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.     

Optimizing chest compressions during delivery-room resuscitation

There is a paucity of data to support the recommendations for cardiac compressions for the newly born. Techniques, compression to ventilation ratios, hand placement, and depth of compression guidelines are generally based on expert consensus, physiologic plausibility, and data from pediatric and adult models.     

Optimizing initial neonatal resuscitation to reduce neonatal encephalopathy around the world

One million two hundred thousand neonatal lives are lost each year due to intrapartum-related events; 99% of these deaths occur in low- and lower middle-income countries. Neonates exposed to intrapartum-related events present with failure to breathe at birth. Quick and effective delivery room management of these neonates is critical in the prevention of brain injury. Given the prominent role of lung aeration in the cardiopulmonary transition at birth, the mainstay of neonatal resuscitation is effective ventilation. Basic neonatal resuscitation focuses on simple stimulation, airway positioning and clearing, and bag-mask ventilation. Although principles for basic neonatal resuscitation remain the same for high- and low-resource settings, guidelines may differ based on available human and material resources. Formal training in basic resuscitation reduces intrapartum-related neonatal mortality in low-resource settings. However, there remain opportunities to improve provider performance for increased impact with other strategies such as regular practice and continuous quality improvement.     

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.     

Caregivers attitudes for very premature infants: what if they knew?

BACKGROUND: Decisions about resuscitation of extremely premature babies are controversial. Such decisions may reflect poor understanding of outcomes. OBJECTIVE: To compare caregivers' attitudes towards the resuscitation of a premature infant if they are only told the infant's gestational age or if they are only given prognostic information for infants at that gestational age. DESIGN/METHODS: Residents and nurses involved in perinatal care were asked whether they would resuscitate a depressed AGA 24-week gestation infant at birth. In another question they were asked whether they would resuscitate a depressed preterm infant with a 50% chance of survival, knowing that of those who survived, 50% would have a development 'within normal limits', 20-25% a serious handicap and 40% with behavioural and/or learning disability. RESULTS: Two hundred and seventy-nine caregivers responded (91% response rate). In the scenario that only presented gestational age, 21% of respondents would resuscitate. In the scenario that only presented prognostic statistics, 51% of respondents would resuscitate (p<0.05). CONCLUSIONS: Providers of perinatal health care respond to vignettes differently depending upon the format in which information is provided. The relative unwillingness to resuscitate a baby of 24-week gestation is surprising since outcomes for such babies are the same or better than those we described in the scenario that provided only outcome data without specifying gestational age. Two explanations are possible: (1) respondents have irrational negative associations with low gestational ages or (2) respondents are unaware of actual outcomes.     

Clinical risk management in newborn and neonatal resuscitation

This chapter aims to provide an overview of aspects of risk management as they might be applied to the practice of resuscitation of the newborn using general principles of risk management and specific standards where they apply. Section 1 considers the matter of hazard and risk and how they may be classified. Figures are presented to provide a clinical perspective on resuscitation with a discussion on the hierarchy of clinical risks operating upon the baby. Section 2 centres on a discussion of those aspects that operate to modify the risks to the baby during a resuscitation, including environmental considerations (location, clinical setting and equipment); staffing issues (establishment, competency, induction and training) and logistics (process, communication and documentation). Section 3 debates the place of cord gases in the context of the diagnosis of perinatal hypoxaemia.     

Knowledge and practical performance gained by Iraqi residents after participation to a neonatal resuscitation program course

Aim:  neonatal resuscitation program (NRP) course is effective in improving knowledge in participants coming from developed as well as developing countries; however, its impact on practical performances has not been yet formally evaluated in participants coming from developing countries. We evaluate the knowledge and the performance on clinical simulations gained by Iraqi residents following participation in the NRP course.
Methods:  A 71-item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was administered to participants before and after the course. All participants were tested with a final Mega code (Mega code A scenario–NRP textbook) to evaluate their performance on clinical simulations.
Results:  Twenty-six obstetrical and 2 pediatric residents participated in the NRP course, respectively. The percentages of correct answers significantly improved from before (52 ± 14%) to immediately after the course (85 ± 7%); p < 0.001. Mean score obtained at the final Mega code was 68 ± 8%. Four out of 28 (14%) participants reached the minimum score required for passing the exam (80%).
Conclusion:  Residents coming from a developing country (Iraq) significantly improved their knowledge attainment following participation in the NRP course; however, their performance on clinical simulations was unsatisfactory, suggesting that this aspect needs to be improved.     

The ethics of delivery-room resuscitation

Perinatal care continues to improve and the number of extremely preterm babies delivered increases. What is the outcome for those babies? Under what circumstances should we not initiate resuscitation or under what circumstances should we discontinue support? How accurate and predictive are the data we have and how can these be improved? Who should make the decisions and how should they be made? Should we follow different guidelines in different settings? The following narrative will examine some of these questions but cannot answer them all.     

Sustained inflation: The lung recruitment maneuvers for neonates

Establishing effective respiration is vital in the transition from fetal to neonatal life. Respiratory support mainly facilitates and creates functional residual capacity and maintains adequate gas exchange. Sustained inflation (SI) delivers prolonged inflation and rapidly creates and establishes the functional residual capacity. The use of SI in preterm infants in the delivery room is still controversial. The optimum settings of SI remain unknown. Animal studies and clinical reports have demonstrated the advantages and disadvantages of SI. In this article, the current literature was reviewed to examine the efficacy of SI in infants.     

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.     

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.     

Time needed to achieve changes in oxygen concentration at the T-Piece resuscitator during respiratory support in preterm infants in the delivery room

OBJECTIVE:

To measure the time needed to achieve changes in fraction of inspired oxygen concentration (FiO₂) from the oxygen blender to the facemask during simulated neonatal resuscitation.

METHOD:

Two oxygen analyzers were placed at each end of the T-Piece. During simulated ventilation, the duration to achieve the set oxygen concentration at the facemask was measured. This was repeated at different gas flow rates (5 L/min, 8 L/min or 10 L/min) and different FiO₂ changes (0.21 to 1.0 to 0.21, with stepwise increases and decreases in 0.05, 0.1 and 0.2 increments).

RESULTS:

A total of 1134 measurements (378 measurements for each flow) were recorded. Overall, the mean (± SD) time required to achieve FiO₂ changes at 5 L/min, 8 L/min and 10 L/min was 36±15 s, 31±14 s and 28±14 s, respectively.

CONCLUSION:

There was a lag time of approximately 30 s to achieve the FiO₂ at the facemask. This delay needs to be considered when making serial adjustments to FiO₂ during neonatal resuscitation.     

Monitoring heart rate in the delivery room

Resuscitation algorithms and guidelines highlight the importance of heart rate (HR) in determining interventions and assessing their effect. However, the actual HR values used are historical based upon normal physiology, and HR at birth may be affected by mode of delivery and timing of cord clamping as well as respiratory status and condition at delivery. Furthermore, the most accurate and effective ways to assess and monitor HR in the newborn infant are only now becoming established. This article examines the importance of HR values and the most widely used methods of estimation as well as some newer modalities which are being developed.     

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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.