Effect of in-hospital training on medical errors made by teams during neonatal resuscitation

BACKGROUND

Neonatal resuscitation is one of the most critical and risky events that requires a high level of individual skill and team performance.

OBJECTIVE

To evaluate the effect of training of resuscitation teams on the frequency and type of medical errors (ME) that result from neonatal resuscitation.

METHODS

A prospective observational study was performed using a checklist to detect ME related to neonatal resuscitation.

RESULTS

The rate of ME was 24.82%. There was a significant reduction in the percentage of errors from 17.28% in pre- pre-training phase to 7.54% in post post-training phase. Near miss MEs (98.77%) were significantly higher than adverse events. The active errors were significantly higher than latent errors, P < 0.001, and decreased from 39.19% during pre-training to 19.64% in the post-training phase. The commission ME s were significantly higher than the omission, P < 0.001. The latent errors percentage was 41.17% of the total errors and were not significantly reduced after training.

CONCLUSION

Training sessions reduced ME that occurred during resuscitation, however careful distinguishing and recognizing the type of MEs is important to plan for further reduction of errors. Special attention to latent errors is imperative as it needs a specific approach rather than just training.

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

OBJECTIVE

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine.

STUDY DESIGN

We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR.

RESULTS

In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine.

CONCLUSIONS

This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Enhanced Neonatal Pulse Oximetry Sounds for the First Minutes of Life: A Laboratory Trial

OBJECTIVE

Auditory enhancements to the pulse oximetry tone may help clinicians detect deviations from target ranges for oxygen saturation (SpO2) and heart rate (HR).

BACKGROUND

Clinical guidelines recommend target ranges for SpO2 and HR during neonatal resuscitation in the first 10 minutes after birth. The pulse oximeter currently maps HR to tone rate, and SpO2 to tone pitch. However, deviations from target ranges for SpO2 and HR are not easy to detect.

METHOD

Forty-one participants were presented with 30-second simulated scenarios of an infant's SpO2 and HR levels in the first minutes after birth. Tremolo marked distinct HR ranges and formants marked distinct SpO2 ranges. Participants were randomly allocated to conditions: (a) No Enhancement control, (b) Enhanced HR Only, (c) Enhanced SpO2 Only, and (d) Enhanced Both.

RESULTS

Participants in the Enhanced HR Only and Enhanced SpO2 Only conditions identified HR and SpO2 ranges, respectively, more accurately than participants in the No Enhancement condition, ps < 0.001. In the Enhanced Both condition, the tremolo enhancement of HR did not affect participants' ability to identify SpO2 range, but the formants enhancement of SpO2 may have attenuated participants' ability to identify tremolo-enhanced HR range.

CONCLUSION

Tremolo and formant enhancements improve range identification for HR and SpO2, respectively, and could improve clinicians' ability to identify SpO2 and HR ranges in the first minutes after birth.

APPLICATION

Enhancements to the pulse oximeter tone to indicate clinically important ranges could improve the management of oxygen delivery to the neonate during resuscitation in the first 10 minutes after birth.

Emergency Cesarean Section in a Dichorionic Diamniotic Twin Pregnancy With Hydrops Fetalis: A Report of a Critical Case

This case report describes the emergent scenario of a 41-year-old primipara at 31.2 weeks of gestation, presenting with abdominal and back pain in the context of a dichorionic diamniotic twin pregnancy complicated by hydrops fetalis. The patient, with a history of hypertension, hyperthyroidism, and a cervical stitch in place, underwent an emergency lower segment cesarean section. The ultrasound revealed an intrauterine left footling in one twin, contributing to the suspected hydrops fetalis. Neonatal complications arose, particularly with Baby B, necessitating immediate resuscitation and intensive care. Successful outcomes were achieved through a well-coordinated multidisciplinary approach involving obstetricians, neonatologists, and anesthesiologists. This case underscores the importance of prompt recognition, timely interventions, and collaborative care in managing complex pregnancies, shedding light on the challenges associated with dichorionic diamniotic twin pregnancies and emphasizing the need for ongoing research to refine perinatal strategies.

The Effects of a Digital Game Simulator versus a Traditional Intervention on Paramedics' Neonatal Resuscitation Performance

Neonatal resuscitation is a skill set that comprises procedures, assessment, decision-making, communication, and teamwork. It is used in an emergency situation in the delivery room with the aim of supporting newborn infants who are not able to begin breathing on their own. Thus, healthcare providers need to refresh their neonatal resuscitation skills periodically, according to the Neonatal Resuscitation Program, to ensure that they can react quickly and effectively in emergency situations. The RETAIN digital game simulator was designed to enable healthcare providers to practice their neonatal resuscitation skills. To evaluate the effectiveness of this game in a laboratory setting, a randomized control trial sampled 42 paramedics who completed a pre-test, were randomly assigned to watch a traditional lecture video on the neonatal resuscitation procedure or to play a novel digital game simulation on the same topic, and then completed a following test. A two-way mixed ANOVA revealed a statistically significant improvement in paramedics' neonatal resuscitation performance over time, which did not differ between conditions. Thus, digital games can provide an enjoyable alternative to traditional practices in refreshing neonatal resuscitation knowledge.

Midwives' Experiences of Intact Cord Resuscitation in Nonvigorous Neonates After Vaginal Birth in Sweden

OBJECTIVE

To describe midwives' experiences of intact cord resuscitation close to the mother for nonvigorous neonates after vaginal birth.

DESIGN

Descriptive qualitative.

SETTING

Four labor wards in Sweden.

PARTICIPANTS

Midwives (N = 13) currently or previously employed in labor wards where the Sustained Cord Circulation and Ventilation (SAVE) study was conducted.

METHODS

We analyzed semistructured interviews using reflexive thematic analysis.

RESULTS

Participants' experiences are presented in an overarching theme: Midwives balance knowledge with doing the right thing in a challenging work environment during intact cord resuscitation. Three primary themes emerged: A New Workflow, Zero Separation: The Big Advantage, and The Midwife: Guardian of Childbirth.

CONCLUSION

The participants were keen to keep the umbilical cord intact even for nonvigorous neonates. They wanted to work with the neonate close to the mother to facilitate zero separation and family participation. Ventilation with an intact umbilical cord was considered a routine to be implemented in the future, but the participants identified certain difficulties with the design of the SAVE study.

Rapid cycle deliberate practice improves resident performance during ELBW resuscitation

BACKGROUND

Neonatal Resuscitation is a required competency for pediatric and family medicine residency programs. Simulation-based training can be used to supplement clinical experience. Rapid Cycle Deliberate Practice (RCDP) has been validated as an effective education model and is gaining favor over traditional simulation models. The aim of this study was to evaluate the effectiveness of a simulation-based rapid cycle deliberate practice (RCDP) intervention on extremely low birth weight (ELBW) infant resuscitation.

METHODS

Pediatric and family practice residents were randomized to control and intervention groups and participated in pre- and post-NICU rotation simulations. The intervention group received one RCDP session. Simulations were scored by blinded video review for overall performance, positive pressure ventilation (PPV), endotracheal intubation and behavioral skills. Surveys assessed confidence in ELBW resuscitation.

RESULTS

Forty-one residents participated in the study. The RCDP group performed better than the control group at post-rotation evaluation for overall resuscitation performance (65% vs 87%, p = 0.004), administering PPV (63% vs 88%, p = 0.006), and validated behavior skills (1.4 vs 2.0, p = 0.019). Residents in the RCDP group reported greater confidence with ELBW resuscitation.

CONCLUSION

An educational intervention using RCDP was associated with improved resident performance and confidence in ELBW resuscitation. RCDP should be considered for NRP and ELBW resuscitation training.

Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review

AIM

This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section).

METHODS

A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022.

RESULTS

We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole.

CONCLUSION

We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.

