

CONCLUSION

HR could be accurately and rapidly assessed using a smartphone application in breathing neonates in a low-resource setting. Clinical assessment by low-end users was less accurate with wider CI but still adds clinically important information in non-breathing neonates. The authors suggest low-end users may benefit from auscultation-focused training. More research is needed to evaluate its feasibility in clinical use.

Doppler Ultrasound for Heart Rate Assessment in a Porcine Model of Neonatal Asphyxia

Objectives: Approximately 10% of newborn infants require resuscitation at birth. Accurate heart rate (HR) assessment guides resuscitation interventions, thereby reducing morbidities and mortality. While existing HR assessment methods have several limitations, the Doppler ultrasound (Doppler-US) might be a promising alternative. We aimed to evaluate accuracy and optimal use of Doppler-US for HR assessments during neonatal asphyxia in a pre-clinical model. Design: HR assessments were performed in 16 term newborn piglets that were anesthetized, intubated, and instrumented. Study I evaluated optimal transducer position, Study II compared aortic (AV) and pulmonary (PV) examination modes, and Study III examined accuracy during asphyxia, for HR assessment. Setting: Experimental setting. Subjects: Asphyxia-induced piglets. Interventions: Study I: Doppler-US (USCOM® 1A) HR was assessed on upper (A), middle (B), and lower (C) third of the sternum; study II: Doppler-US HR was assessed using AV and PV examination modes; study III: HR was assessed during asphyxia. Comparisons were made between Doppler-US and the clinical gold standard for HR assessments, electrocardiography (ECG). Measurements and Main Results: Study I: Mean (SD) Doppler-US HR at position A, B, and C showed no difference when compared to ECG HR. Study II: The mean (SD) Doppler-US HR using AV and PV modes also showed no difference when compared to ECG HR. Study III: Bland-Altman analysis revealed a mean difference (95% limits of agreement) between Doppler-US and ECG HR of 1.5 (-16 to 19) bpm. Additionally, motion artifacts produced false peaks and peak size was seen to decrease as bradycardia progressed. Conclusions: HR assessment using Doppler-US during asphyxia is accurate but has limitations and must be further evaluated prior to clinical use. Doppler-US can be positioned along the sternum and use either AV or PV mode for accurate assessments in a piglet model of neonatal asphyxia.

Neonatal monitoring during delivery room emergencies

Fetal to neonatal transition after birth is a complex, well-coordinated process involving multiple organ systems. Any significant derangement in this process increases the risk of death and other adverse outcomes, underlying the importance of continuous monitoring to promptly detect and correct these derangements by effective resuscitative support. In recent years, there has been increasing efforts to move from subjective and discontinuous monitoring to more objective and continuous monitoring of different physiological parameters. Some of them like pulse oximetry for arterial oxygen saturation and electrocardiography for heart rate monitoring are now part of resuscitation guidelines whereas others like respiratory function monitoring, near infrared spectroscopy, or amplitude integrated electroencephalography are being evaluated. In this review, we describe some of the physiological parameters that can be monitored during delivery room emergencies and review the evidence for some of the monitoring technologies currently being evaluated.

Evaluation of a Tap-Based Smartphone App for Heart Rate Assessment During Asphyxia in a Porcine Model of Neonatal Resuscitation

Objectives: Heart rate (HR) is the most significant parameter to assess a newborn's clinical status at birth. Recently, novel technologies including smartphone applications have been suggested for HR assessment during neonatal resuscitation. The aim of this study was to evaluate the accuracy, speed, and precision of the NeoTapLifeSupport (NeoTapLS) smartphone application using a digital stethoscope (DS) for HR assessment during neonatal resuscitation. Design: Newborn piglets (n = 20, 1-3 days, 1.7-2.4 kg) were anesthetized, intubated, mechanically ventilated, and subjected to 30 min of hypoxia, followed by asphyxia. Asphyxia was induced by clamping the endotracheal tube and disconnecting the ventilator, until asystole was confirmed by zero carotid blood flow (CBF). Setting: Experimental setting. Subjects: Asphyxia-induced newborn piglets. Interventions: During asphyxia, HR assessments were performed with a DS using the NeoTapLS smartphone application, and compared to 6-s method (6 s), and 10-s method (10 s). Measurements and Main Results: Accuracy of obtained HRs was compared to CBF and electrocardiogram and assessment time using NeoTapLS, 6 s, and 10 s were also measured. The mean(SD) HR with the NeoTapLS was 68(26), compared to CBF with 68(27) bpm, 6 s with 68(27), and 10 s with 66(26) bpm during asphyxia. Bland-Altman analysis revealed no difference between HR using the NeoTapLS, 6 s, 10 s, compared to CBF HR, with NeoTapLS showing the smallest difference between 95% limits of agreement. The median (IQR) time required to obtain a HR using the NeoTapLS was 3(2-4) s, compared to 6(6-7), and 10(10-11) s for 6 and 10 s, respectively. Conclusions: Our data suggests that the NeoTapLS is accurate, fast, and precise during neonatal asphyxia to assess heart rate.