Special Care Nursery Research Articles

A double‐blind, randomized, placebo‐controlled trial of melatonin as an adjuvant agent for induction of labor: The MILO trial

AbstractIntroductionMelatonin has been suggested to have a biological role in the onset and progress of labor. We tested the hypothesis that the addition of melatonin during an induction of labor will reduce the need for a cesarean birth.Material and MethodsThis trial underwent protocol amendments that are detailed in the main text of the article. This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000311459). At a multi‐center health service including secondary and tertiary obstetric hospitals, we performed a randomized, double‐blind, placebo‐controlled trial in women with a singleton cephalic pregnancy, free of significant maternal or perinatal complications who were undergoing induction of labor (with or without cervical ripening). Women were randomized to 10 mg melatonin vs placebo, with cervical ripening as required, and then 6‐h during their induction of labor to a maximum of four doses or until birth. The primary outcome was cesarean birth. Secondary outcomes included labor, maternal, and neonatal outcomes. Data were analyzed using intention to treat. Sub‐group analyses based on mode of ripening and parity were also performed.ResultsBetween 2019 and 2021 we randomized 189 women (103 to melatonin and 86 to placebo). The study was prematurely terminated due to logistical complications resulting from the COVID‐19 pandemic. Cesarean rates were 28/103 (27.2%) in the melatonin group versus 20/84 (23.3%) in the placebo group (RR 1.17 95% CI 0.71–1.92). There were no significant differences in rate of cesarean birth between the melatonin and placebo groups for failure to progress (13.4% and 9.3%, respectively, RR 1.46; 95% CI 0.64–3.32) or suspected fetal distress (10.7% and 10.5%, respectively, RR 1.02; 95% CI 0.44–2.34). The melatonin group had significantly lower rates of spontaneous vaginal birth within 24 h (35.0% vs. 50.0%; RR 0.70 95% CI 0.50–0.98). The rates of secondary outcomes such as total length of labor, rate of postpartum hemorrhage, and instrumental birth were comparable. Babies born in the melatonin group were more likely to need admission to the special care nursery, namely for hypoglycemic monitoring (18.5% vs. 8.1% RR 2.26; 95% CI 1.00–5.10).ConclusionsIn women undergoing induction of labor, melatonin does not reduce the cesarean section rate. Melatonin use intrapartum may also be associated with neonatal hypoglycemia.

Systematic review of environmental noise in neonatal intensive care units.

To systematically review the literature on noise exposure within the neonatal intensive care unit/special care nursery settings, specifically to describe: noise characteristics, sources of noise and ways of measuring noise. Systematic searches were conducted through databases Medline, Embase and PubMed. Studies were included if they met the inclusion criteria (1) reported noise characteristics; (2) reported noise exposure measurements; (3) in the neonatal intensive care unit/ special care nursery settings. Methods and key findings were extracted from included studies. Quality analysis was done using a modified version of the Newcastle-Ottawa Scale. We identified 1651 studies, screened 871, reviewed 112 and included 47. All reported NICU average equivalent sound levels were consistently louder than recommended guidelines (45 dB). The most consistent association with higher sound pressure levels were noise sources grouped under people congregation. Half of the studies did not use measuring devices adhering to international sound level meter (SLM) standards. All NICUs exceeded recommended accumulative sound levels. People were the most consistent source of noise. Sound pressure levels need to be consistently measured with devices adhering to international SLM standards in future studies.

O54 - Relinquishing care when breastfeeding a late preterm infant: a qualitative study of mothers in a Special Care Nursery

O54 - Relinquishing care when breastfeeding a late preterm infant: a qualitative study of mothers in a Special Care Nursery

