Beyond basic resuscitation: What are the next steps to improve the outcomes of resuscitation at birth when resources are limited?

Implementation of basic neonatal resuscitation in low- and middle-income settings consistently saves lives on the day of birth. What can be done to extend these gains and further improve the outcomes of infants who require resuscitation at birth when resources are limited? This review considers how resuscitation and post-resuscitation care can advance to help meet the survival goals of the Every Newborn Action Plan for 2030. A brief summary of the evidence for benefit from basic neonatal resuscitation training in low- and middle-income countries highlights key aspects of training, low-dose high-frequency practice, and implementation with single providers or teams. Reorganization of processes of care, as well as new equipment for training and selected clinical interventions can support further quality improvement in resuscitation. Consideration of the resuscitation algorithm itself focuses on important actions for all babies and special considerations for small babies and those not crying after thorough drying. Finally, an examination of the vital elements of assessment and continued stabilization/care in the health facility draws attention to the opportunities for prevention of intrapartum-related events and the gaps that still exist in postnatal care. Extending and improving implementation of basic resuscitation to make it available to all newborns will assure continued benefit to the largest numbers; once high coverage and quality of basic resuscitation are achieved, health systems with maturing capacity can extend survival gains with improved prevention, more advanced resuscitative interventions, and strengthened postnatal care.     

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.     

Neonatal resuscitation capacity in Nepal

Aim: Perinatal asphyxia is a major contributor to the nearly 4 million neonatal deaths worldwide each year in resource‐limited settings. Neonatal resuscitation, a proven method for preventing newborn deaths, is effective only when local caregivers have proper training and access to essential supplies. There are few published data describing neonatal resuscitation capacity in Nepal, where neonatal mortality rates are high. The goal of this study was to quantify neonatal resuscitation capacity at birthing sites in urban and rural Nepal. Methods: Seventeen birth centres ranging from tertiary care hospitals to rural health posts were evaluated. Assessments included standardised interviews of health‐care workers and evaluation of newborn resuscitation areas. The availability of essential resuscitation tools was recorded. Results: Eleven of the 17 health centres conducted deliveries on‐site. Of those, 45% had posted and visible resuscitation algorithms; 72% had infant warmers; 91% had mechanical suction machines; 36% had bulb suctions and 82% had bag‐mask ventilation devices available. Tertiary hospitals were much better equipped compared with smaller health centres. None of the health‐care workers who attended home deliveries had access to algorithms, warming devices, suction or bag‐mask ventilation devices. Conclusions: Availability of appropriate resuscitation supplies was variable in health centres providing delivery services on‐site and was severely deficient among health staff attending to home deliveries. Limited availability of resuscitation equipment may contribute to the high neonatal mortality rates seen in Nepal. Sustainable training programmes and distribution of neonatal resuscitation equipment are critical priorities in this region.     

Helping Babies Breathe: Improving Neonatal Resuscitation and Global Neonatal Mortality

Significant progress has been made in reducing global child mortality rates over the past 2 decades, with the improvements in survival primarily occurring among children between 1 month and 5 years of age. As a result, neonatal mortality now accounts for almost half of all deaths in children less than 5 years of age. Helping Babies Breathe is a neonatal resuscitation program developed by the American Academy of Pediatrics for use in low-resource settings and aims to teach basic resuscitation skills to providers who are present at deliveries. Using a train-the-trainer curricular model and low-cost simulator and equipment, Helping Babies Breathe has been implemented in more than 80 countries to train 500 000 providers and has resulted in a marked decline in early neonatal deaths and fresh stillbirths. Ongoing research is being done to optimize strategies to maintain resuscitation skills and knowledge over time, as well as to develop additional methods to improve neonatal resuscitation in low-resource settings, with hopes of achieving the United Nations Sustainable Development Goals for neonatal mortality rates by 2030 worldwide.     

Anticipation and preparation for every delivery room resuscitation

A majority of babies initiate spontaneous respirations shortly after birth. Up to 10%, however, require resuscitative measures to make the transition from fetus to newborn. Ideally, the need for resuscitation at birth would be predicted before delivery, and a skilled neonatal resuscitation team would be available and ready. This is not always possible. Therefore, neonatal resuscitation teams must be prepared to provide lifesaving resuscitation at every delivery. In this report, we examine risk factors for resuscitation at birth, discuss the importance of communication between obstetric and newborn teams, review key questions to ask before delivery, and investigate antenatal counseling methods. We also investigate ways to prepare for newborn deliveries, including personnel and equipment preparation, and pre-delivery team briefing. Finally, we explore ways in which neonatal resuscitation teams can improve their preparedness through the use of simulation and post-resuscitation debriefing. This report will help neonatal resuscitation teams to anticipate and prepare for every delivery room resuscitation.     

