Delivery Room Practices Research Articles

Effects of delivery room quality improvement on premature infant outcomes.

Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality. This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group. Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death. Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

Perinatal management: What has been learned through the network?

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) has examined the effects of various obstetrical perinatal interventions and neonatal delivery room practices on the newborn with particular focus on those born preterm. Studies exploring the effects and safety of various antepartum maternal medications and the effects of the route and timing of delivery are examined. The NRN has contributed key studies to the evidence base for the International Liaison Committee on Resuscitation neonatal resuscitation guidelines. These studies are reviewed including research on timing of cord clamping, the importance of maintaining euthermia immediately after birth, delivery room ventilation strategies, outcomes following delivery room cardiopulmonary resuscitation, and the effects of prolonged resuscitation efforts. In addition, the NRN’s detailed outcome data at the lowest gestational ages have greatly influenced on how providers counsel families regarding the appropriateness of resuscitation efforts at the lowest gestational ages.

Delivery Room Practice Variation in Different Practice Environments throughout the US

Delivery Room Practice Variation in Different Practice Environments throughout the US

G123(P) Survey of delivery room practice: resuscitation of extreme preterm infants

Aims There are Nuffield Guidelines in place to aid clinicians in their decision-making in the resuscitation of extreme preterm infants. This remains an area where there is varied practice nationally and internationally, and decisions are often case dependant. We sought to survey a cohort of Consultant Paediatricians involved in neonatal resuscitation on their approach to the resuscitation of extreme preterm infants, to assess current attitudes to practice. Methods A questionnaire was designed using an online survey programme, modelled on the Nuffield guidance for resuscitation of extreme preterm infants. This was distributed to a group of Consultants via email and results were collated using the online programme. Results 45 of 68 (66%) Consultants completed the survey. 26% of responders were from level 3 neonatal intensive care units (NICU), 62% from level 2 units and 12% from level 1 units. 91% of responders would always offer intensive care with the intention of admitting to NICU at 25 weeks gestation and above, compared to 58% at 24 weeks and 6.8% at 23 weeks gestation. At 24 weeks, 38% of responders would make the decision of whether to resuscitate based on the infant’s initial clinical condition compared to 61% at 23 weeks. For 23 weeks gestation infants, giving precedence to parents’ wishes (57%) and weighing the baby before commencing resuscitation (32%) were highest. At 22 weeks, 58% of responders would not resuscitate and 29% would not attend the delivery. Conclusion There were varied responses at every gestation. Whilst the majority of 25 week and above gestation infants are offered full intensive care in accordance with Nuffield guidance, this was not the case for 24 week gestation infants. Initial clinical condition and response to initial resuscitation at birth play a larger role in decision making at 23 and 24 weeks. Parents’ wishes and birthweight are more significant factors in decision making at 23 weeks. The varying attitudes to practice at each gestation highlight the challenges in following guidelines in the resuscitation of extreme preterm infants. This calls into question whether there is a need for more consensus.

Marked variation in delivery room management in very preterm infants

BackgroundThe International Liaison Committee on Resuscitation (ILCOR) and UK Resuscitation Council (UKRC) updated guidance on newborn resuscitation in late 2010. ObjectivesTo describe delivery room (DR) practice in stabilisation following very preterm birth (<32 weeks gestation) in the UK. MethodsWe emailed a national survey of current DR stabilisation practice of very preterm infants to all UK delivery units and conducted telephone follow-up calls. ResultsWe obtained 197 responses from 199 units (99%) and complete data from 186 units. Tertiary units administered surfactant in the DR (93% vs. 78%, P=0.01), instituted DR CPAP (77% vs. 50%, P=0.0007), provided PEEP in the delivery room (91% vs. 69%, P=0.0008), and started resuscitation in air or blended oxygen (91% vs. 78%, P=0.04) more often than non-tertiary units. Routine out of hours consultant attendance at very preterm birth was more common in tertiary units (82% vs. 55%, P=0.0005). ConclusionsMarked variation in DR stabilisation practice of very preterm infants persisted one year after the publication of revised UKRC guidance. Delivery room care provided in non-tertiary units was less consistent with current international guidance.