Digital Stethoscope Utility in NICU, SCN, and LDRP Patients

Introduction: To this day, abnormal auscultatory findings on acoustic examination of the cardiovascular system remains the most common reason for referral to a cardiologist. Three limitations exist with acoustic stethoscopes: 1) high selective sensitivity requirement is needed; 2) easy disruption by ambient environmental noise; 3) subjectivity of interpretation based on the provider’s experience, skills, and auditory proficiency. The introduction of digital stethoscopes offered a solution to the limitations of the traditional acoustic stethoscope while at the same time broadening the diagnostic potential of such devices: 1) improvement in sound quality; 2) amplification of the acoustic signal; 3) reduction of ambient noise. The objectives were: 1. To determine the accuracy of the digital stethoscope when used in neonatal intensive care unit (NICU), Special Care Nursery (SCN), and Labor & Delivery Recovery Postpartum (LDRP) patients; and 2. To determine if its use leads to improved detection rates of cardiac pathologies compared to the use of a classic acoustic stethoscope. Methods: This is a single center, prospective study of neonates in the NICU, SCN, and LDRP at Ascension St. John Children’s Hospital. After obtaining informed consent, infants were examined using both acoustic and electronic stethoscopes by trained residents. Data from chart review and echocardiography were also collected. Results from the two stethoscopes were compared to each other and to echocardiographic findings. Data were analyzed using Student’s t-test, the χ 2 test and the McNemar χ 2 test. Results: The study included 15 infants, mean of 33.3 ± 3.8 weeks’ gestation at birth, 46.7% female (7/15) and 66.7% (10/15) black. Of the 15 patients evaluated, for the differential diagnosis and the ECHO results, there was 56% (5/9) better agreement with the electronic stethoscope, 33% (3/9) equivocal agreement between the electronic and acoustic stethoscopes, and 11% (1/9) worse agreement between the electronic stethoscope differential diagnosis and the actual ECHO results. Conclusions: There is a trend towards better agreement between the electronic stethoscope differential diagnosis and the actual ECHO results. A larger sample size is needed to determine true statistical significance of the data and probability.

Development and validation of the caregiver Burden from infant home NGT care instrument

ObjectiveTo design and validate an age and condition-specific health status instrument to best reflect the parental experience caring for these children with complex needs and home Nasogastric Tube (NGT) placement. Study designCombined Qualitative and Quantitative design, testing and implementation for item production and reduction, followed by formal validation by evaluating validity, reliability, and establishing a clinically meaningful change score. SettingsTertiary care, multi-disciplinary aerodigestive center. ParticipantsAll caregivers whose infant met criteria for eligibility for discharge home from the NICU or Special Care Nursery (SCN) with NGT in place were offered inclusion in this group.Intervention/Exposure: Structured qualitative interviews of these caregivers to explore and define these concepts and domains, to item generate and then reduce, and then psychometric analyses. MethodsStructured, moderated qualitative interviews with parents/caregivers of children who have undergone home NGT care of their children for item creation, design, and then reduction. Reliability was assessed by Cronbach alpha analysis. Construct validity and clinically meaningful change score was assessed using various query methods. Main outcome measuresCronbach's alpha to assess reliability, a priori hypotheses validity analyses, and minimally important clinical difference calculation. ResultsScaled scores of this condition specific instrument ranged from 14 to 74 where higher scores indicate better QOL related to managing the NGT. Cronbach's alpha with all 14 items was 0.93. Validity was assessed by a self-assessment question to discriminate between change (95% CI: 8.5–14.1; p < 0.0001) as well as by other comparators to identify the instrument's ability to discriminate among populations where parents felt a difference in experience. The minimally important difference was calculated at 18 points. ConclusionThis represents the initial validation of the first condition and age-specific health status instrument to assess parent experience of caring for infants requiring a home NGT for dysphagia.

Collaborative Recognition of Wellbeing Needs: A Novel Approach to Universal Psychosocial Screening on the Neonatal Unit.

Universal screening for the psychological needs of families in neonatal care is internationally recommended, but is not routinely practiced in the United Kingdom (UK). The present quality improvement project explores the clinical and operational feasibility of a novel approach to universal screening on a neonatal intensive care unit in the UK. The approach to screening taken adopts collaborative, strengths-based and dialogical methods for recognising the psychological needs of families whose baby is in hospital. A novel screening tool, developed through consultation with families, is described. Over one month, 42 out of 80 eligible families engaged with the screening protocol either at admission to the unit, transition to the special care nursery within the unit, or discharge home, with completion rates higher at admission than discharge. This led to an eightfold increase in the number of families accessing targeted or specialist psychological intervention compared to the period prior to this pilot. This project demonstrates the need for adequate capacity in the workforce to carry out a screening programme and to respond to the needs identified.

Antenatal health and perinatal outcomes of Pacific Islander women in Australia with and without gestational diabetes: A ten-year retrospective cohort study.