Femoral Occlusion during Neonatal Cardiopulmonary Resuscitation Improves Outcomes in an Ovine Model of Perinatal Cardiac Arrest

BACKGROUND

The goal of chest compressions during neonatal resuscitation is to increase cerebral and coronary blood flow leading to the return of spontaneous circulation (ROSC). During chest compressions, bilateral femoral occlusion may increase afterload and promote carotid and coronary flow, an effect similar to epinephrine. Our objectives were to determine the impact of bilateral femoral occlusion during chest compressions on the incidence and timing of ROSC and hemodynamics.

METHODOLOGY

In this randomized study, 19 term fetal lambs in cardiac arrest were resuscitated based on the Neonatal Resuscitation Program guidelines and randomized into two groups: femoral occlusion or controls. Bilateral femoral arteries were occluded by applying pressure using two fingers during chest compressions.

RESULTS

Seventy percent (7/10) of the lambs in the femoral occlusion group achieved ROSC in 5 ± 2 min and three lambs (30%) did not receive epinephrine. ROSC was achieved in 44% (4/9) of the controls in 13 ± 6 min and all lambs received epinephrine. The femoral occlusion group had higher diastolic blood pressures, carotid and coronary blood flow.

CONCLUSION

Femoral occlusion resulted in faster and higher incidence of ROSC, most likely due to attaining increased diastolic pressures, coronary and carotid flow. This is a low-tech intervention that can be easily adapted in resource limited settings, with the potential to improve survival and neurodevelopmental outcomes.

Impact of an Educational Clinical Video Combined with Standard Helping Babies Breathe Training on Acquisition and Retention of Knowledge and Skills among Ethiopian Midwives

Helping Babies Breathe (HBB) is an evidence-based neonatal resuscitation program designed for implementation in low-resource settings. While HBB reduces rates of early neonatal mortality and stillbirth, maintenance of knowledge and skills remains a challenge. The extent to which the inclusion of educational clinical videos impacts learners' knowledge and skills acquisition, and retention is largely unknown. We conducted a cluster-randomized controlled trial at two public teaching hospitals in Addis Ababa, Ethiopia. We randomized small training group clusters of 84 midwives to standard HBB vs. standard HBB training supplemented with exposure to an educational clinical video on newborn resuscitation. Midwives were followed over a 7-month time period and assessed on their knowledge and skills using standard HBB tools. When comparing the intervention to the control group, there was no difference in outcomes across all assessments, indicating that the addition of the video did not influence skill retention. Pass rates for both the control and intervention group on bag and mask skills remained low at 7 months despite frequent assessments. There is more to learn about the use of educational videos along with low-dose, high-frequency training and how it relates to retention of knowledge and skills in learners.

Antenatal magnesium sulfate and the need for mechanical ventilation in the first three days of life

BACKGROUND

Antenatal administration of magnesium sulfate (MgSO4) to women in preterm labor has gained widespread use. This study examined the relationship between MgSO4 exposure with neonatal respiratory outcomes.

METHODS

Very low birth weight (VLBW) infants exposed to antenatal MgSO4 were included. Infants who were intubated anytime during the first three days of life were compared to those who were not intubated regarding their demographic and clinical characteristics, MgSO4 therapy, immediate respiratory outcomes, and occurrence of intraventricular hemorrhage (IVH) using student t-test, chi square testing and logistic regression analysis to control for confounding variables. Correlation coefficient of MgSO4 cumulative dose given and duration of infusion with delivery room resuscitation and need for mechanical ventilation in the first 3 days of life were also calculated. Multilinear regression analysis was used to control for confounding factors.

RESULTS

Intubated group included 96 infants while non-intubated group included 171 infants. Although, intubated group has younger gestational age (26 vs. 29 weeks, p < 0.01) and lower birth weight (786 vs. 1115 g (g), p < 0.01), there were no significant differences between groups in regard to MgSO4 cumulative dose (24 vs. 27 g, p = 0.29), infusion time (14.6 vs. 18 h, p = 0.19) or infants' serum magnesium level (2.6 vs. 2.8 milliequivalents (mEq)/L p = 0.86). There was no correlation between cumulative MgSO4 dose with endotracheal intubation or cardiac resuscitation in the delivery room (cc: -0.03, p = 0.66; and 0.02, p = 0.79, respectively) or the need for mechanical ventilation in the first 3 days of life (cc: -0.04 to -0.07, p = 0.21-0.51). In addition, there was no relationship between MgSO4 dose, duration of infusion, or infant's serum magnesium level and occurrence of IVH.

CONCLUSION

Regardless of dose or duration of infusion, antenatal MgSO4 exposure is not associated with increased intubation or mechanical ventilation early in life.

Significance of Neonatal Heart Rate in the Delivery Room-A Review

BACKGROUND

Heart rate (HR) is considered the main vital sign in newborns during perinatal transition, with a threshold of 100 beats per minute (bpm), below which, intervention is recommended. However, recent changes in delivery room management, including delayed cord clamping, are likely to have influenced normal HR transition.

OBJECTIVE

To summarize the updated knowledge about the factors, including measurement methods, that influence HR in newborn infants immediately after birth. Additionally, this paper provides an overview of delivery room HR as a prognostic indicator in different subgroups of newborns.

METHODS

We searched PubMed, EMBASE, and Google Scholar with the terms infant, heart rate, delivery room, resuscitation, pulse oximetry, and electrocardiogram.

RESULTS

Seven studies that described HR values in newborn infants immediately after birth were included. Pulse oximetry-derived HR percentiles after immediate cord clamping may not be applicable to the current practice of delayed cord clamping and the increasing use of delivery room electrocardiograms. Mask ventilation may adversely affect HR, particularly in premature and non-asphyxiated infants. Prolonged bradycardia is a negative prognostic factor, especially if combined with hypoxemia in infants <32 weeks of gestation.

CONCLUSIONS

HR assessment in the delivery room remains important. However, the cardiopulmonary transition is affected by delayed cord clamping, gestational age, and underlying conditions.

Use of Suctioning during Newborn Resuscitation and Its Effects on Heart Rate in a Low-Resource Setting, Tanzania

Suctioning of newborns immediately after birth, as part of delivery room resuscitation, is only recommended if the airway is obstructed. The aim of this study was to describe the use of suctioning during newborn resuscitation among survivors versus those who died within 3 days and potential suction-related heart rate responses and associations to newborn characteristics. This was a retrospective observational study from July 2013 to July 2016 in a referral hospital in rural Tanzania. Research assistants observed and documented all deliveries, newborn resuscitations were video-recorded, and newborn heart rates were captured with a dry-electrode electrocardiogram. Liveborn infants ≥34 weeks gestation who received ventilation and with complete datasets were eligible. All 30 newborns who died were included, and a total of 46 survivors were selected as controls. Videos were annotated and heart rate patterns were observed before and after the suction events. Suctioning was performed more frequently than recommended. No differences were found in suctioning characteristics between newborns who died versus those who survived. In 13% of suction events, a significant heart rate change (i.e., arrhythmia or brief/sustained >15% fall in heart rate) was observed in relation to suctioning. This represents a potential additional harm to already depressed newborns undergoing resuscitation.

Neonatal resuscitation workshop for trainees in standardized medical residency training-a pilot practice in Shenzhen, China

Background

Neonatal resuscitation is an important skillset for clinicians attending deliveries. Accredited neonatal resuscitation training is not obligatory in most training centers of standardized medical residency programs before 2022 in China. We investigated the feasibility and effectiveness of neonatal resuscitation simulation training (neo-RST) in residents in Shenzhen, China.

Methods

Four two-day neo-RST workshops were conducted in the University of Hong Kong-Shenzhen Hospital and Shenzhen Health Capacity Building and Continuing Education Center in 2020-2021. The workshops had Neonatal Resuscitation Program (NRP)® update, skill stations and simulation practice with debriefing. Each participant had the integrated skill station assessment (ISSA) at the end of workshop. Participants of workshops included residents of different disciplines and health care providers (HCPs) of neonatal and obstetrical departments. We compared demographic characteristics, neonatal resuscitation knowledge before training, ISSA overall and categorical scores on skill sets between residents and HCPs.

