Ethical dilemmas of recording and reviewing neonatal resuscitation

Artificial intelligence and informatics in neonatal resuscitation

Neonatal intensive care unit resuscitative care continually evolves and increasingly relies on data. Data driven precision resuscitation care can be enabled by leveraging informatics tools and artificial intelligence. Despite technological advancements, these data are often underutilized due to suboptimal data capture, aggregation, and low adoption of artificial intelligence and analytic tools. This review describes the fundamentals and explores the evidence behind informatics and artificial intelligence tools supporting neonatal intensive care unit resuscitative care, training and education. Key findings include the need for effective interface design for accurate data capture followed by storage and translation to wisdom using analytics and artificial intelligence tools. This review addresses the issues of data privacy, bias, liability and ethical frameworks when adopting these tools. While these emerging technologies hold great promise to improve resuscitation, further study of these applications in neonatal population and awareness of informatics and artificial intelligence principles among clinicians is imperative.

Video recording in the delivery room: current status, implications and implementation

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

Quality improvement initiative: implementing and redefining video review of real-time neonatal procedures using action research

Video review (VR) of procedures in the medical environment can be used to drive quality improvement. However, first it has to be implemented in a safe and effective way. Our primary objective was to (re)define a guideline for implementing interprofessional VR in a neonatal intensive care unit (NICU). Our secondary objective was to determine the rate of acceptance by providers attending VR. For 9 months, VR sessions were evaluated with a study group, consisting of different stakeholders. A questionnaire was embedded at the end of each session to obtain feedback from providers on the session and on the safe learning environment. In consensus meetings, success factors and preconditions were identified and divided into different factors that influenced the rate of adoption of VR. The number of providers who recorded procedures and attended VR sessions was determined. A total of 18 VR sessions could be organised, with an equal distribution of medical and nursing staff. After the 9-month period, 101/125 (81%) of all providers working on the NICU attended at least 1 session and 80/125 (64%) of all providers recorded their performance of a procedure at least 1 time. In total, 179/297 (61%) providers completed the questionnaire. Almost all providers (99%) reported to have a positive opinion about the review sessions. Preconditions and success factors related to implementation were identified and addressed, including improving the pathway for obtaining consent, preparation of VR, defining the role of the chair during the session and building a safe learning environment. Different strategies were developed to ensure findings from sessions were used for quality improvement. VR was successfully implemented on our NICU and we redefined our guideline with various preconditions and success factors. The adjusted guideline can be helpful for implementation of VR in emergency care settings.

The Evolution of Neonatal Patient Safety

Human factors science teaches us that patient safety is achieved not by disciplining individual health care professionals for mistakes, but rather by designing systems that acknowledge human limitations and optimize the work environment for them. Incorporating human factors principles into simulation, debriefing, and quality improvement initiatives will strengthen the quality and resilience of the process improvements and systems changes that are developed. The future of patient safety in neonatology will require continued efforts to engineer and re-engineer systems that support the humans who are at the interface of delivering safe patient care.

Essential newborn care practices for healthy newborns at a district hospital in Pemba, Tanzania: a cross-sectional observational study utilizing video recordings

BACKGROUND

High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries.

OBJECTIVE

To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations.

METHOD

This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics.

RESULTS

None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K.

CONCLUSION

Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns.

State-of-the art training in neonatal resuscitation

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives.

Learning with digital recording and video review of delivery room resuscitation

Digital recording and video review of delivery room resuscitations is a proven useful tool to evaluate neonatal resuscitation program (NRP) technical and non-technical skills. It is also valuable for research, quality improvement, and individual and group learning. Digital recording and video review programs are growing in number, and planning and implementation of digital recording requires careful thought. Consideration of technology requirements, policy implementation, and stakeholder involvement is essential to implement a successful digital recording and video review program. Video review can then be applied for individual and team-based learning. An approach to sustainability and on-going quality review of the program are key components critical to success.

Video recording as an objective assessment tool of health worker performance in neonatal resuscitation at a district hospital in Pemba, Tanzania: a feasibility study

OBJECTIVES

To assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital.

DESIGN

Prospective observational feasibility study.

SETTING

Chake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019.