Pacific Islander (PI) women in Australia have an increased risk of gestational diabetes (GDM); however, their perinatal outcomes are poorly understood. The aim was to determine the maternal characteristics and perinatal outcomes of PI women with and without GDM compared to Australian/European (AE)-born women. A retrospective analysis of perinatal outcomes of singleton deliveries >20 weeks' gestation between 1 January 2011 and 31 December 2020 was conducted at a tertiary provider (Melbourne, Australia). Antenatal details and birth outcomes were extracted from the Birth Outcome Systems database. t-Tests and χ2, univariate and multivariable logistic regression analyses assessed the relationship between ethnicity and outcomes. Of 52,795 consecutive births, 24,860 AE women (13.3% with GDM) and 1207 PI-born women (20.1% with GDM) were compared. PI women had significantly greater pre-pregnancy body mass index (BMI) and significantly lower rates of smoking and nulliparity. PI women with GDM had higher rates of pre-eclampsia (P < 0.001), large-for-gestational age (LGA) neonates (P = 0.037) and neonatal hypoglycaemia (P = 0.017) but lower rates of small-for-gestational age neonates (P = 0.034). Neonatal intensive care unit (NICU)/special care nursery requirements did not increase. After having adjusted for covariates, PI women's risk of LGA neonates (adjusted odds ratio (aOR): 1.06, 95% confidence interval (CI): 0.86-1.31) was attenuated; however, risk of pre-eclampsia (aOR: 1.49, 95% CI: 1.01-2.21) and neonatal hypoglycaemia (aOR: 1.40, 95% CI: 1.01-1.96) still increased. They were less likely to require a primary caesarean section (aOR: 0.86, 95% CI: 0.73-0.99). PI women have higher BMI and GDM rates, contributing to an increased likelihood of adverse perinatal outcomes. BMI is a modifiable risk factor that could be addressed prenatally.

Fetal Surveillance From 39 Weeks’ Gestation to Reduce Stillbirth in South Asian–Born Women

ABSTRACT Women of South Asian background are known to have higher rates of stillbirth than women in other high-income countries, such as Australia or the United Kingdom. To reduce the rate of stillbirth, leading societies recommend antenatal fetal monitoring or induction of labor (IOL) at 41 weeks of gestation regardless of race/ethnicity. However, at 41 weeks' gestation, the risk of stillbirth for South Asian–born women is already up to 5 times higher than for Australian-born women. Initially, the UK National Institution for Health and Care Excellence recommended that all South Asian women undergo IOL earlier, at 39 weeks of gestation. However, this recommendation was criticized as being racist, and perpetuating the myth that race plays a factor in poor outcomes, so it was amended to state that South Asian–born women might benefit from additional monitoring and support. Still, there is no evidence to support this guidance. In July 2017, the State of Victoria in Australia implemented a new clinical guideline to provide South Asian women with biweekly cardiotocography and amniotic fluid measurement at 39 weeks of gestation. The aim of this study was to assess the impact of the new clinical guideline on the rates of stillbirth and select pregnancy outcomes for South Asian women. This was a cohort study that included women with singleton pregnancies who gave birth at term or beyond at a university- affiliated teaching health service located in 3 metropolitan areas in Australia from January 1, 2016, to December 31, 2020. Women were classified as South Asian born if they self-identified as being from Afghanistan, Bangladesh, Bhutan, India, Iran, the Maldives, Nepal, Pakistan, or Sri Lanka. The timeframe between January 1, 2016, and June 30, 2017, represented the period before the change in practice for fetal monitoring for South Asian women; the timeframe between July 1, 2017, and December 31, 2020, represented the period after. Although the new practice was applied to South Asian–born women in the second timeframe, fetal monitoring at 41 weeks was applied to all other women. The primary outcome was stillbirth at the onset of or during labor at 37 weeks and 39 weeks of gestation. The secondary outcomes included neonatal death at &lt;7 days, admission to the special care nursery or neonatal intensive care, Apgar score &lt;7 at 5 minutes, infant birthweight, gestation of birth, IOL, and mode of birth. A total of 3506 South Asian women gave birth before the change in practice, whereas 8532 gave birth postimplementation. The rate of stillbirth at 37 weeks' gestation for South Asian–born women was 2.3 per 1000 births—a 2.6-fold higher rate than for other women (0.9 per 1000 births; P = 0.06). After the change in practice, the rate of stillbirth fell by 64% for South Asian–born women (95% confidence interval, 87%–2%; P = 0.047). The association was stronger when the results were restricted to births after 39 weeks of gestation. Also, after the change in practice, reduced rates for early neonatal death (3.1 per 1000 vs 1.3 per 1000; P = 0.03) and admission to the special care nursery (16.5% vs 11.1%; P &lt; 0.001) were observed. The median gestation of birth for South Asian–born women was 39+3 weeks preimplementation compared with 39+2 weeks postimplementation, a difference of 1 day. The rate of IOL for South Asian–born women was 4.9% higher than other women (95% confidence interval, 1.3%–8.5%; P = 0.008). However, no significant difference was observed between the 2 groups in the rate of IOL per month after the change in practice, nor across the other secondary outcomes. In conclusion, fetal monitoring starting at 39 weeks' gestation among South Asian–born women reduced the rate of stillbirth, neonatal death, and admission to the special care nursery compared with previous guidelines to begin monitoring at 41 weeks.