Retention of skills in neonatal resuscitation

OBJECTIVES:

To evaluate the impact of a neonatal resuscitation course on the theoretical knowledge and practical skills of birthing room personnel, and to evaluate the performance of skills at different times after the course.

DESIGN:

A program evaluation using a before and after cohort study.

SETTING:

Seven level II perinatal centres in the central-east region of Ontario.

PARTICIPANTS:

Seven hundred thirty-seven individuals (medical staff, nurses and respiratory technologists) who worked in birthing rooms.

INTERVENTION:

During an eight-month period, a course in neonatal resuscitation was presented at the perinatal centres. A cohort of 108 (15%) participants received testing before and after the course; the theoretical knowledge and practical performance of 62 of these participants were retested after six and 12 months.

RESULTS:

A significant improvement in both theoretical knowledge and practical skills was seen immediately after the course. Throughout the study, no difference was observed in the performance of nursing staff compared with that of medical staff, nor among the institutions involved. No significant difference in the decline of either theoretical knowledge or practical skills was seen among those who scored well in the original pre-test compared with those who scored poorly.

CONCLUSIONS:

Neonatal resuscitation should be an integral part of continuing education for all personnel involved in obstetrical care because it improves both tested knowledge and performance. Practical skills appear to decline faster than theoretical knowledge. Inservice instruction is required, at least, every six months.     

Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries

Affordable, efficacious, and safe interventions to prevent infections and improve neonatal survival in low-resource settings are needed. Chlorhexidine is a broad-spectrum antiseptic that has been used extensively for many decades in hospital and other clinical settings. It has also been given as maternal vaginal lavage, full-body newborn skin cleansing, and/or umbilical cord cleansing to prevent infection in neonates. Recent evidence suggests that these chlorhexidine interventions may have significant public health impact on the burden of neonatal infection and mortality in developing countries. This review examines the available data from randomized and nonrandomized studies of chlorhexidine cleansing, with a primary focus on potential uses in low-resource settings. Safety issues related to chlorhexidine use in newborns are reviewed, and future research priorities for chlorhexidine interventions for neonatal health in developing countries are discussed. We conclude that maternal vaginal cleansing combined with newborn skin cleansing could reduce neonatal infections and mortality in hospitals of sub-Saharan Africa, but the individual impact of these interventions must be determined, particularly in community settings. There is evidence for a protective benefit of newborn skin and umbilical cord cleansing with chlorhexidine in the community in south Asia. Effectiveness trials in that region are required to address the feasibility of community-based delivery methods such as incorporating these interventions into clean birth kits or training programs for minimally skilled delivery assistants or family members. Efficacy trials for all chlorhexidine interventions are needed in low-resource settings in Africa, and the benefit of maternal vaginal cleansing beyond that provided by newborn skin cleansing needs to be determined.     

Training neonatal skills with simulators?

Aim: To compare two different ways of learning (self-study vs. simulation sessions) the adequate steps to resuscitate a neonate in the 5th year undergraduate medical curriculum.
Methods: One hundred and eighty students attending the 5-week paediatrics rotation were enrolled; 115 were invited to participate in this study, but only 45 students completed it. After a 50-min 'neonatal resuscitation' theoretical interactive class, students were randomly assigned into two groups: the first (n = 21) participated in a 30-min supervised self-study session, while the second (n = 24) attended a 30-min neonatal resuscitation session using the Zoe (Gaumard^® Inc., Miami, FL, USA) simulator.
Results: Tests consisting of 50 multiple-choice questions were taken before the theoretical class (pre-theoretical test), before the self-study or simulation session (pre-test) and after this session (post-test). Pre-test and post-test scores were similar in both groups (p = 0.118 and p = 0.263, respectively).
Conclusion : Simulation-based training of medical students in management of neonatal resuscitation do not led to significant differences on short-term knowledge comparing with traditional method.     

