Death In Delivery Room Research Articles

Maternal and infant morbidity following birth before 27 weeks of gestation: a single centre study

Delivery at extreme preterm gestational ages (GA) <;27 weeks is challenging with limited evidence often focused only on neonatal outcomes. We reviewed management and short term maternal, fetal and neonatal outcomes of births for 132 women (22 + 0 to 26 + 6 weeks’ GA) with a live fetus at admission to hospital and in labour or at planned emergency Caesarean section: 103 singleton and 29 (53 live fetuses) twin gestations. Thirty women (23%) had pre-existing medical problems, 110 (83%) had antenatal complications; only 17 (13%) women experienced neither. Major maternal labour and delivery complications affected 35 women (27%). 151 fetuses (97%) were exposed to antenatal steroids, 24 (15%) to tocolysis and 70 (45%) to magnesium sulphate. Delivery complications affected 11 fetuses, with 12 labour or delivery room deaths; survival to discharge was 75% (117/156), increasing with GA: 25% (1/4), 75% (18/24), 69% (29/42), 73% (33/45) and 88% (36/41) at 22, 23, 24, 25 and 26 weeks GA respectively (p = 0.024). No statistically important impact was seen from twin status, maternal illness or obstetric management. Even in a specialist perinatal unit antenatal and postnatal maternal complications are common in extreme preterm births, emphasising the need to include maternal as well as neonatal outcomes.

Comparison of Respiratory Outcome between Sustained Lung Inflation and Intermittent Positive Ventilation in Preterm Infants Requiring Resuscitation at Birth

Background: Sustained lung inflation (SLI) would permit lung recruitment immediately after birth, improving lung mechanics and reducing the need for intubation and subsequent respiratory support in the neonatal intensive care unit among preterm infants. Aim of the Study: To assess the efficacy of initial sustained lung inflation compared to standard intermittent positive pressure ventilation (IPPV) in preterm infants who need resuscitation in delivery room. Methods: This was prospective randomized observational study that was conducted in the delivery room and NICU of A in shames University hospital from February 2019 to September 2019. The study included 115 preterm infants between 26 - 32 weeks of gestation who needed resuscitation at delivery room. The infants were randomly allocated into 2 groups; SLI group: included the preterm infants who received the SLI at initial inflation pressure of 25 cm H2O for 15 seconds using the Neopuff/T piece. IPPV group: preterm infants who received standard resuscitation; IPPV using the self-inflating bag. The heart rate (HR), oxygen saturation (SpO2), oxygen requirement, and intubation rate as well as need of surfactant in the delivery room were assessed. All cases were evaluated after admission to the NICU for the need of mechanical ventilation in the first 72 hours of life, death in delivery room or NICU and for bronchopulmonary dysplasia or death at 36 weeks post menstrual age (PMA). Results: The percentage of preterm infants who needed resuscitation was 25.5% from the total deliveries during the study period. 56.5% of them received SLI and 43.4% received conventional IPPV. There were no significant differences between the studied groups regarding gestational age, birth weight. Apgar score, heart rate, oxygen saturation was not significantly increased in the SLI group at fifth minutes of age. The percentage of infants who needed further resuscitation was 20% in SLI group and 12% in the IPPV group. There were no significant differences in need for surfactant, CPAP or ventilator among the studied groups. There were no significant differences in relation to complications as BPD, air leak or retinopathy and death between the two groups. Conclusion: This study showed that there was no advantage from use of SLI in delivery room using T-piece upon the conventional IPPV using self-inflating bag.

Overlapping borders: limit of viability and late terminations of pregnancy - a retrospective multicentre observational study.