Results

In 2020-2021, 4 neo-RST workshops were conducted with 48 residents and 48 HCPs. The residents group had less working experience, less prior experience in neo-RST and lower neonatal resuscitation knowledge scores than those of HCPs group. After the workshop, residents had higher overall ISSA score than that of HCPs group (90.2 ± 5.9 vs. 86.3 ± 6.6%, P = 0.003, respectively). There was no significant difference in the numbers of participants scored <80% in residents and HCPs group (3 [6.3%] vs. 7 [14.6%], respectively). Regarding the categorical scores, residents scored significantly higher in preparation, ventilation, crisis resource management and behavioral skills but lower in appropriate oxygen use, when compared with the HCPs.

Conclusion

Neo-RST for residents is feasible with promising short-term educational outcomes. Neo-RST could be implemented in standardized medical residency programs in China.

Outcomes of Neonatal Resuscitation With and Without an Intact Umbilical Cord: A Meta-Analysis

Around the world, very few babies require a more intensive resuscitative effort for stabilization. The optimal timing of an intact umbilical cord to help with resuscitation is controversial. Our objective in the review is to compare the outcomes of neonatal resuscitation with and without an intact umbilical cord. A search of six electronic database libraries was explored for data released between 2014 and 2023. A manual search of secondary references in relevant studies was also performed. Studies focused only on randomized controlled trials comparing the outcomes of neonatal resuscitation with and without an intact umbilical cord at any gestational age. Two reviewers retrieved data for relevant outcomes and independently evaluated trial quality and eligibility. Mortality rate and APGAR (appearance, pulse, grimace, activity, and respiration) scores were noted as common in the two studies. Four randomized control trials were assessed for the impact of delayed cord clamping on neonates. One study focused on neurodevelopmental outcomes and noted significant improvement. Other studies noted delayed clamping as beneficial for improving oxygen saturation, APGAR score, and mortality rate. The meta-analysis included three controlled trials with a total of 528 babies and tested the effects of clamping the umbilical cord either late (n = 264) or early (n = 264). The heterogeneity of mortality and APGAR score at 5 minutes were not significant, which may be because only two studies of each case were available to compare. We concluded that very few studies are available to identify a significant impact of delayed cord clamping in neonates. However, delayed clamping for up to 5 minutes is noted as beneficial to the newborn.

Scale Up of Neonatal Resuscitation Training and Skill Retention in Five Provinces of Nepal

To reduce neonatal mortality attributable to intrapartum hypoxic events, Latter-days Saint Charities (LDSC) and Safa Sunaulo Nepal (SSN) implemented a neonatal resuscitation training, scale-up, and skill retention program. This article reports on the LDSC/SSN dissemination program and newborn outcomes associated with its implementation. To evaluate the program, we used a prospective cohort design to compare outcomes of birth cohorts in 87 health facilities preimplementation and postimplementation of the facility-based training. A paired T-test was used to determine whether baseline and endline values were significantly different. Resuscitation training began with trainers from 191 facilities attending Helping Babies Breathe (HBB) training-of-trainer (ToT) courses. Thereafter, 87 facilities from five provinces received active mentoring, scale-up assistance (6389 providers trained), and skill retention support. The LDSC/SSN program was associated with decreases in the number of intrapartum stillbirths in all provinces except Bagmati. Neonatal deaths within 24 hours of birth decreased significantly in Lumbini, Madhesh, and Karnali provinces. Morbidity associations, as defined by sick newborn transfers, decreased significantly in Lumbini, Gandaki, and Madhesh provinces. The LDSC/SSN model of neonatal resuscitation training, scale-up, and skill retention has the potential to significantly improve perinatal outcomes. It could potentially guide future programs in Nepal and other resource-limited settings.

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.

Capacity Building in Remote Facilitation of Newborn Resuscitation

The past decade has been notable for widespread dissemination of newborn resuscitation training in low-resource settings through simplified training programs including Helping Babies Breathe. Since 2020, implementation efforts have been impacted by restrictions on travel and in-person gatherings with the SARS-CoV-2 pandemic, prompting the development of alternative methods of training. While previous studies have demonstrated feasibility of remote neonatal resuscitation training, this perspective paper covers common barriers identified and key lessons learned developing a cadre of remote facilitators. Challenges of remote facilitation include mastering videoconferencing platforms, establishing personal connections, and providing effective oversight of skills practice. Training sessions can be used to support facilitators in acquiring comfort and competency in harnessing videoconferencing platforms for effective facilitation. Optimization of approaches and investment in capacity building of remote facilitators are imperative for effective implementation of remote neonatal resuscitation training.

Improved neonatal outcomes by multidisciplinary simulation-a contemporary practice in the demonstration area of China

Background

Simulation-based training improves neonatal resuscitation and decreases perinatal mortality in low- and middle-income countries. Interdisciplinary in-situ simulation may promote quality care in neonatal resuscitation. However, there is limited information regarding the effect of multidisciplinary in-situ simulation training (MIST) on neonatal outcomes. We aimed to investigate the impact of MIST on neonatal resuscitation in reducing the incidence of neonatal asphyxia and related morbidities.

Methods

Weekly MIST on neonatal resuscitation has been conducted through neonatal and obstetrical collaboration at the University of Hong Kong-Shenzhen Hospital, China, since 2019. Each simulation was facilitated by two instructors and performed by three health care providers from obstetric and neonatal intensive care units, followed by a debriefing of the participants and several designated observers. The incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy (HIE), and meconium aspiration syndrome (MAS) before (2017-2018) and after (2019-2020) the commencement of weekly MIST were analyzed.

Results

There were 81 simulation cases including the resuscitation of preterm neonates of different gestational ages, perinatal distress, meconium-stained amniotic fluid, and congenital heart disease with 1,503 participant counts (225 active participants). The respective incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS decreased significantly after MIST (0.64%, 0.06%, 0.01%, and 0.09% vs. 0.84%, 0.14%, 0.10%, and 0.19%, respectively, all P < 0.05).

Conclusions

Weekly MIST on neonatal resuscitation decreased the incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS. Implementation of regular resuscitation simulation training is feasible and may improve the quality of neonatal resuscitation with better neonatal outcomes in low- and middle-income countries.

Neurodevelopmental Outcome at 6 Months Following Neonatal Resuscitation in Rural Tanzania

Early bag-mask ventilation (BMV) administered to non-breathing neonates at birth in the presence of birth asphyxia (interruption of placental blood flow) has reduced neonatal mortality by up to 50% in low- and middle-income countries. The neurodevelopmental outcome of neonates receiving BMV remains unknown. Using the Malawi Developmental Assessment Tool (MDAT), infants who received BMV at birth were assessed at 6 months, evaluating gross motor, fine motor, language and social skills. A healthy cohort with no birth complications was assessed with the same tool for comparison. Mean age-adjusted MDAT z-scores were not significantly different between the groups. The number of children having developmental delay defined as a z-score ≤ -2 was significantly higher in the resuscitated cohort for the fine motor and language domain and overall MDAT z-score. The prevalence of clinical seizures post discharge was significantly higher in the resuscitated group and was associated with neurodevelopmental delay. Infants with developmental delay or seizures were more likely to have a 5 min Apgar < 7 and a longer duration of BMV. Most children receiving BMV at birth are developing normally at 6 months. Still, there are some children with impaired development among resuscitated children, representing a subgroup of children who may have suffered more severe asphyxia.

Cross-sectional study in Madagascar demonstrates efficacy of virtual mentoring and flipped classroom modifications of neonatal resuscitation programme Helping Babies Breathe

AIM

The Covid-19 pandemic necessitated virtual adaptation of the neonatal resuscitation programme Helping Babies Breathe (HBB). This study assessed one such virtually mentored and flipped classroom modification in Madagascar.