PARTICIPANTS

All delivering women and their newborns were eligible for participation.

MAIN OUTCOME MEASURES

Motion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen's 8-point framework for feasibility studies.

RESULTS

91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn's head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively.

CONCLUSIONS

It proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

Video recording emergency care and video-reflection to improve patient care; a narrative review and case-study of a neonatal intensive care unit

As the complexity of emergency care increases, current research methods to improve care are often unable to capture all aspects of everyday clinical practice. Video recordings can visualize clinical care in an objective way. They can be used as a tool to assess care and to reflect on care with the caregivers themselves. Although the use of video recordings to reflect on medical interventions (video-reflection) has increased over the years, it is still not used on a regular basis. However, video-reflection proved to be of educational value and can improve teams' management and performance. It has a positive effect on guideline adherence, documentation, clinical care and teamwork. Recordings can also be used for video-reflexivity. Here, caregivers review recordings together to reflect on their everyday practice from new perspectives with regard to context and conduct in general. Although video-reflection in emergency care has proven to be valuable, certain preconditions have to be met and obstacles need to be overcome. These include gaining trust of the caregivers, having a proper consent-procedure, maintaining confidentiality and adequate use of technical equipment. To implement the lessons learned from video-reflection in a sustainable way and to continuously improve care, it should be integrated in regular simulation training or education. This narrative review will describe the development of video recording in emergency care and how video-reflection can improve patient care and safety in new ways. On our own department, the NICU at the LUMC, video-reflection has already been implemented and we want to further expand this. We will describe the use of video-reflection in our own unit. Based on the results of this narrative review we will propose options for future research to increase the value of video-reflection.

Consent for Delivery Room Studies: What Can Be Learned from Perceptions of Parents

BACKGROUND

Obtaining ethically valid consent to participate in delivery room (DR) studies from parents facing an imminent premature birth can be challenging. This study aims to provide insight into parental experiences with and perceptions of consent for DR studies.

METHODS

Semistructured interviews were conducted with parents of very and extreme preterm infants. Interviews were audio-recorded, transcribed, and analyzed using the qualitative data analysis software Atlas. ti V.8.4.

RESULTS

Twenty-five parents were interviewed. Despite being in an emotional and stressful situation, most parents considered being approached for DR studies as valuable. According to parents, this was mostly due to appropriate timing and communication, compassion, and investigators not being obtrusive. Interviewed parents generally decided to accept or decline study participation based on perceived risk. Parents differed widely in how risk of specific study interventions was perceived, but agreed on the fact that parental consent is needed for DR studies that involve risk. There was no consensus among parents on deferred consent for DR studies running at our NICU. However, parents considered deferred consent appropriate for observational studies. Furthermore, it became clear that parental misunderstanding of various aspects of DR studies, including aims, the concept of randomization, and risk associated with specific interventions, was common.

CONCLUSIONS

Insight into parental perceptions of consent for DR studies allowed us to determine areas where the validity of parental consent can be improved. Further research on parental perspectives for consent for DR studies will allow us to establish consent procedures that are considered both valid and valuable.

Methodological and technical considerations for video-based auditing of hand hygiene compliance in clinical practice: an exploratory study

BACKGROUND

Direct observation is the gold standard method for measuring hand hygiene compliance but its utility is increasingly being questioned. Various alternative electronic methods have been proposed, yet there is a paucity of research examining the use of these according to the World Health Organization's (WHO) '5 Moments for Hand Hygiene'. As a part of the process of developing a video-based monitoring system (VMS) capable of measuring hand hygiene compliance against the 5 moments criteria this paper reports methodological and technical issues that might arise from the use of a VMS for auditing in clinical practice.

METHODS

In-depth semi-structured interviews were conducted with 27 Australian content experts in hand hygiene auditing and infection prevention to explore their responses to proposed VMS auditing approaches. Transcripts were analyzed using thematic and content analysis.

RESULTS

Technical and methodological considerations for the use of VMS were interrelated and included concerns surrounding privacy, footage security, fears of surveillance and the potential for medico-legal consequences. Additionally, possible detrimental impacts on healthcare worker (HCW) -patient relationships, issues of cost versus benefits, HCW and patient safety and changes to feedback were also identified.