Based on an incidental observation made in the context of the Swiss National Science Foundation (SNSF) Project 67 &ldquo;End-of-life decision-making in extremely low birth weight infants in Switzerland&rdquo;, this retrospective multicentre observational study aimed to analyse circumstances of delivery room deaths after late termination of pregnancy (LTOP) in Switzerland over a 3-year period. All delivery room deaths (including live and stillbirths) following LTOP among infants with a gestational age between 22 0/7 and 27 6/7 weeks at the nine Swiss level III perinatal centres between 1 July 2012 and 30 June 2015 were analysed. Indications for LTOP were classified as either (a) maternal emergencies or (b) fetal anomalies severe enough to cause significant maternal psychological distress. Whenever possible, specific diagnoses were recorded. Spontaneous intrapartum death and fetal death caused by injection of a cardioplegic drug were distinguished for stillborn infants. A total of 465 delivery room deaths among extremely low gestational age newborns (ELGANs) were identified over the 3-year study period of the SNSF project. Of these, 195 (42%) occurred in the context of LTOP. Central nervous system malformations, chromosomal anomalies, severe congenital heart disease, multiple malformations and maternal emergencies accounted for 70% of all LTOPs. LTOPs resulted in live births in 76 (39%) cases. No correlation between gestational age and rate of live births was observed. Fetal death caused by injection of a cardioplegic drug was documented in only three cases. All infants born alive after LTOP died in the delivery room without resuscitation attempts. The use of drugs for palliative care in these patients was either rare or, alternatively, incompletely documented. LTOPs contribute significantly to mortality rates among ELGANs and should therefore be included in perinatal registries. Uniform reporting of LTOPs should be established. Infants born alive after LTOP are entitled to comprehensive palliative care like any other infant born under different circumstances. Development of national guidelines for LTOPs (including the role of fetal death caused by injection of a cardioplegic drug and palliative birth as an alternative to induced abortion) would be highly desirable to guarantee acceptable standards of care.

Outcomes at 18 to 22 Months of Corrected Age for Infants Born at 22 to 25 Weeks of Gestation in a Center Practicing Active Management

To assess the outcomes in actively managed extremely preterm infants after admission to a neonatal intensive care unit. Retrospective cohort of 255 infants born at 22-25weeks of gestation between 2006 and 2015 at a single study institution. Infants were excluded for congenital anomaly, death in delivery room, or parental request for palliation (n=7). Neurodevelopmental outcomes were analyzed for 169 of 214 survivors (78.9%) at 18-22months of corrected age. Outcomes were evaluated using the Mann-Whitney U, χ2, or Fisher exact test, where appropriate. In addition, cognitive scores of the Bayley Scales of Infant-Toddler Development (3rd edition) were assessed using generalized estimating equations. Seventy infants born at 22-23weeks of gestation (22weeks, n=20; 23weeks, n=50) and 178 infants born at 24-25weeks of gestation (24weeks, n=79; 25weeks, n=99 infants) were included. Survival to hospital discharge of those surviving to NICU admission was 78% (55/70; 95% CI, 69%-88%) at 22-23weeks and 89% (159/178; 95% CI, 84%-93% at 24-25weeks; P=.02). No or mild neurodevelopmental impairment in surviving infants was 64% (29/45; 95% CI, 50%-77%) at 22-23weeks and 76% (94/124; 95% CI, 68%-83%; P=.16) at 24-25weeks. Although survival was lower in infants born at 22-23weeks than at 24-25weeks of gestation, the majority of survivors in both groups had positive outcomes with no or mild neurodevelopmental impairments. Further evaluation of school performance is warranted.

Delivery room deaths of extremely preterm babies: an observational study

ObjectiveMany extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse...

94: Variations in Mortality of Very Preterm Neonates Between Eight National Neonatal Databases: The iNeo Experience

Differences in mortality of very preterm neonates have been reported by national neonatal networks. These may reflect variations in case-mix, practices and population coverage of database. Valid comparisons aimed at identifying reasons for variation between countries require adjustment for potential confounders. To compare mortality rates prior to discharge of very preterm neonates using eight national neonatal databases from nine member countries of the International Network for Evaluating Outcomes in Neonates (iNeo). Data on neonates of 24 to 31 weeks GA, BW <1500 g, without major congenital anomaly and registered in national databases were retrieved from the iNeo database (2007–10). Mortality (all causes) was compared between each country and all others using standardized mortality ratios (SMR) and pair-wise comparisons were performed using AOR (95% CI). Subgroup analyses were conducted for neonates 24 to 28 weeks GA. 58004 neonates were included in the analyses. Mortality ranged from 5% to 17% between countries. SMRs are presented in the Figure. Adjusted OR (95% CI) are presented in the Table. Subgroup analyses of infants 24 to 28 weeks GA provided similar results. Variations in mortality between countries remained after adjustment for available confounders. Explanations for this variation may lie in differences in population coverage, recording of delivery room deaths, death after discharge from Level 3 NICUs, services organization, unmeasured characteristics, or care practices.