Obstetric and Neonatal Care Practices for Infants 501 to 1500 g From 2000 to 2009

To identify changes in clinical practices for infants with birth weights of 501 to 1500 g born from 2000 to 2009. We used prospectively collected registry data for 355,806 infants born from 2000 to 2009 and cared for at 669 North American hospitals in the Vermont Oxford Network. Main outcome measures included obstetric and neonatal practices, including cesarean delivery, antenatal steroids, delivery room interventions, respiratory practices, neuroimaging, retinal exams, and feeding at discharge. Significant changes in many obstetric, delivery room, and neonatal practices occurred from 2000 to 2009. Use of surfactant treatment in the delivery room increased overall (adjusted difference [AD] 17.0%; 95% confidence interval [CI] 16.4% to 17.6%), as did less-invasive methods of respiratory support, such as nasal continuous positive airway pressure (AD 9.9%; 95% CI 9.1% to 10.6%). Use of any ventilation (AD -7.5%; 95% CI -8.0% to -6.9%) and steroids for chronic lung disease (AD -15.3%; 95% CI -15.8% to -14.8%) decreased significantly overall. Most of the changes in respiratory care were observed within each of 4 birth weight strata (501-750 g, 751-1000 g, 1001-1250 g, 1251-1500 g). Many obstetric and neonatal care practices used in the management of infants 501 to 1500 g changed between 2000 and 2009. In particular, less-invasive approaches to respiratory support increased.

INDEPENDENT MIDWIFERY PRACTICE IN POLAND – LEGAL CONSIDERATIONS VERSUS REALITY

Objective. To assess the readiness of midwives in regards to carrying out complex independent care for expecting families during physiological pregnancy, delivery and puerperium; to evaluate the role of midwifery practice during individual preparation of a woman (and her spouse) for childbirth; to define the elements of health education included in preparation for childbirth. Material and method. Design - questionnaire survey. Setting - eight types of hospitals located in and outside of Warsaw. Participants - 291 practicing midwives with current or past practice in the delivery room. Findings. The majority of midwives (232; 80%) declared their readiness to provide complex care to expecting families and offered individual preparation of women (and their spouses) for delivery. Most state obstacle is the lack of practice, the need to improve skills and prevent system. The majority of midwives practice individual preparation of women for childbirth (172; 59%). Midwives complementary education for masters, much less frequently (72; 47%) operate this type of care than the other (76; 71%) - p = 0.001. This form of practice is implemented by the midwives hot properties (25; 83%) - p = 0.017. The most frequent components of prenatal health education included: biological aspects of pregnancy, delivery and puerperium, followed by psychological aspects, hygiene, diet, physical activity and prenatal communication with the child. Conclusions and implications for practice. Independent midwifery practice is not limited by Polish law. The obstacles faced by independent midwives are associated rather with the healthcare system and the mentality of its workers. The profession of midwifery should be strengthened by extensive media campaigns promoting the competency of this professional group, along with the completion of graduate and postgraduate education curricula in aspects useful for running independent practice.

Implementation and Evaluation of “Golden Hour” Practices in Infants Younger Than 33 Weeks' Gestation

Upon review of Vermont Oxford Network data, a Midwest level III neonatal intensive care unit noted increased levels of chronic lung disease (CLD) in infants born at less than 33 weeks gestation. Initial analysis of delivery room practices with these infants showed great variance based on each provider's experience and knowledge. In an effort to standardize processes and to reduce the level of CLD within this subpopulation of infants, providers adopted “golden hour” practices focused on providing respiratory support (use of an inspiratory hold, early continuous positive airway pressure, and intubation criteria), oxygen targeting, thermal regulation, and teamwork. Compliance was tracked via delivery room documentation. Although this is an ongoing quality improvement project, examination at 3 and 6 months postpractice shows increasing compliance with the golden-hour practices. Furthermore, after 6 months of using golden-hour practices, there is a decreased incidence of CLD.