METHODS

A cross-sectional study was performed in September 2021 and May 2022. Healthcare providers were identified by local collaborating organisations. United States-based master trainers collaborated with local trainers on virtually mentored trainings followed by independent trainings. Master trainers were available for consultation via Zoom during the virtual training. A flipped classroom modification and traditional didactic method were compared. Primary outcomes were knowledge and skill acquisition, evaluated by written assessments and objective structured clinical examinations.

RESULTS

Overall, 97 providers completed the curriculum. Written assessment scores improved in both training models (traditional - 74.8% versus 91.5%, p<0.001; flipped classroom - 89.7% versus 93.6%, p<0.05). There was no significant difference among written assessment scores (92.8% versus 91.5%, p=0.62) and significantly higher objective structured clinical examination scores (97.3% versus 89.5%, p<0.001) for the independent training compared to the virtually mentored training.

CONCLUSION

The virtually mentored HBB training was followed by a successful independent training as measured by participant knowledge and skill acquisition, supporting the efficacy of virtual dissemination.

Low Apgar score and need for resuscitation increased the probability of receiving therapeutic hypothermia more strongly than acidosis at birth

AIM

The aim of this study was to investigate how individual markers for birth asphyxia, so-called A criteria, were associated with the probability of receiving therapeutic hypothermia.

METHODS

This population-based cohort study included 1336 live-born singleton term infants with any A criterion in the Stockholm-Gotland Region, Sweden during 2008 to 2014. The Swedish Neonatal Quality Register and National Patient Register were used for data collection. Results were presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

There were 89 infants, 44 boys and 45 girls with mean gestational age 40.5 weeks, who received therapeutic hypothermia. Low Apgar score, aOR 12.44 (95% CI 5.99-25.86), and resuscitation, aOR 9.18 (95% CI 3.77-22.34), were strongly associated with therapeutic hypothermia. A pH <7.0 was less associated with the outcome, aOR 2.02 (95% CI 1.02-4.0). No infant who received therapeutic hypothermia fulfilled the criteria of base deficit ≥16 mmol/L only.

CONCLUSION

A low Apgar score of and/or a need for resuscitation is more relevant for identifying infants eligible for therapeutic hypothermia, compared to other A criteria. This knowledge could be used clinically to identify cases for review and avoid unnecessary monitoring of infants.

Newborns requiring resuscitation: Two thirds have heart rate ≥100 beats/minute in the first minute after birth

AIM

The aim was to study the prevalence of bradycardia at birth in newborns requiring positive pressure ventilation (PPV), distribution of first measured heart rate (HR), changes in HR before start of PPV and HR response to PPV.

METHODS

A population-based study including newborns ≥30 weeks' gestation receiving PPV at birth. HR was captured immediately after birth and continuously throughout resuscitation using the dry-electrode ECG device NeoBeat. Time of birth was registered in the Liveborn app. Provision of PPV was captured by video.

RESULTS

We included 98 newborns receiving PPV at birth. Among newborns with HR measured within 60 s after birth, median (quartiles) first HR was 112 (84, 149) bpm recorded 19 (14, 37) s after birth, of which 33% had first HR <100 and 10% had first HR <60 bpm respectively. First HR was widely distributed. Median HR at start PPV 69 s after birth was 129 bpm. In newborns with an initial low HR, HR typically remained low for 20 s of PPV before increasing rapidly over the next 20-30 s.

CONCLUSIONS

First measured HR was ≥100 bpm in two thirds of newborns receiving PPV. In bradycardic infants, HR did not increase until after 20 s of PPV.

PROspective Meta-analysis Of Trials of Initial Oxygen in preterm Newborns (PROMOTION): Protocol for a systematic review and prospective meta-analysis with individual participant data on initial oxygen concentration for resuscitation of preterm infants

BACKGROUND

Clinicians favour low oxygen concentrations when resuscitating preterm infants immediately after birth despite inconclusive evidence to support this practice. Prospective meta-analysis (PMA) is a novel approach where studies are identified as eligible for inclusion in the meta-analysis before their results are known.

AIMS

To explore whether high (60%) or low (30%) oxygen is associated with greater efficacy and safety for the initial resuscitation (immediately after birth) of preterm infants born at <29 weeks' gestation.

METHODS

We will conduct a prospective meta-analysis (PMA) with individual participant data (IPD). We will perform a systematic search to identify ongoing RCTs including infants <29 weeks' gestation randomised to high (60%) or low (30%) oxygen for initial resuscitation after birth. IPD will be sought for all infants randomised for the purpose of meta-analysis. We will employ a one-stage random-effects approach to IPD meta-analysis. Potential heterogeneity and the differential effect of high or low oxygen will be explored through subgroup and interaction analyses. The primary outcome of this study is all-cause mortality prior to hospital discharge. There will be a follow-up analysis of neurodevelopmental outcomes once available.

RESULTS/CONCLUSION

The results of neonatal outcomes at hospital discharge are expected by 2025, and neurodevelopmental outcomes by 2027.

Improving Communication to Neonatal Resuscitation Team Members During High-Risk Births

OBJECTIVE

To determine whether implementation of a written communication tool in labor and delivery during high-risk births improves communication, preparation, and satisfaction of responding neonatal resuscitation team members.

DESIGN

Quality improvement project with a pretest and posttest design.

SETTING/LOCAL PROBLEM

Two labor and delivery units and a third labor-delivery-recovery-postpartum unit within a health care system in the southeastern United States.

PARTICIPANTS

Nurses, nurse practitioners, respiratory therapists, and physicians who are part of the neonatal resuscitation team.

INTERVENTIONS/MEASUREMENTS

A researcher-designed, written communication tool titled the High-Risk Delivery Communication Tool was implemented in the settings. A researcher-designed measurement tool titled the Neonatal High-Risk Delivery Communication Scale was used as a before-and-after survey to measure communication to the neonatal resuscitation team, preparation for high-risk births, and satisfaction with communication from labor and delivery nurses.

RESULTS

Findings from all portions of the Neonatal High-Risk Delivery Communication Scale indicated statistically significant improvements in communication, preparation, and neonatal resuscitation team member neonatal resuscitation team satisfaction while attending high-risk births. Scores improved on every item regarding hand-off, risk factor communication, preparation, and satisfaction.

CONCLUSION

Implementing a communication tool for use in high-risk births may improve communication to neonatal resuscitation team members, enhance preparation for neonatal care, and increase team members' satisfaction with interprofessional communication.

Four Different Finger Positions and Their Effects on Hemodynamic Changes during Chest Compression in Asphyxiated Neonatal Piglets

Background: The Neonatal Life Support Consensus on Science With Treatment Recommendations states that chest compressions (CC) be performed preferably with the 2-thumb encircling technique. The aim of this study was to compare the hemodynamic effects of four different finger positions during CC in a piglet model of neonatal asphyxia. Methods: Seven asphyxiated post-transitional piglets were randomized to CC with 2-thumb-, 2-finger-, knocking-fingers-, and over-the-head 2-thumb-techniques for one minute at each technique. CC superimposed with sustained inflations were performed manually. Results: Seven newborn piglets (age 0-4 days, weight 2.0-2.1 kg) were included in the study. The mean (SD) slope rise of carotid blood flow was significantly higher with the 2-thumb-technique and over-the-head 2-thumb-technique (118 (45) mL/min/s and 121 (46) mL/min/s, respectively) compared to the 2-finger-technique and knocking-finger-technique (75 (48) mL/min/s and 71 (67) mL/min/s, respectively) (p < 0.001). The mean (SD) dp/dt_min (as an expression of left ventricular function) was significantly lower with the 2-thumb-technique, with -1052 (369) mmHg/s, compared to -568 (229) mmHg/s and -578(180) mmHg/s (both p = 0.012) with the 2-finger-technique and knocking-finger-technique, respectively. Conclusion: The 2-thumb-technique and the over-the-head 2-thumb-technique resulted in improved slope rises of carotid blood flow and dp/dtmin during chest compression.

Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study

Introduction

Emergency neonatal resuscitation equipment is often organized into "code carts". Simulation studies previously examined human factors of neonatal code carts and equipment; however, visual attention analysis with eye-tracking might further inform equipment design.