Scoping review of systematic reviews of nursing interventions in a neonatal intensive care unit or special care nursery.

To identify, synthesise and map systematic reviews of the effectiveness of nursing interventions undertaken in a neonatal intensive care unit or special care nursery. This scoping review was conducted according to the JBI scoping review framework. Review included systematic reviews that evaluated any nurse-initiated interventions that were undertaken in an NICU or SCN setting. Studies that reported one or more positive outcomes related to the nursing interventions were only considered for this review. Each outcome for nursing interventions was rated a 'certainty (quality) of evidence' according to the Grading of Recommendations, Assessment, Development and Evaluations criteria. Systematic reviews were sourced from the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis for reviews published until February 2023. A total of 428 articles were identified; following screening, 81 reviews underwent full-text screening, and 34 articles met the inclusion criteria and were included in this review. Multiple nursing interventions reporting positive outcomes were identified and were grouped into seven categories. Respiratory 7/34 (20%) and Nutrition 8/34 (23%) outcomes were the most reported categories. Developmental care was the next most reported category 5/34 (15%) followed by Thermoregulation, 5/34 (15%) Jaundice 4/34 (12%), Pain 4/34 (12%) and Infection 1/34 (3%). This review has identified nursing interventions that have a direct positive impact on neonatal outcomes. However, further applied research is needed to transfer this empirical knowledge into clinical practice. Implementing up-to-date evidence on effective nursing interventions has the potential to significantly improving neonatal outcomes. No patient or public involvement in this scoping review.

An audit of the maternal medicine clinic: Cancer and pregnancy.

To explore the incidence and complexity of women presenting for maternity care who require concurrent cancer care, and to report the birth outcomes of these women. A retrospective audit of women attending a 'high risk' maternal medicine clinic at an Australian tertiary maternity hospital between 1 October 2021 and 30 April 2023 was conducted. The inclusion criteria were a diagnosis of cancer and a concurrent pregnancy, or a diagnosis of cancer prior to the current pregnancy. Clinic lists and coding data were screened via the electronic medical record to identify potential subjects. Data were collected from the individual maternity and neonatal records. Forty of 705 (5.7%) women attending the maternal medicine clinic met the inclusion criteria, of which ten had a new diagnosis of cancer in pregnancy and 30 presented for maternity care after a previous diagnosis of cancer. Cancer therapy during pregnancy included surgery and chemotherapy. Most pregnancies (92.5%) resulted in term deliveries (≥37 weeks gestation). Four neonates were preterm, and one was small-for-gestational-age. Caesarean section delivery and post-partum haemorrhage were more common than expected, but the rate of other adverse pregnancy outcomes was consistent with the background population. Over half of neonates required neonatal intensive care unit / special care nursery admission but the indications for admission were common, self-limiting conditions, and the length of stay was short (mean <5.0 days). Approximately 6% of women attending the maternal medicine clinic had a current or previous diagnosis of cancer. Most pregnancies resulted in term deliveries and neonatal outcomes were excellent.