Condições de assistência ao recém-nascido na sala de partos: inquérito nacional (2009).

In Portugal, since 1989, the rates of maternal, perinatal and neonatal mortality present a significant decrease, after the implemented perinatal network. The continuous assessment of the existing conditions at the different levels of perinatal care is essential to identify deviations from normality and may allow the optimization of quality of care. To obtain information on and to evaluate the conditions and practices of neonatal resuscitation at the Portuguese delivery rooms, in order to propose measures for improvement of neonatal care. An electronic questionnaire was sent to 35 hospitals with maternity. The survey included questions regarding to human and material resources, characteristics of delivery room practices used in stabilization / resuscitation of the newborn, number of deliveries and number of newborns transferred after birth per year, as well as issues related with the collaboration of obstetric teams. Thirty centres (86%) answered the questionnaire, 16 of the respondents were level III maternities/hospitals. In eight (27%) centres a paediatrician is present at all deliveries, whereas in the remaining centres a paediatrician is available only for risk situations. The material unavailable in some centres include cardio-respiratory monitoring equipment, support device with pressure controlled ventilation, oxygen blender, ventilator, CPAP (continuous positive airway pressure), neonatal transport incubators and equipments for thoracocentesis and paracentesis. The criteria used for prophylactic surfactant and oxygen use are very different among the various centres. All centres reported transferring newborns after birth, either because of lack of differentiation of care or vacant beds. The centres with perinatal support reported less cooperation of the obstetric teams. The care of the newborn in the national delivery rooms can and should be improved. It is necessary to adapt the equipment and human resources to the needs of each centre. Protocols and practices such as oxygen and "prophylactic" surfactant must be updated, transport after birth must be reduced and the communication with the obstetric teams should be improved.

Experience on Delivery Room Practice of Male Nursing Students.

This study was to understand the meaning of experience in delivery room practice of male nursing students. This is qualitative research using focus groups. Data were collected by group interviews from May 22 to June 20, 2010. The focus group interviews were conducted to 14 male nursing students who had experience clinical practice in delivery room. Data were analyzed through Colaizzi's method, in which meaningful statements were extracted. Five theme clusters were identified from thirteen themes and twenty four sub-themes. The five theme clusters were 1) cultural perception of gender role, 2) perceived reality of male nurse, 3) difficulty in approaching clients, 4) counter-educational environment, 5) insight and new perception. For the purposes of remedying male nurse students' problems experienced during clinical practice in delivery room, it seems that there is a need for reeducating nurses' perception of male nurse students and develop programs specially dedicated to clinical practice of male nurse students.

Implementation of a Delayed Cord Clamping (Dcc) Protocol for Preterm Infants and Delivery Room Practice

Implementation of a Delayed Cord Clamping (Dcc) Protocol for Preterm Infants and Delivery Room Practice

Delivery room practices in infants born through meconium stained amniotic fluid: a national survey

Based on the results of two large RCTs, guidelines from NRP/AAP, ILCOR, ACOG, and from Argentinean scientific societies for intrapartum and postpartum management of pregnancies with Meconium Stained Amniotic Fluid (MSAF) have radically changed. However, there are no data as to current delivery room management of infants born through MSAF. 1) To assess current delivery room approaches in infants born through MSAF in Argentina; 2) To evaluate the adherence to NRP/AAP recommendations among different centers. A 20-question anonymous web-mail based survey was sent to 121 institutions with > or = 500 births a year. The response rate was 63% representing 182,540 deliveries/year (26% of the total number of births in the country). Among the surveyed institutions, 24% were located in the city of Buenos Aires and 72% were public hospitals. Although no longer recommended, the following procedures are frequently performed: 1) Oro-nasopharingeal suctioning of meconiumstained infants before the delivery of the shoulders: sometimes, 50% of centers; always, 7 %. 2) Routine tracheal suctioning in vigorous infants, 30%. 3) Glottis exposure under laryngoscopy, 13 % for thin-consistency MSAF and 43% for thick-consistency MSAF. On the contrary, and although strongly recommended, only 69% of depressed infants have tracheal suctioning before ventilation. Up to 7% of centers perform other non recommended procedures such as chest compression and pressure over the larynx, to avoid breathing, and gastric lavage. In spite of not being currently recommended, intrapartum suction and postnatal intubation and suction of vigorous infants with MSAF are commonly performed in Argentina while in depressed newborns the latter procedure is not always carried out. Our study confirms the frequent gaps observed between scientific evidence, guidelines and clinical practice.

