Delivery Room Setting Research Articles

Heated Humidifier versus Heat-and-Moisture Exchanger During Positive Pressure Ventilation With a T-Piece Resuscitator in Rabbits.

There are many proven benefits of the use of conditioned gases in mechanically ventilated patients. In spite of this, its use in the delivery room is limited, perhaps because of known difficulties with heated humidifiers (HH); moreover, there is no evidence regarding the use of heat-and-moisture exchangers (HME) in a delivery room setting. We sought to asess the airway's absolute humidity level using three diferents strategies: HH, HME and unconditioned gases. We conducted an experimental study in 12 intubated rabbits ventilated with a T-piece resuscitator. Absolute humidity levels in inspired gases were measured at baseline and at 5, 10, 15, and 20 min while using HH, HME, or no conditioning method (ie, unconditioned). The animals were initially randomized to one of the 3 interventions, and each animal underwent the other methods with at least 24 h between each test. There were no differences in vital signs at baseline or at the end of the procedures. Mean absolute humidity at the end of the tests was 38.2 ± 1.7 g/m3 for HH, 28.9 ± 4.7 g/m3 for HME, and 13.9 ± 5.1 g/m3 for unconditioned gas (P = .003). During ventilation with a T-piece resuscitator, the absolute humidity was the highest with HH. The absolute humidity with HME was lower, but it was still significantly more than that with unconditioned gas. Therefore, the use of a T-piece resuscitator with HME could be a good alternative to HH given that positive-pressure ventilation is used ideally for short periods of time in the delivery room.

Caregivers' perception of women's dignity in the delivery room: A qualitative study.

Dignified care is one of the moral responsibilities of professional caregivers. However, in many cases the dignity of hospitalized patients, especially women in the delivery room, is not maintained. Dignity is an abstract concept and there has been no previous research exploring the dignity of pregnant women in the delivery room in Iran. The objective of this study is to define and explain the concept of dignity for pregnant women in the delivery room from the perspectives of professional caregivers. This is qualitative research. The data were collected through in-depth semi-structured individual interviews. The conventional content analysis method was used to analyze the data. In qualitative content analysis, participant narrative is examined in-depth and sorted into categories and themes. Potential participants who met the entrance criteria for this study were approached between July 2016 and February 2017. In all, 20 professional caregivers working in the delivery room setting within Iranian general hospitals were invited to participate in the study. The sampling was done through targeted sampling until saturation was achieved. The research ethics committee of the Shiraz University of Medical Sciences has approved the study's protocol and all commonly recognized ethical principles were followed throughout the study. The findings of this study were presented in three main themes, including "privacy," "respecting patients' preferences," and "comprehensive attention" and eight categories. Women in the delivery room need to be taken care of in an environment where healthcare staff promote the preservation of dignity through maintaining privacy, by providing attentive care and through ensuring that patient preferences regarding care and treatment are respected. In such an environment, the dignity of these women would be maintained and desirable outcomes achieved.

Abstract 166: Insertion or Replacement of an Advanced Airway is Not Associated With Adverse Outcome in Neonatal Intensive Care Unit Cardiopulmonary Resuscitation

Introduction: There is a paucity of data regarding variables that impact the outcome in patients who require cardiopulmonary resuscitation (CPR) in the neonatal intensive care unit (NICU). The impact of initial need or replacement of an existing advanced airway (AA) has not been described in this population. The 2016 Neonatal Resuscitation Program (NRP) places emphasis on AA placement prior to initiating compressions in the delivery room setting. We hypothesized that providers would similarly emphasize airway placement for NICU CPR. Methods: We conducted a retrospective review of patients requiring CPR with chest compressions from 2012 to 2017 across 10 NICUs in San Antonio, Texas. We identified cases by clinician selection of a CPR code and by a review of all patients who died prior to NICU discharge. Results: We review a total of 211 NICU CPR events, 210 of which had complete data regarding the AA. An AA was present at the onset of CPR for 179 (85.2%) of CPR events and an existing airway replaced during CPR for 31 (14.7%) CPR events. All patients without an AA present at onset of CPR had an airway immediately placed. The median time to insertion of AA was 1 minute (IQR 1, 5 minutes). In comparing patients who had an AA present at CPR onset versus absent AA, there was no significant difference in rate of return of spontaneous circulation (ROSC, 63.7% vs 64.5%, p=0.92) or time to ROSC (10.2 vs 12.7 min, p=.66). The median time for replacement of an AA during CPR was 1 minute (IQR 1, 4 minutes). Those with a time to replace the AA of >= 5 minutes had a similar ROSC rate compared to those who had AA replacement in < 5 minutes (75% vs 73.7%, p=.96). The decision to replace an AA during CPR was associated with a non-significant increase in rate of ROSC (74.2% vs 62%, p=0.19) and no significant difference in time to ROSC (11.5 min vs. 10.4 min, p=0.65). Conclusions: The achievement of ROSC or time to ROSC are not impacted by the need to place an initial AA at the onset of CPR or the need to replace the AA during CPR in the NICU. This may be due to the rapid initial placement and replacement of the AA observed in NICU CPR events. These data indicate that NICU CPR providers emphasize rapid AA placement similar to NRP guidelines.

Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!

BackgroundAlmost 20% of neonates experience pain during delivery or the period following birth. AimTo describe the practices of pain assessment in the maternity wards in the greater Paris area, France. MethodsAn e-mail questionnaire was sent to each practitioner in the 96 maternity units in Île de France between December 2013 and February 2014. ResultsIn all, 63 (65%) questionnaires were completed. Pain was assessed in 43 (68%) maternity units, mostly using the French scale “échelle de douleur et d’inconfort du nouveau-né” (EDIN). In total, 20 maternity units (32%) reported no pain assessment, mainly because they considered it to be too time-consuming, or because they argued that no pain scale was adequate; they relied on clinical signs or on the obstetric history for assessing and treating pain. About 40% of the maternity units using the EDIN scale judged it unsuitable for evaluating pain in term neonates in maternity units. ConclusionThis first regional study on pain assessment in the maternity ward showed that nearly two thirds of centers assessed pain. This rate may be overestimated because of the reporting method used. The EDIN scale is the most widely used tool but seems unsuitable especially for the delivery room setting. Studies should be conducted to test other tools for assessing neonatal pain in the delivery room.

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

Hospitals have struggled for years regarding the handoff process of communicating patient information from one health care professional to another. Ineffective handoff communication is recognized as a serious patient safety risk within the health care community. It is essential to take communication into consideration when examining the safety of neonates who require immediate medical attention after birth; effective communication is vital for positive patient outcomes, especially with neonates in a delivery room setting. Teamwork and effective communication across the health care continuum are essential for providing efficient, quality care that leads to favorable patient outcomes. Interprofessional simulation and team training can benefit health care professionals by improving interprofessional competence, defined as one’s knowledge of other professionals including an understanding of their training and skillsets, and role clarity. Interprofessional teams that include members with specialization in obstetrics, gynecology, and neonatology have the potential to considerably benefit from training effective handoff and communication practices that would ensure the safety of the neonate upon birth. We must strive to provide the most comprehensive systematic, standardized, interprofessional handoff communication training sessions for such teams, through Graduate Medical Education and Continuing Medical Education that will meet the needs across the educational continuum.

Inadvertent Methylergometrine Administration to a Neonate with Underline Acyanotic Congenital Heart Disease

Background: Methylergometrine is an ergot alkaloid of ergonovine used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergometrine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, cyanosis, seizures, and death. Case Report: A term male infant was inadvertently given 0.04 mg of methylergometrine intramuscularly. The error was only noted when the baby developed central cyanosis, after administration, identifying it as methylergometrine rather than vitamin K. The local poison center was notified, and the infant was transferred to the neonatal intensive care unit level III for observation. Few minutes after cyanosis, the infant was noted to have oxygen desaturations and prolonged apnea required oxygen via nasal cannula and ventilation as a respiratory support to maintain his oxygen. ECG and ECHO were done and ECG was normal and ECHO showed Large ASD secondum. Feeding was started by 48 hours of life, and the infant was discharged home in good condition after a 96-hour stay without further complications. Disscussion: Because of the potential for serious adverse events, Look- alike Sound- alike policy and precaution is required to be applied to prevent accidental administration of methylergometrine to the neonate as a result of possible confusion with vitamin K in the early post-partum period.