Common mental disorders and perinatal outcomes in Victoria, Australia: A population-based retrospective cohort study

PurposeCommon mental disorders (non-psychotic mental health conditions which impact on day-to-day functioning) are increasingly common in childbearing women and may impact significantly on both maternal and neonatal outcomes. Our study examines the associations between common mental disorders and perinatal outcomes. MethodsWe used routinely collected perinatal data (2009–2016) for this population-based retrospective cohort study (n = 597,522 singleton births). We undertook multiple logistic regression adjusting for key maternal medical conditions and sociodemographic factors to determine associations between maternal common mental disorders and adverse perinatal outcomes with confidence intervals set at 95%. ResultsWomen with common mental disorders were more likely to have an induction of labour and caesarean birth, have a postpartum haemorrhage (PPH), and be admitted to the Intensive Care Unit (ICU) than women without common mental disorders. Neonates of women with common mental disorders were more likely to have an Apgar score at five minutes of less than seven (a measure of neonatal wellbeing at birth), be born preterm and low birthweight, be admitted to the Special Care Nursery or Neonatal Intensive Care Unit (SCN/NICU) and have a congenital anomaly than neonates of women without common mental disorders. ConclusionCommon mental disorders during the perinatal period were associated with poorer perinatal outcomes for mothers and their neonates. Strategies that enable early recognition and response to maternal common mental disorders should be developed to mitigate the consequential impact on maternal and infant wellbeing.

The outcomes for women planning a VBAC at a private hospital in Australia.

Rates of cesarean birth (CBs) are steadily increasing and account for 36.7% of all births in New South Wales (NSW), with primary cesareans driving the increase. NSW Health guidelines recommend women attempt a vaginal birth after a previous CB (VBAC); however, rates of VBAC are decreasing, particularly within the private hospital setting. This study aimed to determine the rates of adverse outcomes for women who planned a VBAC (pVBAC) compared with women who planned an elective repeat CB (pERCB) at one private hospital in Sydney, Australia. This retrospective data review evaluated patient records over a 10-year period (2010-2019). Records (n = 2039) were divided into four groups: pVBAC, pVBAC + EMCB, labor + ERCB (lab + ERCB), and pERCB. The incidence of adverse maternal and neonatal outcomes is reported as counts and percentages. Regression and chi-squared tests were used to compare groups. Significance was determined at a p-value of <0.05. Overall, very low rates (N = 148, 7.3%) of women had a VBAC compared with a repeat CB at this private hospital over the 10-year period. The incidence of adverse outcomes was low regardless of study group. Outcomes differed significantly between groups for postpartum hemorrhage (pERCB seven times less likely than VBAC group) and special care nursery admission (pVBAC + EMCB is 4.6 times more likely than in the VBAC group). Overall, it is safe to attempt a VBAC at this private hospital, and labor after a cesarean should be recommended, yet very few women had a VBAC at the study site. The incidence of adverse outcomes was low compared with other published research.

Outcomes for pregnant women with Borderline Personality Disorder who attended a specialist antenatal service.

Our study focussed on the obstetric and psychosocial outcomes of pregnant women with Borderline Personality Disorder (BPD) who received care via a specialist antenatal clinic in Western Australia. This study is a retrospective examination of outcomes for 80 women with a confirmed diagnosis of BPD, with findings compared with published population outcome data for the state. Pregnant women with BPD appeared to be at a risk of complications including pre-eclampsia and special care nursery admission for their newborns when compared to population data. Furthermore, the studied women had elevated rates of psychiatric admissions during pregnancy, child protection involvement, and domestic violence. Polypharmacy exposure was frequent, with the likely impact on obstetric and neonatal outcomes requiring further study. The findings reinforced the notion that pregnant women with BPD experience complex multifaceted vulnerabilities and require enhanced multidisciplinary care. Our study further calls for the development of clinical practice guidelines for managing BPD in the perinatal period.