CONCLUSIONS

The primary methodological and technical issues to overcome in order to implement VMS for hand hygiene auditing in clinical practice, centered upon issues of acceptability to patients and health professionals, privacy, consent and liability.

CHECKLIST

COREQ.

Debriefing: A Tool to Enhance Education and Practice in NICU

Debriefing, a facilitator-guided reflection of an educational experience or critical incident, is an important tool in improving the safety and quality of practice in the NICU. Unlike feedback, which is often a one-way discussion, debriefing is a purposeful, 2-way reflective discussion which is based on experiential learning theory. The purpose of this article is to review the theoretical basis of debriefing and describe styles and tools for debriefing that can be applied in the NICU.

Reviewing recordings of neonatal resuscitation with parents

BACKGROUND

Recording of neonatal resuscitation, including video and respiratory parameters, was implemented for research and quality purposes at the neonatal intensive care unit (NICU) of the Leiden University Medical Center, and parents were offered to review the recording of their infant together with a neonatal care provider. We aimed to provide insight in parental experiences with reviewing the recording of the neonatal resuscitation of their premature infant.

METHODS

This study combined participant observations during parental review of recordings with retrospective qualitative interviews with parents.

RESULTS

Parental review of recordings of neonatal resuscitation was observed on 20 occasions, reviewing recordings of 31 children (12 singletons, 8 twins and 1 triplet), of whom 4 died during admission. Median (range) gestational age at birth was 27+5 (24+5-30+3) weeks. Subsequently, 25 parents (13 mothers and 12 fathers) were interviewed.Parents reported many positive experiences, with special emphasis on the value for getting hold of the start of their infant's life and coping with the trauma of neonatal resuscitation. Reviewing recordings of neonatal resuscitation frequently resulted in appreciation for the child, the father and the medical team. Timing and set-up of the review contributed to positive experiences. Parents considered screenshots/copies of the recording of the resuscitation of their infant as valuable keepsakes of their NICU story and reported that having the screenshots/video comforted them, especially when their child died during admission.

CONCLUSION

Parents consider reviewing recordings of neonatal resuscitation as valuable. These positive parental experiences could allay concerns about sharing recordings of neonatal resuscitation with parents.

Deferred consent for delivery room studies: the providers' perspective

OBJECTIVE

To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios.

METHODS

We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0.

RESULTS

Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent.

CONCLUSION

Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.

Neonatal resuscitation guideline adherence: simulation study and framework for improvement

We wanted to assess newborn life support (NLS) knowledge and guideline adherence, and provide strategies to improve (neonatal) resuscitation guideline adherence. Pediatricians completed 17 multiple-choice questions (MCQ). They performed a simulated NLS scenario, using a high-fidelity manikin. The literature was systematically searched for publications regarding guideline adherence. Forty-six pediatricians participated: 45 completed the MCQ, 34 performed the scenario. Seventy-one percent (median, IQR 56-82) of the MCQ were answered correctly. Fifty-six percent performed inflation breaths ≤ 60 s, 24% delivered inflation breaths of 2-3 s, and 85% used adequate inspiratory pressures. Airway patency was ensured 83% (IQR 76-92) of the time. Median events/min, compression rate, and percentage of effective compressions were 138/min (IQR 130-145), 120/min (IQR 114-120), and 38% (IQR 24-48), respectively. Other adherence percentages were temperature management 50%, auscultation of initial heart rate 100%, pulse oximeter use 94%, oxygen increase 74%, and correct epinephrine dose 82%. Ten publications were identified and used for our framework. The framework may inspire clinicians, educators, researchers, and guideline developers in their attempt to improve resuscitation guideline adherence. It contains many feasible strategies to enhance professionals' knowledge, skills, self-efficacy, and team performance, as well as recommendations regarding equipment, environment, and guideline development/dissemination.Conclusion: NLS guideline adherence among pediatricians needs improvement. Our framework is meant to promote resuscitation guideline adherence. What is Known: • Inadequate newborn life support (NLS) may contribute to (long-term) pulmonary and cerebral damage. • Video-based assessment of neonatal resuscitations has shown that deviations from the NLS guideline occur frequently; this assessment method has its audiovisual shortcomings. What is New: • The resuscitation quality metrics provided by our high-fidelity manikin suggest that the adherence of Dutch general pediatricians to the NLS guideline is suboptimal. • We constructed a comprehensive framework, containing multiple strategies to improve (neonatal) resuscitation guideline adherence.