Objectives

To evaluate human factors of neonatal resuscitation equipment by: (1) comparing epinephrine preparation speed from adult pre-filled syringe vs. medication vial, (2) comparing equipment retrieval times from two carts and (3) utilizing eye-tracking to study visual attention and user experience.

Methods

We conducted a 2-site randomized cross-over simulation study. Site 1 is a perinatal NICU with carts focused on airway management. Site 2 is a surgical NICU with carts improved with compartments and task-based kits. Participants were fitted with eye-tracking glasses then randomized to prepare two epinephrine doses using two methods, starting with an adult epinephrine prefilled syringe or a multiple access vial. Participants then obtained items for 7 tasks from their local cart. Post-simulation, participants completed surveys and semi-structured interviews while viewing eye-tracked video of their performance. Epinephrine preparation times were compared between the two methods. Equipment retrieval times and survey responses were compared between sites. Eye-tracking was analyzed for areas of interest (AOIs) and gaze shifts between AOIs. Interviews were subject to thematic analysis.

Results

Forty HCPs participated (20/site). It was faster to draw the first epinephrine dose using the medication vial (29.9s vs. 47.6s, p < 0.001). Time to draw the second dose was similar (21.2s vs. 19s, p = 0.563). It was faster to obtain equipment from the Perinatal cart (164.4s v 228.9s, p < 0.027). Participants at both sites found their carts easy to use. Participants looked at many AOIs (54 for Perinatal vs. 76 for Surgical carts, p < 0.001) with 1 gaze shifts/second for both.Themes for epinephrine preparation include: Facilitators and Threats to Performance, and Discrepancies due to Stimulation Conditions. Themes for code carts include: Facilitators and Threats to Performance, Orienting with Prescan, and Suggestions for Improvement. Suggested cart improvements include: adding prompts, task-based grouping, and positioning small equipment more visibly. Task-based kits were welcomed, but more orientation is needed.

Conclusions

Eye-tracked simulations provided human factors assessment of emergency neonatal code carts and epinephrine preparation.

Neonatal resuscitation after birth: Swedish midwives' experiences of and perceptions about separation of mothers and their newborn babies

INTRODUCTION

This study aimed to investigate midwives' experiences of and perceptions about mother-baby separation during resuscitation of the baby following birth.

METHODS

A qualitative study was conducted using an author-designed questionnaire. Fifty-four midwives from two Swedish birth units with different working methods regarding neonatal resuscitation - at the mother's bedside in the birth room or in a designated resuscitation room outside the birth room - completed the questionnaire. Data were analyzed using qualitative content analysis.

RESULTS

Most midwives had experience of removing a newborn baby in need of critical care from the birth room, thus separating the mother and baby. The midwives identified the difficulties and challenges involved in carrying out emergency care in the birth room after birth and had divergent opinions about what they considered possible in these birth situations. They agreed on the benefits, for both mother and baby, in performing emergency care in the birth room and avoiding a separation altogether, if possible.

CONCLUSIONS

There are good opportunities to reduce separation of mother and baby after birth; training, knowledge, education and the right environmental conditions are important factors in successfully implementing new ways of working. It is possible to work towards reducing separation and this work should continue and strive to eliminate separation as far as possible.

Is it feasible to avoid suction before spontaneous breathing is established?

BACKGROUND

Suctioning of the posterior pharynx immediately after birth during neonatal resuscitation can produce a vagal response resulting in bradycardia or apnea. The feasibility of delaying any airway suctioning and avoiding deep suctioning has not been studied.

OBJECTIVES

To test the hypothesis that newborn resuscitation is feasible with the following two guidelines: 1) avoiding any suctioning until the infant establishes spontaneous respiration, and 2) avoiding the use of deep suction with catheters.

STUDY DESIGN

A quality improvement project was implemented using these two guidelines. Infants' mouth was cleaned with a dry cloth. No suction was started until infants establish spontaneous breathing. Then, bulb suction was used to clear secretions from the sides of the mouth and the nose without reaching the back of the pharynx. Deep suction using catheters was not used. Neonatal staff and physicians received biweekly training to support these changes. Resuscitation data before and after the practice change were compared.

RESULTS

A total of 999 sequential cases were compared; of them 501 and 498 infants were resuscitated before and after the implementation of the new practice, respectively. Suction before spontaneous breathing occurred in 12.4% in the first cohort. There were no differences between groups except for less use of oxygen with the new guidelines (12.4% vs 4.4%, P < 0.001).

CONCLUSION

Avoidance of any suction prior to spontaneous breathing and not applying deep suction with catheters are feasible during newborn resuscitation. These practices are associated with decreased exposure to oxygen in the delivery room.

Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation

AIM

The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation.

METHODS

The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019.

RESULTS

The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial.

CONCLUSION

Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.

Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs

Background

Umbilical cord milking (UCM) at birth causes surges in arterial blood pressure and blood flow to the brain, which may explain the high risk of intraventricular haemorrhage (IVH) in extremely preterm infants receiving UCM. This high risk of IVH has not been reported in older infants.

Objective

We hypothesized that lung aeration before UCM, reduces the surge in blood pressure and blood flow induced by UCM.

Methods

At 126 days' gestation, fetal lambs (N = 8) were exteriorised, intubated and instrumented to measure umbilical, pulmonary, cerebral blood flows, and arterial pressures. Prior to ventilation onset, the umbilical cord was briefly (2-3 s) occluded (8 times), which was followed by 8 consecutive UCMs when all physiological parameters had returned to baseline. Lambs were then ventilated. After diastolic pulmonary blood flow markedly increased in response to ventilation, the lambs received a further 8 consecutive UCMs. Ovine umbilical cord is shorter than the human umbilical cord, with ∼10 cm available for UCMs. Therefore, 8 UCMs/occlusions were done to match the volume reported in the human studies. Umbilical cord clamping occurred after the final milk.

Results

Both umbilical cord occlusions and UCM caused significant increases in carotid arterial blood flow and pressure. However, the increases in systolic and mean arterial blood pressure (10 ± 3 mmHg vs. 3 ± 2 mmHg, p = 0.01 and 10 ± 4 mmHg vs. 6 ± 2 mmHg, p = 0.048, respectively) and carotid artery blood flow (17 ± 6 ml/min vs. 10 ± 6 ml/min, p = 0.02) were significantly greater when UCM occurred before ventilation onset compared with UCM after ventilation.

Conclusions

UCM after ventilation onset significantly reduces the increases in carotid blood flow and blood pressure caused by UCM.

[Caregivers' experiences with extreme prematurity]

Neonatal intensive care units receive very immature premature newborns. Mortality and morbidity rates remain high in this particularly fragile population. Caregivers involved with the child and his or her parents may experience moral distress. There are few studies on the experience of caregivers in these situations. Training, service architecture and sharing of experiences with specifically trained psychologists can improve this experience in these highly technical services.

Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial)

BACKGROUND

Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers.

OBJECTIVE

This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training.

METHODS

Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider's Guide (VR group) or the digitized HBB Provider's Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider's Guide or the digitized HBB Provider's Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical).

RESULTS

A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048).

CONCLUSIONS

The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries.

Quasi-experimental quantitative study of training programme for nurses and midwives regarding provision of neonatal resuscitation in selected governmental hospital, (Sudan), 2018

AIMS

To measure the effectiveness of educational programmes for nurses regarding knowledge and practice of advanced resuscitation for newborn infants.

DESIGN

This is a quasi-experimental study in (Sudan, White Nile state), to evaluate the effectiveness of designed guidelines regarding advanced neonatal resuscitation for midwives during the period November 2020-January 2021.