Reduction in spontaneous and iatrogenic preterm births in twin pregnancies during COVID-19 lockdown in Melbourne, Australia: a multicenter cohort study

BackgroundMelbourne, Australia, recorded one of the longest and most stringent pandemic lockdowns in 2020, which was associated with an increase in preterm stillbirths among singleton pregnancies. Twin pregnancies may be particularly susceptible to the impacts of pandemic disruptions to maternity care due to their higher background risk of adverse perinatal outcomes.MethodsMulticenter retrospective cohort study of all twin pregnancies birthing in public maternity hospitals in Melbourne. Multivariable log-binomial regression models were used to compare perinatal outcomes between a pre-pandemic group to women in whom weeks 20+0 to 40+0 of gestation occurred entirely during one of two lockdown-exposure periods: exposure 1 from 22 March 2020 to 21 March 2021 and exposure 2 from 22 March 2021 to 27 March 2022.ResultsTotal preterm births < 37 weeks were significantly lower in exposure 1 compared with the pre-pandemic period (63.1% vs 68.3%; adjusted risk ratio 0.92 95% CI 0.87–0.98, p = 0.01). This was mainly driven by fewer spontaneous preterm births (18.9% vs 20.3%; adjusted risk ratio 0.95 95% CI 0.90–0.99, p = 0.04). There were also lower rates of preterm birth < 34 weeks (19.9% vs 23.0%, adjusted risk ratio 0.93 95% CI 0.89–0.98 p = 0.01) and total iatrogenic births for fetal compromise (13.4% vs 20.4%; adjusted risk ratio 0.94 95% CI 0.89–0.98, p = 0.01). There were fewer special care nursery admissions (38.5% vs 43.4%; adjusted risk ratio 0.91 95% CI 0.87–0.95, p < 0.001) but no significant changes in stillbirth (1.5% vs 1.6%; adjusted risk ratio 1.00 95% CI 0.99–1.01, p = 0.82). Compared with the pre-pandemic period, there were more preterm births < 28 weeks and neonatal intensive care unit admissions in exposure 2.ConclusionsMelbourne’s first lockdown-exposure period was associated with lower preterm births in twins without significant differences in adverse newborn outcomes. Our findings provide insights into the influences on preterm birth and the optimal timing of delivery for twins.

Skin-to-skin contact for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BackgroundSkin-to-skin contact between mother and infant after birth is recommended to promote breastfeeding and maternal-infant bonding. However, its impact on the incidence of neonatal hypoglycaemia is unknown. We conducted a systematic review and meta-analysis to assess this.MethodsPublished randomised control trials (RCTs), quasi-RCTs, non-randomised studies of interventions, cohort, or case–control studies with an intervention of skin-to-skin care compared to other treatment were included without language or date restrictions. The primary outcome was neonatal hypoglycaemia (study-defined). We searched 4 databases and 4 trial registries from inception to May 12th, 2023. Quality of studies was assessed using Cochrane Risk of Bias 1 or Effective Public Health Practice Project Quality Assessment tools. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results were synthesised using RevMan 5.4.1 or STATA and analysed using random-effects meta-analyses where possible, otherwise with direction of findings tables. This review was registered prospectively on PROSPERO (CRD42022328322).ResultsThis review included 84,900 participants in 108 studies, comprising 65 RCTs, 16 quasi-RCTs, seven non-randomised studies of intervention, eight prospective cohort studies, nine retrospective cohort studies and three case–control studies. Evidence suggests skin-to-skin contact may result in a large reduction in the incidence of neonatal hypoglycaemia (7 RCTs/quasi-RCTs, 922 infants, RR 0.29 (0.13, 0.66), p < 0.0001, I2 = 47%). Skin-to-skin contact may reduce the incidence of admission to special care or neonatal intensive care nurseries for hypoglycaemia (1 observational study, 816 infants, OR 0.50 (0.25–1.00), p = 0.050), but the evidence is very uncertain. Skin-to-skin contact may reduce duration of initial hospital stay after birth (31 RCTs, 3437 infants, MD -2.37 (-3.66, -1.08) days, p = 0.0003, I2 = 90%, p for Egger’s test = 0.02), and increase exclusive breastmilk feeding from birth to discharge (1 observational study, 1250 infants, RR 4.30 (3.19, 5.81), p < 0.0001), but the evidence is very uncertain.ConclusionSkin-to-skin contact may lead to a large reduction in the incidence of neonatal hypoglycaemia. This, along with other established benefits, supports the practice of skin-to-skin contact for all infants and especially those at risk of hypoglycaemia.