Impact of Fetal Weight Estimation on the Prediction of Neonatal Morbidity and Mortality at the Limit of Viability

Introduction: To determine the accuracy of estimated fetal weight (EFW) at the limit of viability in a delivery room setting and its impact on the prediction of neonatal outcome. Material and Methods: In this retrospective, single-center cohort study we included patients with preterm birth between 23⁰/₇ and 26⁰/₇ weeks of gestation. Neonates were divided into 3 groups according to birth weight at delivery (accuracy index 90-110%, <90%, >110%). Neonatal outcome for each group was categorized into survival with and without impairment and death, with a follow-up period of 6 weeks. Results: Eighty-seven newborns were included, with 62.1% accurately estimated. Gestational age at birth, fetal sex, maternal body mass index, and time interval between birth and ultrasound affected the accuracy of EFW. Chances of survival were significantly higher in the underestimated group for birth weight at delivery compared with estimated weight (p < 0.001), with risk of death being significantly lower (p < 0.001). The reverse was true for overestimated infants, for both risk of death and chances of survival. At 6 weeks' follow-up, there were significantly more deceased overestimated infants (p = 0.041). Discussion: Our study shows that inaccuracy of EFW at the limit of viability occurs frequently in a delivery room setting with a potential impact on neonatal outcome.

간호대학생의 분만실 임상실습 질 향상 방안

본 연구는 간호대학생의 분만실 실습 중 수행내용을 파악하고 임상실습 환경에 따른 간호대학생의 실습 수행도 및 만족도를 분석하여 실습의 질 향상을 위한 개선방안을 제시하고자 하였다. 연구결과 간호대학생의 분만실 임상실습은 대부분 관찰 위주로 진행되고 있었고, 제한된 영역에서만 직접수행과 보조적 수행을 경험하였다. 간호대학생의 임상수행 만족도는 69%정도의 비교적 낮은 수준을 보였다. 임상실습지에 따른 차이를 분석한 결과 여성전문병원의 분만실에서 실습 한 간호대학생은 종합병원에서 보다 더 많은 관찰을 수행 할 수 있었고, 그에 따라 만족도 점수 또한 높았다. 분만실 임상실습에서 관찰 및 보조적 수행이 많을수록 만족도는 상승하였다. 결과에서 확인된 실습 중 부족한 직접수행은 시뮬레이션기반 임상실습 등을 통해 보완할 수 있을 것이다. 또한 병원 실무자와의 긴밀한 의사소통을 기반으로 실습지를 확보하고, 다양한 간호대상자를 경험하고 관찰할 수 있도록 지도하는 것은 간호대학생의 임상실습 만족도와 질 향상을 위한 전략으로서 제시될 수 있겠다. Purpose of this study was to provide strategies to improve quality in clinical practice by identifying the nursing student contents of clinical practice, performance level and satisfaction in the delivery room setting and correlations between the performance level and satisfaction. As the result, Nursing students were mostly rely on observational experiences with very limited experiences of performance and assist. Nursing students' clinical practice satisfaction were relatively low with 69 percentile score. The women's health clinic group showed higher score on frequency of clinical observation, clinical practice satisfaction than the tertiary hospital group. Correlations among frequencies of observation, assist and satisfaction were identified. Simulation based clinical practice as alternative ways to enhance students' performance level, utilizing community based speciality healthcare facilities for clinical practice, increasing observational experiences in the clinical field were suggested as strategies to improve quality of nursing clinical practice and ultimately to improve quality of healthcare services.

PO-0661 Transfer Of Behavioural Neonatal Resuscitation Skills Learnt On Simulator In The Simulation Room To Clinical Practice In The Delivery Room

Introduction Transfer of behavioural skills learnt in the simulation room to the delivery room setting has not been well addressed. Methodology We queried the physicians and nurses who participated in resuscitation in an actual delivery room setting. Their training included simulation based training for previous 4 years with emphasis on behavioural skills. Open ended questions included: (1) What went well?, (2) What did not go well?, (3) What would you do differently?, (4) Other comments. Results 32 events attended by teams of nurses and physicians were the focus of analysis. There was overlapping of physicians and nurses attending different events. 74 nurses and 35 physicians completed questionnaires that formed the database. Teamwork and communication (2 hallmarks of behavioural skills) were analysed. 40/74 (54.05%) of nurses and 13/35 (37.14%) of physicians responded that teamwork was good. 11/74 (14.86%) of nurses and 12/35 (34.28%) physicians responded that communication was good. None of the nurses commented negatively about the teamwork bur 2/35 (5.71%) physicians mentioned that teamwork did not go well. 10/74 (13.51%) of nurses and 6/35 (17.24%) of physicians mentioned that communication was not good. Thus, 68.91% of nurse responses and 71.42% of physician responses were favourable for teamwork and communication. Calling for help and delegating responsibility were also noted on the responses. Discussion Based on our open ended questionnaire, we conclude that physicians and nurses consider teamwork and communication to be important and these skills are being utilised in the delivery room setting. These results encourage us to continue our study.