浙江省49家医院新生儿窒息复苏及培训现状调查

目的对浙江省三级和二级医院新生儿窒息复苏及人员培训情况进行基线调查。方法采用分层随机抽样法在浙江省11个地级市中每个地级市以抽签法抽取5所医院参与调查,其中地级市医院2所,县级医院3所。自制调查问卷,内容包括新生儿复苏开展情况,人员培训,产房、手术室复苏设备情况,新生儿出生窒息发生和死亡情况。 结果10/11个地级市49家医院纳入分析,其中三级医院23家（46.9％）,二级医院26家。①49家医院均有开展新生儿窒息复苏抢救的能力,三级医院均定期举办新生儿复苏培训。三级医院NICU病房配备率高于二级医院(87.0％ vs 34.6%,P=0.001 8)。②必备设备的配备：三级和二级医院产房和手术室在新生儿复苏气囊、辐射保温台、喉镜、气管导管和新生儿面罩的配备率均超过90%。高级设备的配备：三级医院产房和手术室血氧饱和仪配备率较高（72.7%）,脐静脉导管、喉管、T组合复苏器和空氧混合器的配备率均低于50%。③无论是三级还是二级医院,儿科医生院内和院外培训率均最高,麻醉师培训率最低。除儿科医生外的其他各类接产人员院内和院外培训率在三级和二级医院间差异均有统计学意义（P均<0.05）。④2004至2010年的年活产数在三级和二级医院中均呈逐年增加趋势。三级和二级医院新生儿年死亡率和出生窒息病死率均呈下降趋势,但总体上三级医院高于二级医院。二级医院重度窒息占出生窒息的比例总体上高于三级医院。 结论需加强各类接产人员复苏培训,提高复苏人员的复苏技能及理论水平,购置必备的复苏设备,进一步改善各级医院现有的复苏条件。     

Resuscitation of newborn infants with room air or oxygen

Oxygen is a toxic agent and a critical approach regarding its use during resuscitation at birth is developing. Animal data indicate that room air is efficient for newborn resuscitation. Three clinical studies have established that normal ventilation is delayed after oxygen resuscitation. Oxidative stress is augmented for several weeks in infants exposed to oxygen at birth – the long-term implications of these observations remain unclear. There are limited data regarding the use of room air during complicated resuscitations, i.e. in meconium aspiration, the severely asphyxiated infant and in the preterm infant. Thus, it is necessary to continue ongoing rigorous examination of the long-accepted practice of oxygen administration during neonatal resuscitation.     

Drugs in the delivery room

The need for cardiopulmonary resuscitation in newborns is quite rare, as most non-vigorous infants respond well to effective ventilation. For the minority of babies who do not respond to adequate ventilation, chest compressions are necessary using the preferred two thumb technique. Since effective ventilation remains a key component to successful resuscitation, chest compressions are coordinated with ventilations in a 3:1 ratio. If despite adequate ventilation and compressions, the heart rate remains below 60 beats per minute, epinephrine is indicated. The intravenous route is preferred over the endotracheal route and the recommended dose of epinephrine is 0.01–0.03 mg/kg. This can be repeated every 3–5 min until return of spontaneous circulation is achieved. In rare instances, when there is no response to these above measures and in infants who show evidence of significant hypovolemia, volume replacement should be considered.     

新生儿困难复苏相关危险因素分析

目的分析新生儿困难复苏的相关危险因素。方法以2011年1月至2015年10月分娩的活产满28周窒息儿(1分钟Apgar评分0~7分)为研究对象,经复苏后,以5分钟Apgar评分8~10分新生儿为5分钟复苏顺利组,0~7分新生儿为5分钟复苏困难组,进行相关危险因素的分析;5分钟复苏困难新生儿继续复苏后,20分钟Apgar评分8~10分的新生儿列为20分钟复苏顺利组,0~7分新生儿为20分钟复苏困难组,再进行危险因素分析。结果纳入1分钟窒息新生儿743例,其中5分钟复苏困难新生儿130例,另外613例复苏顺利,早产、低出生体质量、1分钟Apgar评分0~3分、产时感染性发热、胎盘异常、妊娠后期阴道出血、双胎输血综合征、胎儿畸形与5分钟复苏困难有明显的相关性(P均0.05)。5分钟复苏困难新生儿继续复苏后,20分钟复苏困难新生儿32例,与复苏顺利组新生儿98例比较,两组在1分钟Apgar评分0~3分、5分钟Apgar评分0~3分方面比较差异均有统计学意义(P均0.05)。1分钟窒息新生儿中的2例前置血管和8例胎儿水肿新生儿,在5分钟和20分钟仍复苏困难。结论窒息新生儿复苏影响因素较多,其中前置血管、胎儿水肿所致窒息复苏困难。     

Evaluation of the role of the neonatal nurse practitioner in resuscitation of preterm infants at birth