Decreased fetal movements – An audit of predictors and an evaluation of management based on a locally developed flow chart

ObjectivesDecreased fetal movements (DFM) is associated with adverse pregnancy outcomes. We aimed to look at the risk factors associated with DFM and outcomes of women who presented with and without DFM and outcomes before and after the implementation of a locally developed flow chart based on an evidence-based guideline. Study designThis was a retrospective audit of 1165 women ≥ 28 weeks’ gestation with a singleton pregnancy who presented with concerns regarding DFM. We compared labor and neonatal outcomes to 4706 in a control group who did not present with concerns regarding FM. We also compared the same pregnancy outcomes before and after the implementation of hospital guidelines on the management of DFM. Statistical analyses were performed primarily using Chi square analysis and relative risk. Results and conclusions1165 women presented 1645 times with DFM. Women presenting with DFM were younger, (82.8% vs 79.0%, p= <0.01 were 20 to 34-years old), tended to have a higher BMI (42.9% vs 34.4%, p=<0.001 with BMI ≥ 30) and were more likely to have mental health conditions (31.1% vs 24.2%, p=<0.01). There was no difference in the composite neonatal outcome including stillbirth, 5 min APGAR < 7 and Special Care Nursery (SCN) admission between DFM and control (22.9 vs 24.8% respectively, P = 0.18). There was no difference in perinatal outcomes pre- and post-implementation of the hospital guidelines on DFM management. Women presenting with DFM were more likely to have an induction (40.7% vs 29.9% p=<0.01) but not more likely to have a caesarean section (30.9% vs 28.8% respectively, p = 0.16). There were increasing rates of IOL with increasing number of presentations for DFM. Adoption of and adherence to locally developed guidelines was an opportunity to ensure all clinicians provide consistent advice on management and timing of birth for women presenting with DFM.

Neonatal early-onset sepsis calculator: Impact on antibiotic use in a level II neonatal unit in Western Australia

BackgroundOveruse of empirical intravenous antibiotics in neonates in high-income countries (HICs) is well documented. The Kaiser Permanente neonatal early-onset sepsis (EOS) calculator is an evidence-based sepsis risk assessment tool that has demonstrated potential to reduce antibiotic usage in this population. The incidence of early-onset sepsis in most HICs is 0.4–0.8 per 1000 live births. The objective was to evaluate the calculator's impact on antibiotic rates and length of stay in a regional level II Special Care Nursery. MethodsA single-centre retrospective cohort study compared antibiotic administration rates in the first 72 h in neonates ≥35 weeks gestation born during two 6-month periods in 2019 (pre-EOS calculator) and 2021 (post-EOS calculator). Electronic and paper case records were accessed to capture data. Continuous data were summarised using mean and standard deviation, and categorical data were summarized using frequency distributions. There were 951 (2019) and 1129 (2021) infants born during the study periods. ResultsFollowing implementation of the calculator, antibiotic exposure decreased from 13.7% to 4.7% of all neonates without reported negative outcomes. Mean length of stay for neonates born across the two periods decreased from 2.38 to 2.13 days. Indications for antibiotic use shifted more towards clinical condition and away from obstetric risk factors. There were no culture-proven cases of sepsis or readmissions with EOS in either period. ConclusionImplementation of the EOS calculator significantly reduced exposure to antibiotics, without adverse outcomes.

Characteristics and outcomes of respiratory distress among term infants born in a regional setting.

Respiratory distress is the leading cause of admission to neonatal units and is a common indication for medical retrieval. Whilst approximately 25% of births in NSW occur in regional centres, there is a paucity of neonatal research in these settings. To describe the characteristics and outcomes of term neonates admitted with respiratory distress to two regional special care nurseries (SCNs) and identify variables associated with the need for medical retrieval. We describe a cohort of 629 term infants admitted to the SCN in two regional hospitals, 2015-2019. We describe the admission characteristics, level of respiratory support, biochemical investigations, diagnosis and outcomes. During the study period, 629 eligible term infants were admitted, retrieval occurred in 29 (4.6%). Those admitted were more often male (66.5%), with a mean gestational age of 39 + 1 weeks (±9 days) and birth weight of 3470 g (±500 g). Infants requiring medical retrieval had higher PaCO2 on blood gas analysis (59.8 mmHg vs. 53.3 mmHg, OR 1.03, p = 0.02). There was no association between maternal GBS status, meconium-stained liquor, gestational age, or raised inflammatory markers and medical retrieval. Transient tachypnoea of the newborn was the most common diagnosis of neonates admitted to SCN with respiratory distress. Among term infants admitted to a SCN for respiratory distress most were male, of a normal birthweight and born in good condition. Within our cohort there was no association between retrieval and maternal GBS colonisation, meconium-stained liquor or raised infectious biomarkers. Medical retrieval was infrequent and was associated with higher PaCO2 on initial blood gas analysis. We present a large cohort of term newborn infants managed for respiratory distress in a regional setting over a five-year period. Retrieval was infrequent, and outcomes for the cohort were excellent with no deaths during the study period.