Perinatal Outcomes for Extremely Preterm Babies in Relation to Place of Birth in England

Extremely premature babies bear the highest risk for significant mortality and morbidity. This study was performed to evaluate the hypothesis that birth in, or transfer to, designated referral centers can lead to lower mortality and morbidity rates among survivors of early preterm birth. For all births at 22 to 26 weeks’ gestation in all 182 maternity hospitals in England during 2006, data were obtained on place of maternal booking and delivery for all live births. Neonatal transfers and major neonatal morbidities to discharge from hospital were assessed. A neonatal unit was categorized as level 1, 2, or 3. Level 1 services were hospitals that transfer any woman whose baby was expected to need intensive care, level 2 services transfer women expected to deliver at less than 27 weeks, and level 3 services provide complete medical neonatal intensive care. An antenatal transfer was any transfer to a level 3 service between booking and delivery; neonatal transfers occurred within 24 hours of birth. Outcomes to discharge were compared between level 3 and level 2 services, with and without transfers, and by activity level of level 3 neonatal units. Odds ratios (ORs) were adjusted for gestation and birth weight. A total of 52, 84, and 46 hospitals had level 1, 2, and 3 units, respectively. Of 2460 live births, 244 (9.9%) occurred in level 1, 829 (33.7%) occurred in level 2, and 1387 (56.4%) occurred in level 3 services. In total, 382 women were transferred to level 3 services before birth (440 fetuses) and 288 babies were neonatal transfers within 24 hours. Rates for stillbirths and delivery room deaths were 23% and 42% in level 3 and level 1 services, respectively. Mortality was lower in level 3 compared with level 2 services (OR, 0.65; 95% confidence interval [CI], 0.55–0.78). The transferred babies had lower mortality compared with those who were booked and were born in either level 3 or level 2 services (crude ORs, 1.48; 95% CI, 1.26–1.75, and 2.21; 95% CI, 1.87–2.61, respectively; P < 0.001 for both). After adjustment, babies born to mothers who were not transferred from a level 2 service had increased odds of death compared with those who were transferred (adjusted OR [aOR], 1.44; 95% CI, 1.09–1.90). No difference in survival was found between those transferred antenatally to and those booked and born in level 3 services (aOR, 1.08; 95% CI, 0.83–1.41). Survival rates at hospital discharge were 36.8% and 47.2% in level 2 and 3 services, respectively. After adjustment, only fetal and early neonatal deaths (aOR, 0.59; 95% CI, 0.46–0.75) as well as overall mortality remained statistically significant. For the women who were not transferred to a level 3 service, the aOR was 1.52 (95% CI, 1.03–2.26) for fetal antenatal death and 1.49 (95% CI, 1.10–2.02) for overall early neonatal death. The rates for survivors without morbidity were 11% and 8% for level 3 and 2 services, respectively. Neonatal survival was improved for extremely premature babies treated in level 3 services in England. Hospital expertise and activity are important factors in improved outcomes for high-risk pregnancies with threatened extremely preterm birth.

Chemokines plasma levels in preterm newborns of preeclamptic mothers

Information on leukocyte activation in newborn infants of preeclamptic mothers is scarce. IL-8 and GRO-α are the main pro-inflammatory cytokines involved in leukocyte activation. The objective was to evaluate IL-8 and GRO-α plasma levels in preterm newborns infants of preeclamptic mothers. Newborns with gestational age <36weeks and birth weight <2000g were included and divided: non-preeclamptic (n=64) and preeclamptic groups (n=55). Exclusion criteria were major congenital malformations, inborn errors of metabolism or chromosomal anomalies, congenital infections, death in delivery room, and maternal chronic hypertension without preeclampsia. IL-8 and GRO-α were measured by enzyme immunoassay in the first 48h. Groups were similar in birth weight, gestational age, Apgar scores at 5min, sepsis, RDS, mechanical ventilation, TPN, NEC, intraventricular hemorrhage and death. The preeclamptic group had more neutropenia, SGA, cesarean section, and less rupture of membranes >18h. IL-8 was higher in the non-preeclamptic [157.1pg/mL (86.4–261.3) and 26.54pg/mL (3.6–87.2) p<0.001]. GRO-α levels were similar in both groups [229.5pg/mL (116.6–321.3) and 185.5pg/mL (63.9–306.7) p=0.236]. After multiple regression analysis only absence of preeclampsia was associated with high IL-8 levels. Our data suggest that leukocyte activation may be impaired in infants of preeclamptic mothers.