BACKGROUND: Changes in the work patterns and numbers of medical staff in training grades pose a significant challenge to those responsible for the provision of an effective clinical neonatal service. Advanced neonatal nurse practitioners (ANNPs) may have a role in this changing neonatal service. The effectiveness of the ANNP has been established in North America but has not been properly evaluated in the United Kingdom. AIM: To evaluate the effectiveness of ANNPs in resuscitation of preterm babies at birth against the standard set by junior medical staff. SETTING: Regional neonatal intensive care unit. METHOD: Retrospective analysis of resuscitation details, other basic data, and clinical outcomes of 245 preterm (< 33 weeks gestation) babies born in Liverpool Women's Hospital between January 1998 and April 1999. RESULTS: Resuscitation teams led by ANNPs provided the same resuscitation interventions as those provided by medically led teams. Although babies resuscitated by ANNP led teams were no more likely to be intubated, they were intubated more quickly and received surfactant sooner (p = 0.0001) than babies resuscitated by medically led teams. Babies attended by ANNP led teams were less likely to be hypothermic on admission to the neonatal unit (p = 0.013). CONCLUSION: ANNPs are effective in the resuscitation of preterm babies at birth.     

Effects of tidal volume and positive end-expiratory pressure during resuscitation of very premature lambs

Background: Guidelines recommend neonatal resuscitation without controlling tidal volume or positive end-expiratory pressure (PEEP). However, these may improve gas exchange, lung volume and outcome. Aim: To investigate resuscitation of very premature lambs with a Laerdal bag without PEEP versus volume guarantee ventilation with PEEP. Methods: Anaesthetized lambs (n=20) delivered at 125 d gestation were randomized to three groups receiving 15 min resuscitation: (1) Laerdal bag and no PEEP; (2) ventilation with a tidal volume of 5 ml/kg and 8 cm H₂O PEEP; (3) ventilation with 10 ml/kg and 8 cm H₂O PEEP. They were then all ventilated for 2 h with tidal volumes of 5 or 10 ml/kg, and 8 cm H₂O PEEP. Ventilation parameters and blood gases were recorded. Results: Different tidal volumes affected PaCO₂ within minutes, with 10 ml/kg causing severe hypocarbia. PEEP had little effect on PaCO₂. Oxygenation improved significantly with PEEP of 8 cm H₂O, irrespective of tidal volume.

Conclusion: Very premature lambs can be resuscitated effectively using volume-guarantee ventilation and PEEP. Tidal volumes affected PaCO₂ within minutes but had little effect on oxygenation. PEEP halved the oxygen requirement compared with no PEEP. Resuscitating premature babies with controlled tidal volumes and PEEP might improve their outcome.     

Positive pressure ventilation at neonatal resuscitation: review of equipment and international survey of practice

Background: The equipment used to provide positive pressure ventilation to newborns needing resuscitation at delivery varies between institutions. Devices were reviewed and their use surveyed in a sample of neonatal centres worldwide. Aim: To determine which equipment is used to resuscitate newborns at delivery in a sample of teaching hospitals around the world. Methods: A questionnaire was sent via e-mail to a neonatologist at each of 46 NICUs in 23 countries on five continents, asking which resuscitation equipment they used. If it was not returned, follow-up was by e-mail. Results: Data were obtained from 40 (87%) centres representing 19 countries. Round face masks are used at 34 (85%) centres, anatomically shaped masks are used exclusively at six (15%) and a mixture of types are used at 11 (28%). Straight endotracheal tubes are used exclusively at 36 (90%) centres; shouldered tubes are used infrequently at three of the four centres that have them. The self-inflating bag is the most commonly used manual ventilation device (used at 33 (83%) centres), the Laerdal Infant Resuscitator™ the most popular model. Flow-inflating bags are used at 10 (25%) centres. The Neopuff Infant Resuscitator™ is used at 12 (30%) centres. Varying oxygen concentrations are provided during neonatal resuscitation at half of the centres, while 100% oxygen is routinely used at the other half.

Conclusions: This survey shows considerable variation in practice, reflecting this lack of evidence and consequent uncertainty among clinicians. Comparison of the two most popular manual ventilation devices, the Laerdal Infant Resuscitator and the Neopuff Infant Resuscitator, is urgently required.     