Early life predictors of obstructive sleep apnoea in young adults: Insights from a longitudinal community cohort (Raine study)

ObjectiveEarly-life obstructive sleep apnoea (OSA) predictors are unavailable for young adults. This study identifies early-life factors predisposing young adults to OSA. MethodsThis retrospective study included 923 young adults and their mothers from the Western Australian Pregnancy Raine Study Cohort. OSA at 22 years was determined from in-laboratory polysomnography. Logistic regression was used to identify maternal and neonatal factors associated with OSA in young adulthood. ResultsOSA was observed in 20.8% (192) participants. Maternal predictors of OSA included gestational diabetes mellitus (odds ratio (OR) 9.54, 95% confidence interval (CI) 1.7, 58.5, P = 0.011), preterm delivery (OR 3.18, 95%CI 1.1,10.5, P = 0.043), preeclampsia (OR 2.95, 95%CI 1.1,8.0, P = 0.034), premature rupture of membranes (OR 2.46, 95%CI 1.2, 5.2, P = 0.015), age ≥35 years (OR 2.28, 95%CI 1.2,4.4, P = 0.011), overweight and obesity (pregnancy BMI≥25 kg/m2) (OR 2.00, 95%CI 1.2,3.2, P = 0.004), pregnancy-induced hypertension (OR 1.89, 95%CI 1.1,3.2, P = 0.019), and Chinese ethnicity (OR 2.36,95%CI 1.01,5.5, P = 0.047). Neonatal predictors included male child (OR 2.10, 95%CI 1.5,3.0, P < 0.0001), presence of meconium-stained liquor during delivery (OR 1.60, 95%CI 1.0,2.5, P = 0.044) and admission to special care nursery (OR 1.51 95%CI 1.0,2.2, P = 0.040). Higher birth lengths reduced OSA odds by 7% for each centimetre (OR 0.93, 95%CI 0.87, 0.99, P = 0.033). ConclusionsA range of maternal and neonatal factors predict OSA in young adults, including those related to poor maternal metabolic health, high-risk pregnancy and stressful perinatal events. This information could assist in the early identification and management of at-risk individuals and indicates that better maternal health may reduce the likelihood of young adults developing OSA.

Study protocol: Generation Victoria (GenV) special care nursery registry.

Newborn babies who require admission for specialist care can experience immediate and sometimes lasting impacts. For babies admitted to special care nurseries (SCN), there is no dataset comparable to that of the Australian and New Zealand Neonatal Network (ANZNN), which has helped improve the quality and consistency of neonatal intensive care through standardised data collection. We aim to establish a proof-of-concept, Victoria-wide registry of babies admitted to SCN, embedded within the whole-of-Victoria Generation Victoria (GenV) cohort. This prototype registry is a depth sub-cohort nested within GenV, targeting all babies born in Victoria from Oct-2021 to Oct-2023. Infants admitted to SCN are eligible. The minimum dataset will be harmonised with ANZNN for common constructs but also include SCN-only items, and will cover maternal, antenatal, newborn, respiratory/respiratory support, cardiac, infection, nutrition, feeding, cerebral and other items. As well as the dataset, this protocol outlines the anticipated cohort, timeline for this registry, and how this will serve as a resource for longitudinal research through its integration with the GenV longitudinal cohort and linked datasets. The registry will provide the opportunity to better understand the health and future outcomes of the large and growing cohort of children that require specialist care after birth. The data would generate translatable evidence and could lay the groundwork for a stand-alone ongoing clinical quality registry post-GenV.