Breastfeeding and early weaning practices in northeast Brazil: a longitudinal study.

To describe breastfeeding practices from 0 to 12 months of age in 4 small towns that are representative of urban northeast Brazil and to identify factors associated with introduction of other milk in the first month of life. From January to August 1998, 364 mothers were interviewed at delivery to ascertain antenatal care; delivery room practices; and their intentions regarding breastfeeding, pacifiers, and introduction of water, teas, and other milk. Their perceptions of home support and the advantages of breastfeeding also were assessed. Thereafter, daily information about feeding practices was collected at twice-weekly home visits. When other milk was started, a second interview was conducted to ascertain initial and current breastfeeding problems and use of a pacifier. Reasons for starting other milk were investigated using 5-point Likert scales. Mothers were positive toward breastfeeding, and 99% breastfed their new infant. Few intended to breastfeed exclusively, and in the first week 80% gave water/tea and 56% used a pacifier. The median duration of exclusive breastfeeding was 0 days, and the median age for starting other milk was 24 days. The median duration of breastfeeding was 65 days for mothers who started other milk within 1 month and 165 days for other mothers. After adjustment for confounding variables, the main factors associated with introduction of other milk within 1 month were pacifier use in the first week (odds ratio [OR], 4.01; 95% confidence interval [CI]: 2.07-7.78), intention to start other milk in the first month (OR, 3.79; 95% CI: 1.74-8.24), giving water/tea in the first week (OR, 3.07; 95% CI: 1.56-6.03), and leaving the maternity ward before breastfeeding was started (OR, 2.59; 95% CI: 1.34-5.04). Although breastfeeding is common in this community, it rarely is exclusive and takes place for a relatively short duration. Identification of risk factors for early introduction of other milk offers potential avenues for future intervention, including improvement of breastfeeding support in antenatal and maternity services.

Early adaptation of human skin following birth: a biophysical assessment

Background/aims: Successful adaptation to postnatal life requires rapid physiological transitions in multiple organ systems. Mechanisms regulating stratum corneum water interactions and evaporative heat loss, for example, are pivotal in making the transition from the warm, aqueous prenatal state to a cold, dry postnatal environment. Understanding these mechanisms is important in formulating skin care guidelines in early infancy.Methods: One hundred and one full term infants were enrolled prospectively and evaluated in three maternity hospitals over the first few hours after birth. Skin surface electrical capacitance and optical imaging were performed over selected body sites after placement under a radiant warming device. A selected group of infants were occluded with a plastic wrap following towel drying in the delivery room. Specific measurements included baseline skin hydration, continuous capacitive reactance, peak water sorption, rate of water desorption, skin pH, and grading of optical images for abnormal skin desquamation.Results: Occlusion of the skin surface following birth delays the normal fall in surface hydration and transepidermal water movement (TEWM). Sites exposed to the radiant warmer (chest) exhibited decreased hydration and increased pH compared to non‐exposed sites (back). Desquamation was increased over the chest compared to the back as judged by optical image grades. Significant inverse correlations were noted between baseline skin hydration and the ability to desorb surface water. Unexpectedly, females exhibited significantly increased desorption of exogenously applied water with a near significant increase in maternal‐infant bonding time.Conclusions: Newborn infant stratum corneum undergoes a slow (minutes to hours) diminution in surface hydration following birth; this is a function of body site, position, and exposure to the radiant warmer. Practices such as occlusion of the skin surface at birth delay the normal drying process. The data support potential gender specific differences in skin surface water handling and/or delivery room practices. Focus on the complex process of newborn skin adaptation provides a physiological framework for skin care protocols extending into infancy, childhood, and later life.