Benefits of recording and reviewing neonatal resuscitation: the providers' perspective

OBJECTIVE

To assess benefits of recording and reviewing neonatal resuscitation as experienced by neonatal care providers.

DESIGN

A qualitative study using semistructured interviews questioning neonatal care providers about their experiences with recording and reviewing neonatal resuscitation. Data were analysed using the qualitative data analysis software Atlas.ti V.7.0.

SETTING

Neonatal care providers working at neonatal intensive care units (NICUs) of the Leiden University Medical Center, the Netherlands, and the University of Pennsylvania School of Medicine, USA, participated in this study.

RESULTS

In total, 48 NICU staff members were interviewed. Reported experiences and attitudes are broadly similar for both NICUs. All interviewed providers reported positive experiences and benefits, with special emphasis on educational benefits. Recording and reviewing neonatal resuscitation is used for various learning activities, such as plenary review meetings and as tool for objective feedback. Providers reported to learn from reviewing their own performance during resuscitation, as well as from reviewing performances of others. Improved time perception, reflection on guideline compliance and acting less invasively during resuscitations were often mentioned as learning outcomes. All providers would recommend other NICUs to implement recording and reviewing neonatal resuscitation, as it is a powerful tool for learning and improving. However, they emphasised preconditions for successful implementation, such as providing information, not being punitive and focusing on the benefits for learning and improving.

CONCLUSION

Recording and reviewing neonatal resuscitation is considered highly beneficial for learning and improving resuscitation skills and is recommended by providers participating in it.

Midwives' perceptions of women's mobile phone use and impact on care in birth suite

BACKGROUND

Women's use of mobile phones while in birth suite has been recognised as a common occurrence. However, no evidence has been reported around midwives' perceptions of how women's mobile phone use impacts midwifery care in birth suite.

OBJECTIVE

To explore midwives' perceptions of women's mobile phone use and impact on care in the labour and birth environment.

METHODS

A qualitative descriptive study was undertaken. Transcriptions from focus groups were subjected to thematic analysis.

FINDINGS

Ten focus groups involving 63 Australian midwives were conducted. Four key themes and corresponding subthemes were identified: 'considering consent' which encompassed the subthemes 'establishing boundaries' and 'taken by surprise'; 'competing with the phone' encompassing 'missing the experience' and 'delaying care'; 'being with woman' encompassing 'affecting relationships' and 'not my right to deny'; and finally 'bringing others into the room' with subthemes of 'keeping in touch' and 'seeking a second opinion'.

CONCLUSIONS

This is the first study to explore midwives perceptions of women's mobile phone use and the impact on a midwife's ability to provide care in birth suite. Findings suggest that women's mobile phone use can influence the relationship between the midwife and the woman and contributes to delays in providing care. Midwives shared how they experienced tensions around their right to grant permission for their image to be recorded. Finally, mobile phones have allowed others not present in the birth suite to access women and influence their decision making.

IMPLICATIONS FOR PRACTICE

It is widely recognised women are bringing their mobile phones into the labour and birth environment. Therefore, it is important we explore midwives perceptions around the tensions and concerns that exist, so they can be addressed.

Improving Guideline Compliance and Documentation Through Auditing Neonatal Resuscitation

Objective: Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Study design: Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. Results: A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median (IQR) gestational age of 30 (27-35) weeks vs. 30 (29-33) weeks (p = 0.64) and birth weight of 1368 (998-1780) grams vs. 1420 (1097-1871) grams (p = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; p < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO₂), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% (p < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Conclusion: Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study

OBJECTIVES

To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.

DESIGN SETTING AND PATIENTS

A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017.

INTERVENTIONS

Using a data collection form and video recordings, we registered and analysed resuscitative interventions.

MAIN OUTCOME MEASURES

Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns.

RESULTS

All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54-221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks' gestational age were returned to parental care without further follow-up.