METHODS

Data were collected using two tools: semi-structured questionnaire and checklist. The number of the respondents to the questionnaire is 75 nurses. Statistical analyses were conducted using SPSS (version 22). Data were expressed as percentages. The results show that the level of knowledge is improved significantly after training programme interventions, with safe practice reaching (98.70%) compared with a pre-test percentage of (11.5%). This indicates a steep rise in safe practice after the simulation section, a sharp decrease in unsafe practice after the practical section, followed by subsequent decrease in neonatal mortality rate. This paper has been guided by (STROBE, cohort study) checklist.

RESULTS

The study concluded that the majority of nurses and midwives have some knowledge regarding advanced neonatal resuscitation but still, there is a practice gap because of a shortage of facilities and lack of training, However, training programmes do add value on knowledge and practice for nurses and eventually decrease neonatal mortality rate.

Air, Air, Air: a champion midwife programme in Tanzania using HOT neonatal resuscitation-lessons learned

BACKGROUND

Tanzania has approximately 40 000 newborn deaths per year, with >25% of these linked to intrapartum-related hypoxia. The Helping Babies Breathe© and Golden minute© (HBB©) programme was developed to teach skilled intervention for non-breathing neonates at birth. While Helping Babies Breathe© and Golden minute©, providing training in simulated bag and mask ventilation, is theoretically successful in the classroom, it often fails to transfer to clinical practice without further support. Furthermore, the proclivity of midwives to suction excessively as a first-line intervention is an ingrained behaviour that delays ventilation, contributing to very early neonatal deaths.

METHODS

The 'champion' programme provided guided instruction during a real-life resuscitation. The site was Amana Hospital, Tanzania. The labour ward conducts 13 500 deliveries annually, most of which are managed by midwives. Brief mannikin simulation practice was held two to three times a week followed by bedside hands-on training (HOT) of bag and mask skills and problem solving while reinforcing the mantra of 'air, air, air' as the first-line intervention during a real-life emergency.

RESULTS

Champion midwives (trainers) guided instructions given during a real emergency at the bedside caused learners beliefs to change. Trainees observed changes in baby skin colour and the onset of spontaneous breathing after effective ventilation.

CONCLUSIONS

Visible success during an actual real-life emergency created confidence, mastery and collective self-efficacy.

Telementoring initiative for newborn care providers in Kenya, Pakistan and Tanzania

OBJECTIVES

To support governments' efforts at neonatal mortality reduction, UNICEF and the American Academy of Pediatrics launched a telementoring project in Kenya, Pakistan and Tanzania.

METHODS

In Fall 2019, an individualised 12-session telementoring curriculum was created for East Africa and Pakistan after site visits that included care assessment, patient data review and discussion with faculty and staff. After the programme, participants, administrators and UNICEF staff were surveyed and participated in focus group discussions.

RESULTS

Participants felt the programme improved knowledge and newborn care. Qualitative analysis found three common themes of successful telementoring: local buy-in, use of existing training or clinical improvement structures, and consideration of technology needs.

CONCLUSIONS

Telementoring has potential as a powerful tool in newborn education. It offers more flexibility and easier access than in-person sessions. This project has the potential for scale-up, particularly when physical distancing and travel restrictions are the norm.

Incidence of Intrapartum-Related Events at the Largest Obstetric Hospital in Hanoi, Vietnam: A Retrospective Study

Every year, 2.4 million neonates die during their first month of life and even more suffer permanent injury. The main causes are intrapartum-related events, prematurity, and infection, with sub-Saharan Africa and southern Asia being the worst affected regions. With a focus on intrapartum-related events, we aimed to assess the neonatal demographic characteristics, clinical management, and outcomes among neonates born at the largest obstetric hospital in Hanoi, Vietnam. This was a retrospective cross-sectional study that included all the inborn neonates in November 2019, which was selected as a representative month. A total of 4554 neonates were born during the study period. Of these, 1.0% (n = 44) were stillbirths, 0.15% (n = 7) died in hospital, 0.61% (n = 28) received positive pressure ventilation at birth, and 0.15% (n = 7) were diagnosed with hypoxic ischemic encephalopathy. A total of 581 (13%) neonates were admitted to the neonatal unit, among which the most common diagnoses were prematurity (37%, n = 217) and infection (15%, n = 89). Except for the intrapartum-related events, our findings are consistent with the previously documented data on neonatal morbidity. The intrapartum-related events, however, were surprisingly low in number even in comparison to high-income countries. Research on the current clinical practice at Phu San Hanoi Hospital may bring further clarity to identify the success factors.

Perceptions and experiences of Congolese midwives implementing a low-cost battery-operated heart rate meter during newborn resuscitation

BACKGROUND

900,000 newborns die from respiratory depression each year; nearly all of these deaths occur in low- and middle-income countries. Deaths from respiratory depression are reduced by evidence-based resuscitation. Electronic heart rate monitoring provides a sensitive indicator of the neonate's status to inform resuscitation care, but is infrequently used in low-resource settings. In a recent trial in the Democratic Republic of the Congo, midwives used a low-cost, battery-operated heart rate meter (NeoBeat) to continuously monitor heart rate during resuscitations. We explored midwives' perceptions of NeoBeat including its utility and barriers and facilitators to use.

METHODS

After a 20-month intervention in which midwives from three facilities used NeoBeat during resuscitations, we surveyed midwives and conducted focus group discussions (FGDs) regarding the incorporation of NeoBeat into clinical care. FGDs were conducted in Lingala, the native language, then transcribed and translated from Lingala to French to English. We analyzed data by: (1) coding of transcripts using Nvivo, (2) comparison of codes to identify patterns in the data, and (3) grouping of codes into categories by two independent reviewers, with final categories determined by consensus.

RESULTS

Each midwife from Facility A used NeoBeat on an estimated 373 newborns, while each midwife at facilities B and C used NeoBeat an average 24 and 47 times, respectively. From FGDs with 30 midwives, we identified five main categories of perceptions and experiences regarding the use of NeoBeat: (1) Providers' initial skepticism evolved into pride and a belief that NeoBeat was essential to resuscitation care, (2) Providers viewed NeoBeat as enabling their resuscitation and increasing their capacity, (3) NeoBeat helped providers identify flaccid newborns as liveborn, leading to hope and the perception of saving of lives, (4) Challenges of use of NeoBeat included cleaning, charging, and insufficient quantity of devices, and (5) Providers desired to continue using the device and to expand its use beyond resuscitation and their own facilities.

CONCLUSION

Midwives perceived that NeoBeat enabled their resuscitation practices, including assisting them in identifying non-breathing newborns as liveborn. Increasing the quantity of devices per facility and developing systems to facilitate cleaning and charging may be critical for scale-up.

Teamwork and Adherence to Guideline on Newborn Resuscitation-Video Review of Neonatal Interdisciplinary Teams

BACKGROUND

Little is known about the importance of non-technical skills for the adherence to guidelines, when teams of midwives, obstetricians, anesthesiologists, and pediatricians resuscitate and support the transition of newborns. Non-technical skills are competences underpinning successful teamwork in healthcare. These are usually referred to as leadership, situational awareness, communication, teamwork, decision making, and coping with stress and fatigue.

OBJECTIVE

By review of videos of teams managing newborns with difficult transition, we aimed to investigate whether the level of the teams' non-technical skills was associated with the degree of adherence to guidelines for newborn resuscitation and transitional support at birth.

METHODS

Four expert raters independently assessed 43 real-life videos of teams managing newborns with transitional difficulties, two assessed the non-technical score and two assessed the clinical performance. Exposure was the non-technical score, obtained by the Global Assessment Of Team Performance checklist (GAOTP). GAOTP was rated on a Likert Scale 1-5 (1 = poor, 3 = average and 5 = excellent). The outcome was the clinical performance score of the team assessed according to adherence of the European Resuscitation Counsel (ERC) guideline for neonatal resuscitation and transitional support. The ERC guideline was adapted into the checklist TeamOBS-Newborn to facilitate a structured and simple performance assessment (low score 0-60, average 60-84, high 85-100). Interrater agreement was analyzed by intraclass correlation (ICC), Bland-Altman analysis, and Cohen's kappa weighted. The risk of high and low clinical performance was analyzed on the logit scale to meet the assumptions of normality and constant standard deviation.