影响早产儿行为神经测定因素的分析

目的 探讨新生儿行为神经测定(NBNA)在早产儿的应用及影响其评估指标的因素.方法 选择2006年1月至2007年6月在我院新生儿科住院治疗的123例早产儿,分别在纠正胎龄40周时进行NBNA评分,分析胎龄、出生体重、是否机械通气以及机械通气时间、围生期是否有致脑损伤的高危因素对NBNA评分的影响.结果 胎龄<30周、～32周、～34周早产儿及出生体重<1 250 g、～1 500 g、～2 000 g早产儿NBNA评分差异均具有显著性(P<0.01),胎龄越低、出生体重越低,NBNA评分越低;需机械通气的早产儿NBNA评分明显低于未上呼吸机者(P<0.01),机械通气时间＞7 d NBNA评分明显低于＜7 d者(P<0.05);围生期有出血性和缺血性脑损伤、间接胆红素≥256.5 μmol/L、血糖反复<2.6 μmol/L、发生感染者NBNA评分明显降低(P<0.01);臀位、钳产、吸引产早产儿NBNA评分明显低于剖宫产和顺产者(P<0.01);Apgar评分为0～3分者NBNA评分明显低于4～7分和≥8分者(P<0.01).结论 胎龄、出生体重、是否机械通气、机械通气时间、异常的分娩方式、合并重度窒息均影响早产儿的NBNA评分.对于早产儿,特别是胎龄<32周,出生体重<1 500 g,存在致脑损伤高危因素的早产儿,生后3～7 d内应行头颅B超检查,及早发现颅内病变,尽早干预,减少后遗症的发生.     

Laryngeal mask airway use during neonatal resuscitation: a survey of practice across newborn intensive care units and neonatal retrieval services in Australian New Zealand Neonatal Network

This is an Australia New Zealand Neonatal Network (ANZNN) wide survey to identify current practice and guide future practice improvement for the use of laryngeal mask airway (LMA) during neonatal resuscitation. An online questionnaire containing 13 questions was sent out to all tertiary neonatal centres (n = 29 units) and neonatal transport units (n = 4) within ANZNN. The non‐tertiary (level‐II) centres were not included. Response from a senior neonatologist at each centre was received and evaluated. Twenty‐two services (67%) had LMA available; of that only, 40% felt the competency of staff to be adequate; and 59% had routine training in LMA use. During neonatal resuscitation, 68% units reported using LMA if endotracheal intubation was unsuccessful after two or more failed intubation attempts and only 18% used it before intubation if face mask ventilation was inadequate. This survey highlighted variations in practice across the tertiary neonatal centres in ANZNN network. One‐third of the units lack LMA availability and the units with LMA, face concerns of underutilisation and lack of skills for its use.     

《2015年美国儿科学会新生儿复苏指南》解读

窒息是导致新生儿死亡及神经系统严重后遗症的主要原因之一,而快速评估、正确决策是新生儿复苏成功的关键。2015年10月美国儿科学会的新生儿复苏专业组发表了更新的《新生儿复苏指南》,对许多重要问题,包括快速评估的项目、延迟脐带结扎、羊水胎粪污染是否需要气管内吸引、早产儿复苏用氧及正压通气等进行了更新,并建议新生儿复苏培训工作应比现在2年的间隔更要频繁。     

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??Asphyxia is a major cause of neonatal death and serious sequelae of nervous system. Timely evaluation and proper strategies are crucial to successful neonatal resuscitation. In October 2015??the neonatal resuscitation group of the American Academy of Pediatrics published updated guidelines for neonatal resuscitation. The guideline updated information on fast evaluation items??delayed ligation of the umbilical cord??intratracheal suction for neonates with meconium-contaminated amniotic fluid??oxygen for resuscitation of preterm infants and positive pressures ventilation. Meanwhile the guideline suggested that resuscitation training should be more frequent than the current interval of two years.     

Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India

The impact of a neonatal resuscitation programme (NRP) on the incidence, management and outcome of birth asphyxia was evaluated in 14 teaching hospitals in India. Two faculty members from each institution attended a neonatal resuscitation certification course and afterwards trained staff in their respective hospitals. Each institution provided 3 months pre-intervention and 12 months post-intervention data. Introduction of the NRP significantly increased awareness and documentation of birth asphyxia, as judged by an increased incidence of asphyxia based on apnoea or gasping at 1 and 5 minutes (p < 0.001 and < 0.01, respectively). A significant shift towards more rational resuscitation practices was indicated by a decline in the use of chest compression and medication (p < 0.001 for each), and an increase in the use of bag and mask ventilation (p < 0.001). Although overall neonatal mortality did not decrease, asphyxia-related deaths declined significantly (p < 0.01).