Pulse Oximeter Sensor Application During Neonatal Resuscitation: A Randomized Controlled Trial

This study was done to compare 2 techniques of pulse oximeter sensor application during neonatal resuscitation for faster signal detection. Sensor to infant first (STIF) and then to oximeter was compared with sensor to oximeter first (STOF) and then to infant in ≥28 weeks gestations. The primary outcome was time from completion of sensor application to reliable signal, defined as stable display of heart rate and saturation. Time from birth to sensor application, time taken for sensor application, time from birth to reliable signal, and need to reapply sensor were secondary outcomes. An intention-to-treat analysis was done, and subgroup analysis was done for gestation and need for resuscitation. One hundred fifty neonates were randomized with 75 to each technique. The median (IQR) time from sensor application to detection of reliable signal was longer in STIF group compared with STOF group (16 [15-17] vs. 10 [6-18] seconds; P <0.001). Time taken for application of sensor was longer with STIF technique than with STOF technique (12 [10-16] vs. 11 [9-15] seconds; P = 0.04). Time from birth to reliable signal did not differ between the 2 methods (STIF: 61 [52-76] seconds; STOF: 58 [47-73] seconds [P = .09]). Time taken for signal acquisition was longer with STIF than with STOF in both subgroups. In the delivery room setting, the STOF method recognized saturation and heart rate faster than the STIF method. The time from birth to reliable signal was similar with the 2 methods.

Board 399 - Research Abstract LMA/IO Placement Versus ETT/UVC Placement during Simulation in New NRP Trainees (Submission #471)

Introduction/Background Endotracheal intubation is the preferred procedure taught in the Neonatal Resuscitation Program (NRP) when a secure airway is needed. Studies show that pediatric residents are successful only 21-62% of the time, often requiring multiple attempts and taking longer than recommended. The laryngeal mask airway (LMA) is an alternate device that can be used to provide a secure airway. The preferred procedure taught in NRP for obtaining emergency vascular access is umbilical venous catheter (UVC) placement. Studies have shown intraosseous (IO) insertion to require less skill and practice and take less time than UVC placement for emergency vascular access. Pediatric residents can take six times as long to place an emergency UVC compared to IO. The purpose of this study was to compare the success and time to establish a secure airway and emergency vascular access during simulated neonatal resuscitation using LMA/IO versus endotracheal tube (ETT)/UVC in new NRP trainees. Methods Seventeen fourth year medical students on a pediatric rotation were recruited. They completed NRP training two days prior to study participation. The participants viewed a video demonstration of the four skills (ETT, LMA, UVC and IO) and performed each procedure on a manikin or task trainer with guidance from an experienced NRP provider. The students then participated in a simulated delivery room scenario, where a secure airway and vascular access were needed. They were randomized to either LMA and IO or ETT and UVC. The scenarios were recorded for data collection and analysis. Data was also collected in real time by observers in the delivery room. After the delivery room scenario, the students were surveyed to assess experience and perceived confidence with each skill. Results Success of LMA placement was 100% versus 62.5% with ETT (p = 0.082). The median number of attempts was 1 for the LMA versus 2.5 for ETT (p = .009). The median total airway management time using LMA was 88 seconds versus 173 seconds with ETT (p < .001) and median procedure time of LMA insertion was 23 seconds, compared to 119 seconds for ETT (p = .015). The rate of success and median time to obtain vascular access using IO catheter versus UVC did not significant differ (both p > 0.4). Conclusion In this pilot study in a simulated delivery room setting, there was a statistically significant difference in the time to placement and number of attempts favoring LMA versus ETT. IO insertion was faster than UVC placement, although not statistically significant with the small sample size. If larger studies support our findings, NRP training may need to include LMA as the preferred method for a secure airway, particularly in those who do not routinely perform delivery room resuscitation. Disclosures None.

Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation

Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room. Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique. The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use. In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.

A new device (Cicogna) for transferring the neonate in the delivery room setting: a randomised, controlled trial

Objective. We developed a new system (‘cicogna’) for transferring the neonates into the delivery room setting. Our aim was to compare the ‘cicogna’ system and the conventional method (plastic basin) with regard to the time needed to transfer the neonate from the operating table to the radiant warmer; and to evaluate the degree of approval for the ‘cicogna’ expressed by the midwives.Study design. In a prospective, randomised, controlled trial including 100 infants (gestational age ≥34 weeks), we measured the time elapsed from the umbilical cord clamping to the positioning of the neonate under the radiant warmer using the ‘cicogna’ system or the conventional method. Midwives involved in the study were asked to fill out a final, written evaluation regarding the feasibility and the safety of the devices.Results. The time elapsed from the cord clamping to the positioning of the infant under the radiant warmer was significantly shorter for infants who were managed with the ‘cicogna’ system compared with infants who received standard care: 18.7 ± 5.6 s vs. 24.5 ± 9.0 s (p < 0.001). In the evaluation forms, 19 out of 20 midwives (95%) evaluated the ‘cicogna’ as good or excellent.Conclusions. In comparison with the conventional method, ‘cicogna’ decreased the time needed to transfer the neonate into delivery room setting and received a high degree of approval by personnel involved in neonatal care. It appears to be a feasible and safe method for transferring the neonate in the setting of the delivery room.

Improving the delivery room setting in developing countries: the opinion of local health caregivers

Neonatal mortality has remained steady or increased in many developing countries. A pragmatic approach to the organization of the delivery room setting, where a large part of neonatal deaths occurs, could detect the priorities for potential ameliorative interventions. We evaluated the local health caregivers' opinions regarding the priority areas for improving the hospital delivery room setting in developing countries. Twenty-eight participants to a World Health Organization (WHO) workshop were asked to fill out an anonymous, written questionnaire regarding the priorities that could significantly improve their hospital delivery room setting. The three most important interventions for improving the delivery room setting were classified as following: education of all staff in newborn care (28%), optimize doctor-nurse/patient ratio (15%), equipment (14%), maternal-antenatal care (13%), role and responsibilities (8%), salary (8%), neonatal intensive care unit facilities (6%), availability of a specialized team for neonatal resuscitation (5%) and improve the building (3%). Education of health staff in newborn care, personnel organization and equipment availability are valued as high priorities by local health caregivers for improving the delivery room setting in developing countries. The opinion of operators involved in maternal and neonatal health may contribute to better design interventions in setting with limited resources.

LOOK BEFORE YOU CLAMP

The umbilical cord is a critical connection between the embryo (and later, the fetus) and the placenta. The umbilical cord houses the blood vessels that are responsible for nourishing the fetus. Proper umbilical cord function is essential for growth and development before birth. A review of the embryologic origin of the umbilical cord aids in understanding abdominal wall and umbilical cord defects that can present in the newborn period. In the delivery room, inspection of the umbilical cord is an integral part of the first minutes of life. Any abnormality either within the cord structure or in the areas surrounding the base of the cord may necessitate a delay in shortening the cord. Surgical consultation may also be indicated. This issue of Focus on the Physical will provide a step-by-step guide to cord assessment in the delivery room setting. Pictures showing normal, atypical, and abnormal umbilical cords and common abdominal wall defects will be presented along with a brief discussion of the significance and clinical implications of each of these findings.

Behavioral interaction of fathers with infants and mothers in the immediate postpartum period

This study describes paternal behaviors of first-time fathers with their partner and new-born immediately after birth and identifies a progression of behaviors with the infant within the first 15 minutes after birth. Videotapes were made of 24 first-time fathers observed at birth in a traditional delivery room setting. Utilizing an ethological approach to define behavioral codes, episodes of paternal behavior were measured with time interval sampling. Using a modified frequency method, behaviors were identified in four main categories: proximity, gaze, touch, and movement. The analysis showed that proximity and gaze were high-frequency behaviors and touch and movement were low-frequency behaviors. A progression of behaviors was identified, with gaze starting out high and diminishing, proximity and movement increasing over time, and touch remaining low but constant. Limitations of the setting and implications for clinical practice and research are discussed.