Categorizing Neonatal Deaths: A Cross-Cultural Study in the United States, Canada, and The Netherlands

To clarify the process of end-of-life decision-making in culturally different neonatal intensive care units (NICUs). Review of medical files of newborns >22 weeks gestation who died in the delivery room (DR) or the NICU during 12 months in 4 NICUs (Chicago, Milwaukee, Montreal, and Groningen). We categorized deaths using a 2-by-2 matrix and determined whether mechanical ventilation was withdrawn/withheld and whether the child was dying despite ventilation or physiologically stable but extubated for neurological prognosis. Most unstable patients in all units died in their parents' arms after mechanical ventilation was withdrawn. In Milwaukee, Montreal, and Groningen, 4% to 12% of patients died while receiving cardiopulmonary resuscitation. This proportion was higher in Chicago (31%). Elective extubation for quality-of-life reasons never occurred in Chicago and occurred in 19% to 35% of deaths in the other units. The proportion of DR deaths in Milwaukee, Montreal, and Groningen was 16% to 22%. No DR deaths occurred in Chicago. Death in the NICU occurred differently within and between countries. Distinctive end-of-life decisions can be categorized separately by using a model with uniform definitions of withholding/withdrawing mechanical ventilation correlated with the patient's physiological condition. Cross-cultural comparison of end-of-life practice is feasible and important when comparing NICU outcomes.

Causes and Circumstances of Neonatal Deaths in 108 Consecutive Cases over a 10-Year Period at the Children’s Hospital of Lucerne, Switzerland

Background: Neonatal deaths still represent the largest percentage of overall childhood mortality. Many deaths of neonates are preceded by end-of-life decisions; however, decision-making practices have been reported to vary widely from country to country. Objectives: To analyze principal causes and circumstances of all consecutive neonatal deaths at our institution over a 10-year period. Methods: All neonates who had died either in the delivery room (DR) or the neonatal intensive care unit (NICU) between January 1, 1997 and December 31, 2006 were identified. Demographic information, principal causes and circumstances of death were abstracted from the individual medical records. Results: There were approximately 72,000 live births in the catchment area of our center with 15,150 deliveries occurring at the Women’s Hospital of Lucerne. Of the 108 deaths identified, 29 occurred in the DR (DR mortality rate 0.2%) and 79 in the NICU (NICU mortality rate 2.3%). The majority of DR deaths occurred in the setting of primary nonintervention and were related to extreme prematurity (n = 20), lethal congenital malformations (n = 6) and trisomy 13 (n = 2). One patient with severe perinatal asphyxia died despite full resuscitative efforts. In the NICU, overall mortality rate was inversely related to gestational age (GA). Cardiovascular and respiratory system failures were the predominant causes of death in premature infants with a GA <32 weeks, whereas CNS catastrophes accounted for the majority of deaths in the more mature NICU population. End-of-life decisions were common with less than 10% of deaths occurring despite maximal intensive care. Conclusions: In our perinatal center, primary nonintervention and redirection of care are the most common circumstances of death in neonates. This reflects our belief that, apart from futility, quality-of-life considerations are an important part of decision making in neonatology.

Delivery Mode and Severe Intraventricular Hemorrhage in Single, Very Low Birth Weight, Vertex Infants

To investigate the association between delivery mode and grade 3-4 intraventricular hemorrhage in singleton, vertex presenting, very low birth weight (VLBW) (1,500 g or less) liveborn infants. The Israel National VLBW Infant Database includes perinatal and neonatal data on greater than 99% of all VLBW newborns. A total of 4,658 singleton vertex-presenting infants born at 24-34 weeks were included (1995-2004). Infants with lethal congenital malformations, delivery room deaths, and home deliveries were excluded. Our population-based observational study evaluated the effect of delivery mode and confounding variables on severe intraventricular hemorrhage using univariable and multivariable logistic regression analyses. The rate of severe intraventricular hemorrhage was 10.4%. Cesarean delivery rate was 54.3%. The rate of severe intraventricular hemorrhage was 7.7% for infants delivered by cesarean compared with 13.6% in vaginal delivery (P<.001). However, analysis according to gestational age showed that the rate of severe intraventricular hemorrhage was similar in cesarean and vaginal delivery in all gestational age groups. In the multivariable model, cesarean delivery had no effect on the odds for severe intraventricular hemorrhage (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.77-1.24). Other factors independently associated with severe intraventricular hemorrhage included gestational age (OR 0.71, 95% CI 0.68-0.75 for each week increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30-0.61), no antenatal steroids (OR 2.70, 95% CI 2.12-3.45), 1-minute Apgar score 0-3 (OR 1.72, 95% CI 1.33-2.21), delivery room resuscitation (OR 2.16, 95% CI 1.65-2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03-1.59). In this population-based study, the odds for severe intraventricular hemorrhage were not influenced by mode of delivery in vertex-presenting singleton VLBW infants after controlling for gestational age. II.