RESULTS

Teams with an excellent non-technical score had a relative risk 5.5 [95% confidence interval (CI) 2.4-22.5] of high clinical performance score compared to teams with average non-technical score. In addition, we found a dose response like association. The specific non-technical skills associated with the highest degree of adherence to guidelines were leadership and teamwork, coping with stress and fatigue, and communication with parents. Inter-rater agreement was high; raters assessing non-technical skills had an interclass coefficient (ICC) 0.88 (95% CI 0.79-0.94); the neonatologists assessing clinical performance had an ICC of 0.81 (95% CI 0.66-0.89).

CONCLUSION

Teams with an excellent non-technical score had five times the chance of high clinical performance compared to teams with average non-technical skills. High performance teams were characterized by good leadership and teamwork, coping with stress, and fatigue and communication with parents.

Bridging the gap in neonatal resuscitation in Zambia

Neonatal resuscitation has been poorly instituted in many parts of Africa and most neonatal resuscitation algorithms are adapted from environments with abundant resources. Helping Babies Breathe (HBB) is an algorithm designed for resource-limited situations and most other algorithms are designed for resource-rich countries. However, there are neonatal referral centers in resource-limited countries who may provide more advanced resuscitation. Thus, we developed a neonatal resuscitation algorithm for a resource-limited country (Zambia) which considers more advanced interventions in situations where they can be provided. The algorithm described in this paper is based on the Newborn Life Support algorithm from the UK as well as the HBB algorithm and accounts for all situations in a resource-limited country. Most importantly, it focuses on non-invasive ventilation but includes advice on more advanced resuscitation including intravenous access, fluid management, chest compressions and adrenaline for resuscitation. Although intubation skills are included in neonatal training workshops, it is not the main focus of the algorithm as respiratory support equipment is scarce or lacking in most health facilities in Zambia. A home-grown neonatal resuscitation algorithm for a resource-limited country such as Zambia is likely to bridge the gap between limited situations requiring only bag and mask ventilation and better equipped institutions where more advanced resuscitation is possible. This algorithm will be rolled out in all training institutions and delivery facilities across Zambia over the next months.

Tactile stimulation in very preterm infants and their needs of non-invasive respiratory support

AIM

Despite the lack of evidence, current resuscitation guidelines recommend tactile stimulation in apneic infants within the first minutes of life. The aim was to investigate whether timing, duration or intensity of tactile stimulation influences the extent of non-invasive respiratory support in extremely preterm infants during neonatal resuscitation.

METHODS

In an observational study, we analyzed 47 video recordings and physiological parameters during postnatal transition in preterm infants below 32^0/7 weeks of gestational age. Infants were divided into three groups according to the intensity of respiratory support.

RESULTS

All infants were stimulated at least once during neonatal resuscitation regardless of their respiratory support. Only 51% got stimulated within the first minute. Rubbing the feet was the preferred stimulation method and was followed by rubbing or touching the chest. Almost all very preterm infants were exposed to stimulation and manipulation most of the time within their first 15 min of life. Tactile stimulation lasted significantly longer but stimulation at multiple body areas started later in infants receiving prolonged non-invasive respiratory support.

CONCLUSION

This observational study demonstrated that stimulation of very preterm infants is a commonly used and easy applicable method to stimulate spontaneous breathing during neonatal resuscitation. The concomitant physical stimulation of different body parts and therefore larger surface areas might be beneficial.

What Helping Babies Breathe knowledge and skills are formidable for healthcare workers?

INTRODUCTION

Most neonatal deaths occur in the first week of life, due to birth asphyxia. Helping Babies Breathe (HBB), is a simulation-based neonatal resuscitation training program to improve knowledge and skills. There is little information on which knowledge items or skill steps are challenging for the learners.

METHODS

We used training data from NICHD's Global Network study to understand the items most challenging for Birth Attendants (BA) to guide future curriculum modifications. HBB training was provided in 15 primary, secondary and tertiary level care facilities in Nagpur, India. Refresher training was provided 6 months later. Each knowledge item and skill step was ranked from difficulty level 1 to 6 based on whether 91%-100%, 81%-90%, 71%-80%, 61%-70%, 51%-60% or <50% of learners answered/performed the step correctly.

RESULTS

The initial HBB training was conducted in 272 physicians and 516 midwives of which 78 (28%) physicians and 161 (31%) midwives received refresher training. Questions related to timing of cord clamping, management of a meconium-stained baby, and steps to improve ventilation were most difficult for both physicians and midwives. The initial steps of Objective Structured Clinical Examination (OSCE)-A i.e. equipment checking, removing wet linen and immediate skin-to-skin contact were most difficult for both groups. Midwives missed stimulating newborns while physicians missed cord clamping and communicating with mother. In OSCE-B, starting ventilation in the first minute of life was the most missed step after both initial and 6 months refresher training for physicians and midwives. At the retraining, the retention was worst for cutting the cord (physicians level 3), optimal rate of ventilation, improving ventilation & counting heart rate (midwives level 3), calling for help (both groups level 3) and scenario ending step of monitoring the baby and communicating with mother (physicians level 4, midwives 3).

CONCLUSION

All BAs found skill testing more difficult than knowledge testing. The difficulty level was more for midwives than for physicians. So, the HBB training duration and frequency of retraining can be tailored accordingly. This study will also inform subsequent refinement in the curriculum so that both trainers and trainees will be able to achieve the required proficiency.

Neonatal resuscitation monitoring: A low-cost video recording setup for quality improvement in the delivery room at the resuscitation table

BACKGROUND

The quality of neonatal resuscitation after delivery needs to be improved to reach the Sustainable Development Goals 3.2 (reducing neonatal deaths to <12/1,000 live newborns) by the year 2030. Studies have emphasized the importance of correctly performing the basic steps of resuscitation including stimulation, heart rate assessment, ventilation, and thermal control. Recordings with video cameras have previously been shown to be one way to identify performance practices during neonatal resuscitation.

METHODS

A description of a low-cost delivery room set up for video recording of neonatal resuscitation. The technical setup includes rechargeable high-definition cameras with two-way audio, NeoBeat heart rate monitors, and the NeoTapAS data collection tools for iPad with direct data export of data for statistical analysis. The setup was field tested at Mulago National Referral Hospital, Kampala, Uganda, and Phu San Hanoi Hospital, Hanoi, Vietnam.

RESULTS

The setup provided highly detailed resuscitation video footage including data on procedures and team performance, heart rate monitoring, and clinical assessment of the neonate. The data were analyzed with the free-of-charge NeoTapAS for iPad, which allowed fast and accurate registration of all resuscitative events. All events were automatically registered and exported to R statistical software for further analysis.

CONCLUSIONS

Video analysis of neonatal resuscitation is an emerging quality assurance tool with the potential to improve neonatal resuscitation outcomes. Our methodology and technical setup are well adapted for low- and lower-middle-income countries settings where improving neonatal resuscitation outcomes is crucial. This delivery room video recording setup also included two-way audio communication that potentially could be implemented in day-to-day practice or used with remote teleconsultants.

Improving Pediatric/Neonatology Residents' Newborn Resuscitation Skills With a Digital Serious Game: DIANA

BACKGROUND

Serious games, and especially digital game based learning (DGBL) methodologies, have the potential to strengthen classic learning methodology in all medical procedures characterized by a flowchart (e.g., neonatal resuscitation algorithm). However, few studies have compared short- and long-term knowledge retention in DGBL methodologies with a control group undergoing specialist training led by experienced operators. In particular, resident doctors' learning still has limited representation in simulation-based education literature.

OBJECTIVE

A serious computer game DIANA (DIgital Application in Newborn Assessment) was developed, according to newborn resuscitation algorithm, to train pediatric/neonatology residents in neonatal resuscitation algorithm knowledge and implementation (from procedure knowledge to ventilation/chest compressions rate). We analyzed user learning curves after each session and compared knowledge retention against a classic theoretical teaching session.