Ethical dilemmas in the delivery room

The decision to withhold or withdraw life support in the neonatal intensive care unit (NICU) is common but is never routine. Often, moral demands make such decisions difficult and emotionally exhausting. But, what is perhaps more challenging from the moral point of view is the transition from the delivery room to the NICU. A satisfactory analysis of the moral issues of delivery room practices must include a discussion of quality of life, the best interest of the infant, the best interests of the family members, and futile treatment. Although these topics are relevant in any discussion of the moral justification of the omission, withdrawal, or use of treatment for patients, they are especially telling when entertained in the context of the transition of the fetus to a newborn. This article uses these four topics as a moral compass for certain decisions made in the delivery room.

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is the most common chronic respiratory disease that results from complications related to the lung injury during the treatment of respiratory distress syndrome, or develops in older infants when abnormal lung growth occurs. The definition and classification of BPD have changed since the original diagnosis was established many years ago. The incidence of BPD continues to grow as lower-birth-weight infants continue to survive. The primary focus of all treatment associated with premature infants is on prevention of BPD. Surfactant replacement, invasive and noninvasive ventilation techniques, management of the patent ductus arteriosus, cautious management of oxygen therapy, caffeine, inhaled nitric oxide, and changes in delivery room practices have been studied to assess their effects on the development of the disease. Other strategies used to reduce the long-term effects of this chronic lung disease include bronchodilators, inhaled and systemic steroids, nutrition management, and selected ventilator strategies. The prevention of BPD is targeted at minimizing effects of this pulmonary disease and preventing the long-term sequelae associated with its treatment.

A study on stress of the nursing student in delivery room practice

The purpose of this study is the extent of the stress of the nursing students during the period of delivery room practice, according to whether they have their practical experience and in which situations they received. The subject of this study is 62 nursing students (who experienced delivery room practice at an early stage) in Kang Weon C. Junior College of nursing and 62 nursing students (who experienced delivery room practice at a latter stage) in J. Junior College of Nursing (total 124 students) from March 1988 to December 1988. The results of this study are summerized as follows. 1. According to the general characteristics, it revealed that they have not any relations between the religion, the numbers of family, health status and the extent of stress during the nursing students have experienced in the delivery room practice (p greater than .05). 2. It revealed that there were much differences to the extent of stress they have experienced during the delivery room practice between the nursing students (who experienced delivery room practice at an early stage) in C. Junior College of Nursing and nursing students (who experienced delivery room practice at a latter stage) in J. Junior College of Nursing (p less than .000). 3. In ten items of the stress that was confronted by nursing practice, they had much differences to the extent of stress perception for the students during the period of delivery room practice between each college (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Gonococcal ophthalmia neonatorum: Relationship of maternal factors and delivery room practices to effective control measures

Gonococcal ophthalmia (proved by cultures) occurred in 11 infants delivered at the Jewish Hospital and Medical Center of Brooklyn (JHMCB) during a three and one-half-year period. Two more infants had conjunctivitis with presumptive evidence of gonococci (Gram stain of eye discharge). Silver nitrate was instilled in the eyes of the neonates by registered nurses. Maternal histories of these infants showed lack of prenatal care in ten, history of gonorrhea in pregnancy in three, and positive serology (STS) in two; ten of the mothers were unmarried. The over-all incidence of gonorrhea at the JHMCB prenatal clinic screening program is very low (0.02 per cent). Prevention of neonatal gonorrheal ophthalmia depends on: vigorous screening of mothers at delivery as well as during prenatal visits, careful attention to instillation of silver nitrate in the neonates' eyes, development of serologic tests for gonorrhea, and improved bacteriologic methods for culturing the organism.