Short‐term outcome after active perinatal management at 23—25 weeks of gestation. A study from two Swedish tertiary care centres. Part 2: infant survival

To determine neonatal survival rates based on both foetal (stillborn) and neonatal deaths among infants delivered at 23-25 wk, and to identify maternal and neonatal factors associated with survival. The medical records of 224 infants who were delivered in two tertiary care centres in 1992-1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Data were analysed by gestational age groups and considered in three time periods. Logistic regression models were used to identify factors associated with survival. The rate of foetal death was 5%. Of infants born alive, 63% survived to discharge. Survival rates including foetal deaths in the denominator at 23, 24 and 25 wk were 37%, 61% and 74%, respectively, and survival rates excluding foetal deaths were 43%, 63% and 77%, respectively. Of infants born with 1-min Apgar scores of 0-1, 43% survived. In the total cohort, survival rates including foetal deaths in the denominator increased from 52% in time period 1 to 61% in time period 2 and 74% in time period 3 (p < 0.02). On multivariate logistic regression analysis, higher birthweight (OR: 1.91 per 100 g increment; 95% CI: 1.45-2.52), female gender (OR: 3.33; 95% CI: 1.65-6.75), administration of antenatal steroids (OR: 2.95; 95% CI: 1.46-5.98) and intrauterine referral from a peripheral hospital (OR: 2.35; 95% CI: 1.18-4.68) were associated with survival. Apgar score < or = 3 at 1 min (OR: 0.46; 95% CI: 0.22-0.95) was associated with decreased survival. The use of antenatal steroids was protective at 23-24 wk (OR: 5.2; 95% CI: 2.0-13.7), but not at 25 wk. Active perinatal management that included universal initiation of neonatal intensive care virtually eliminated intrapartum stillbirths and delivery room deaths, and resulted in survival rates that compare favourably with those of recent studies. However, the policies of active care postponed death in non-survivors. Individual variations in outcome in relation to the infant's condition at birth as reflected by the Apgar scores preclude the making of treatment decisions in the delivery room.

Survival of very preterm infants: Epipage, a population based cohort study

Objective: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. Design: A prospective observational population based study. Setting: Nine regions of France in...

Survival of very preterm infants: Epipage, a population based cohort study

<b>Objective:</b> To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. <b>Design:</b> A prospective observational population based study. <b>Setting:</b> Nine regions of France in 1997. <b>Patients:</b> All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. <b>Main outcome measure:</b> Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. <b>Results:</b> A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. <b>Conclusion:</b> Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.

Treatment decisions for the extremely premature infant

Treatment decisions for the extremely premature infant

Outcome of extremely‐low‐birthweight infants

The overall 1-year survival rate of 261 infants born at 500 g-999g over a 7-year period was 46%. The survival rate of the 220 inborn infants, corrected for birth defects, would have increased from 47% to 57% if delivery room deaths were excluded and to 62% if postneonatal deaths had also been ignored. Survival improved progressively with increasing 100g weight groups. The disability rate in the 108 survivors who were at least 2 years old corrected for prematurity was 28% with little variation between the 100g weight groups. There were no significant trends in annual perinatal mortality, 1-year survival and disability rate in survivors over the study period for the inborn population. The male infants had significantly lower normal-survival rate than the female infants. Small-for-gestational-age infants, comprising 11% of the inborn group, had significantly better survival but a higher disability rate. Multiple births had significantly lower survival and normal-survival rates than had singleton births. Infants whose mothers were transferred for delivery at the perinatal centre before onset of labour had a significantly better survival rate than those whose mothers had 'booked' and those who were transferred in labour.