METHODS

Pediatric/neonatology residents of the Azienda Ospedaliera Universitaria Pisana (AOUP) were invited to take part in the study and were split into a game group or a control group; both groups were homogeneous in terms of previous training and baseline scores. The control group attended a classic 80 min teaching session with a neonatal trainer, while game group participants played four 20 min sessions over four different days. Three written tests (pre/immediately post-training and at 28 days) were used to evaluate and compare the two groups' performances.

RESULTS

Forty-eight pediatric/neonatology residents participated in the study. While classic training by a neonatal trainer demonstrated an excellent effectiveness in short/long-term knowledge retention, DGBL methodology proved to be equivalent or better. Furthermore, after each game session, DGBL score improved for both procedure knowledge and ventilation/chest compressions rate.

CONCLUSIONS

In this study, DGBL was as effective as classic specialist training for neonatal resuscitation in terms of both algorithm memorization and knowledge retention. User appreciation for the methodology and ease of administration, including remotely, support the use of DGBL methodologies for pediatric/neonatology residents education.

Spontaneous breathing approach in mild congenital diaphragmatic hernia: A resuscitation algorithm

BACKGROUND

Infants with a congenital diaphragmatic hernia (CDH) and expected mild pulmonary hypoplasia have an estimated survival rate of 90%. Current guidelines for delivery room management do not consider the individual patient's disease severity, but an individualized approach with spontaneous breathing instead of routine mechanical ventilation could be beneficial for the mildest cases. We developed a resuscitation algorithm for this individualized approach serving two purposes: improving the success rate by structuring the approach and providing a guideline for other centers.

METHODS

An initial algorithm was discussed with all local stakeholders. Afterwards, the resulting algorithm was refined using input from international experts.

RESULTS

Eligible CDH infants: left-sided defect, observed to expected lung-to-head ratio ≥50%, gestational age at birth ≥37.0 weeks, and no major associated structural or genetic abnormalities. To facilitate fetal-to-neonatal transition, we propose to start stabilization with non-invasive respiratory support and to adjust this individually.

CONCLUSIONS

Infants with mild CDH might benefit from an individualized approach for neonatal resuscitation. Herein, we present an algorithm that could serve as guidance for centers implementing this.

What Is Teamwork? A Mixed Methods Study on the Perception of Teamwork in a Specialized Neonatal Resuscitation Team

INTRODUCTION

Neonatal resuscitation is a team-based activity involving many decisions and tasks. Non-technical factors, such as teamwork, are increasingly recognized as impacting how well-neonatal resuscitation is performed, and therefore influencing infant outcomes. Prior studies on teamwork in neonatal resuscitation have focused on quantification of teamwork behaviors, or the effects of team training. This study aimed to explore healthcare providers' own perception of teamwork in this specialized environment to identify perceived barriers and facilitators to effective team functioning.

METHODS

This single-center exploratory sequential mixed methods study used two phases. First, semi-structured interviews were conducted, and thematic analysis used to identify themes. Subsequently, interview data informed the development of quantitative surveys to explore selected themes in the wider team.

RESULTS

From ten semi-structured interviews, seven themes were identified including: (1) Team Composition, (2) Effective Communication, (3) Team leadership, (4) Hierarchy, (5) Team Training, (6) Debriefing, and (7) Physical Environment. Perceived teamwork facilitators include role assignment, familiarity, team composition, talking out loud to maintain shared mental models, leadership, and team training. Perceived barriers included time pressures, ad hoc team, ineffective leadership, and space limitations. Selected themes (Communication, Speaking up, Hierarchy, and Leadership) were further explored via electronic surveys distributed via email to all members of the resuscitation team. There were 105 responses; a response rate of ~53%. All respondents agreed or strongly agreed that speaking up is important; however, not all felt comfortable doing so. Neonatal fellows (14%) and nurses (12%) were most likely to report not feeling comfortable speaking up. All respondents agreed that team communication is important to an effective resuscitation. Most respondents (91.5%) agreed that a hierarchy exists within the team; 54.3% believed that hierarchy positively contributes to effective resuscitation. All respondents agreed or strongly agreed that having a clearly defined leader is important in delivery room resuscitations. Ineffective leadership was the most cited reason for poor team communication.

CONCLUSIONS

In this mixed methods study of perceptions of teamwork within a specialized, multi-disciplinary neonatal resuscitation team, communication, hierarchy, and leadership were positively perceived and facilitates teamwork. However, even in this environment, some nurses and trainees expressed discomfort with speaking up.

Survey on currently applied interventions in neonatal resuscitation (SCIN): A study protocol

INTRODUCTION

Around 140 million children are born every year and post-natal transition is uncomplicated in the vast majority. However, around 5%-15% of neonates receive supportive interventions during transition. Recent data on the interventions used is scarce. More data on the frequencies with which these interventions are used is needed to evaluate neonatal resuscitation, guide recommendations and to generate hypotheses for further research. The following protocol describes an international, multicentre survey on the interventions currently applied during neonatal resuscitation.

OBJECTIVES

To determine the frequencies at which different supportive interventions recommended by European Resuscitation Council (ERC) guidelines for neonatal resuscitation are used. To compare the frequencies between hospitals and patient groups and to investigate possible factors influencing any differences found.

METHODS

Participating hospitals will collect data on all interventions performed during neonatal resuscitation over a period of 6 months. All hospitals providing perinatal care are eligible regardless of size and designated level of neonatal care. Every neonate requiring more interventions than basic drying and tactile stimulation during the first 30 min of life will be included. The targeted sample size is at least 4,000 neonates who receive interventions. After anonymization, the data is pooled in a common database and descriptive and statistical analysis is performed globally and in subgroups. Possible correlations will be investigated with phi coefficient and chi square testing.

ETHICS AND DISSEMINATION

Consent of the institutional review board of the Technical University Dresden was obtained for the local data collection under the number BO-EK-198042022. Additionally, approval of local ethical or institutional review boards will be obtained by the participating hospitals if required. Results will be published in peer-reviewed journals and presented at suitable scientific conferences.

The Effect of a Higher Bias Gas Flow on Imposed T-Piece Resistance and Breathing in Preterm Infants at Birth

OBJECTIVE

The resistance created by the PEEP-valve of a T-piece resuscitator is bias gas flow dependent and might affect breathing in preterm infants. In this study we investigated the effect of a higher bias gas flow on the imposed inspiratory and expiratory T-piece resistance and expiratory breaking manoeuvres (EBM) in preterm infants during spontaneous breathing on CPAP at birth.

METHODS

In a retrospective pre-post implementation study of preterm infants <32 weeks gestation, who were stabilised with a T-piece resuscitator, a bias gas flow of 12 L/min was compared to 8 L/min. All spontaneous breaths on CPAP within the first 10 min of starting respiratory support were analysed on a breath-by-breath basis to determine the breathing pattern of each breath and to calculate the imposed inspiratory and expiratory T-piece resistance (Ri, Re), flow rates and tidal volume.

RESULTS

In total, 54 infants were included (bias gas flow 12 L/min: n = 27, 8 L/min: n = 27) with a median GA of 29⁺⁶ (28⁺⁴-30⁺³) and 28⁺⁵ (25⁺⁶-30⁺³), respectively (p = 0.182). Ri and Re were significantly lower in the 12 L/min compared to 8 L/min bias flow group [Ri: 29.6 (26.1-33.6) vs. 46.4 (43.0-54.1) cm H₂O/L/s, p < 0.001; Re: 32.0 (30.0-35.1) vs. 48.0 (46.3-53.9) cm H₂O/L/s, p < 0.001], while the incidence of EBM [77% (53-88) vs. 77% (58-90), p = 0.586] was similar.

CONCLUSION

During stabilisation of preterm infants at birth with a T-piece resuscitator, the use of a higher bias gas flow reduced both the imposed inspiratory and expiratory T-piece resistance for the infant, but this did not influence the incidence of EBMs.