CONCLUSIONS

The need for resuscitative interventions after birth was frequent in this unselected population in a high-resource setting, but full cardiopulmonary resuscitation was rare. Short-term outcomes were good, suggesting that most newborns treated with resuscitative interventions were not severely affected.

Adherence to the neonatal resuscitation algorithm for preterm infants in a tertiary hospital in Spain

BACKGROUND

There is evidence that delivery room resuscitation of very preterm infants often deviates from internationally recommended guidelines. There were no published data in Spain regarding the quality of neonatal resuscitation. Therefore, we decided to evaluate resuscitation team adherence to neonatal resuscitation guidelines after birth in very preterm infants.

METHODS

We conducted an observational study. We video recorded resuscitations of preterm infants < 32 weeks' gestational age and evaluated every step during resuscitation according to a score-sheet specifically designed for this purpose, following Carbine's method, where higher scores indicated that more intense resuscitation maneuvers were required. We divided the score achieved by the total possible points per patient to obtain the percentage of adherence to the algorithm. We also compared resuscitations performed by staff neonatologists to those performed by pediatricians on-call. We compared percentages of adherence to the algorithm with the Chi-square test for large groups and Fisher's exact test for smaller groups. We compared assigned Apgar scores with those given after analyzing the recordings and described them by their median and interquartile range. We measured the interrater agreement between Apgar scores with Cohen's kappa coefficient. Linear and logarithmic regressions were drawn to characterize the pattern of algorithm adherence. Statistical analysis was performed using SPSS V.20. A p-value < 0.05 was considered significant. Our Hospital Ethics Committee approved this project, and we obtained parental written consent beforehand.

RESULTS

Sixteen percent of our resuscitations followed the algorithm. The number of mistakes per resuscitation was low. Global adherence to the algorithm was 80.9%. Ventilation and surfactant administration were performed best, whereas preparation and initial steps were done with worse adherence to the algorithm. Intubation required, on average, 2.2 attempts; success on the first attempt happened in 33.3% of cases. Only 12.5% of intubations were achieved within the allotted 30 s. Many errors were attributable to timing. Resuscitations led by pediatricians on-call were performed as correctly as those by staff neonatologists.

CONCLUSIONS

Resuscitation often deviates from the internationally recognized algorithm. Perfectly performed resuscitations are infrequent, although global adherence to the algorithm is high. Neonatologists and pediatricians need intubation training.

Video analysis for the evaluation of vaginal births: a prospective observational study

AIMS OF THE STUDY Video documentation is nowadays well established in many fields of medicine, but mostly in unreal situations such as simulation training. We here present the application of video for teaching and learning purposes during the birth process. The aim of video documentation during labour is to provide an observational tool for obstetric care by midwives and obstetricians, with the opportunity for evaluation and education afterwards, especially in absence of the woman in labour and her family. METHODS Between February 2015 and June 2017, we conducted a prospective observational study on women aged over 18 years with singleton pregnancies with vertex presentation at term, who gave birth vaginally in the labour ward at the Division of Obstetrics of the University Hospital of Zurich. The end of birth (crowning of the head and fetal extraction) with the manual actions and manoeuvers performed was recorded on video in 100 births. Procedures were analysed afterwards by a senior consultant and evaluated with the staff involved. RESULTS We found frequent notable omissions during vaginal deliveries, concerning technical and nontechnical skills. Those aspects included inappropriate aseptic technique (e.g., no sterile underlay or sterile gloves), improper fetal head slowdown during expulsion, lack of visualisation of the perineum during fetal extraction/expulsion, lack of hip, shoulder and arm guiding while extracting the fetus, inappropriate episiotomy technique (wrong handling of the scissors, cutting angle too steep) and improper communication between the woman giving birth and the staff. During vacuum extractions, incorrect positioning of the cup, and inappropriate direction of pulling and handling of the cup were recorded. CONCLUSIONS Video analysis of obstetric procedures in the labour ward is an easily applicable and very useful tool for teaching and learning purposes. It contributes to showing and improving the quality of procedures and the interactions of the staff and can be used for staff evaluation. ​ Registered at ClinicalTrials.gov (registration number NCT02295904)