Enteral feeding of preterm neonates: a survey of Australian neonatologists.

Postnatal growth restriction has been recently identified as a serious problem in preterm, especially extremely low birth weight neonates who are also at the highest risk for necrotizing enterocolitis (NEC). The fear of NEC and the difficulties in interpreting the signs of feed intolerance continue to be responsible for the variations in enteral feeding practices for these neonates. Such variations in clinical practice (e.g. fluid management, feeding regimens) have also been proposed to represent the 'iatrogenic' component of NEC. The findings of a survey (a questionnaire for self-administration and anonymous response) to document the enteral feeding practices of Australian neonatologists for neonates < 32 weeks' gestation are reported. A few controversial feeding practices are discussed in the light of the current evidence. The importance of minimizing variations in nutritional practices is emphasized.     

Heat loss prevention in the delivery room for preterm infants: a national survey of newborn intensive care units.

BACKGROUND: Hypothermia incurred during delivery room resuscitation continues to cause morbidity in infants <29 weeks gestation. Three recent trials have shown that wrapping such infants instead of drying prevents heat loss, resulting in higher infant temperatures at Newborn Intensive Care Unit (NICU) admission. OBJECTIVE: To describe current NICU practices with respect to wrapping preterm infants to prevent heat loss in the delivery room. STUDY DESIGN: E-mail survey of neonatologists from national registry using a web-based survey tool. RESULTS: Of 411 e-mails successfully delivered, 125 (30%) responded. Most (87%) represented level III NICUs. Almost one-fifth of respondents (20%) use occlusive material instead of drying preterms in the delivery room. Considerable variation exists regarding choice of wrap and duration of use. Few adverse events were reported. CONCLUSION: "In all" was added -This implies 20% of all NICU's changed practice, 20% of level III NICUs responding have changed delivery room resuscitation practices rapidly in response to new evidence. No "gold" standard exists nationally and there is considerable variation in practice. Neonatal resuscitation guidelines for premature infants should include recommendations regarding choice occlusive wrap and application techniques.     

Parental influence on clinical management during neonatal intensive care: a survey of US neonatologists

Abstract

Objective: Family-centered care (FCC), which includes involving parents in conversations about medical management, is increasingly employed in the neonatal intensive care unit (NICU). Our aim was to determine which care decisions are discussed by neonatologists with families most frequently and the percentage of clinicians influenced by such conversations.

Methods: Anonymous web-based survey provided to 2137 neonatologists assessing information sharing and parental involvement.

Results: Thousand and two neonatologists responded in which 893 fully completed the surveys. 88% practice FCC. Topics most frequently discussed with parents were blood transfusion, steroids for lung disease and patent ductus arteriosus (PDA) surgery, each being reported and discussed by more than 90% of respondents. Many therapies, including aminoglycoisdes, total parenteral nutrition, and phototherapy, were discussed with parents by far fewer clinicians. Additionally, parents had most influence on clinicians in two categories, blood transfusion and steroids, with more than 70% reporting that their practice was influenced by parental opinion if communicated. For some topics, such as PDA surgery and central line placement, conversations impacted few clinicians.

Conclusions: FCC appears to have an impact on NICU clinical decision-making processes, some more than others. Further investigation in this area may provide information on how to best communicate with families and run effective, efficient FCC rounds.     

超声在产房中的应用

超声进产房是现代产科规范化管理的新要求之一。在产科紧急情况下，超声可以帮助临床医师快速准确地对胎儿状况、胎儿胎盘位置、宫腔及腹腔情况做出判断；指导产程管理，选择合适的分娩方式，实施恰当的助产操作；在超声引导下进行介入性操作。近年来超声在产房中的应用也有很多进展，如超声产程评估的新指标、超声引导辅助麻醉穿刺和插管、超声评估容量负荷等，这为母婴安全提供了进一步的保障。     

产房内危重症的处理

日常工作中产房发生急救事件较多，其中肩难产、子宫破裂、产后出血、脐带脱垂、子痫、羊水栓塞、胎盘早剥是较常见的一些危重症。为了达到良好的救治效果，产房必须具备技术过硬、反应快速的团队以及随时可用的设备，平时危重症急救的演练是提高产房危重症急救能力的有效措施。     

Benefits of ultrasonography in the delivery room

Ultrasonography should benefit many pathological events which occur in delivery rooms. The authors analyse the scarce literature about this subject and propose indications in which this complementary examination seems to be interesting.     

Usefulness of ultrasound in the delivery room

The use of diagnostic ultrasound and the diffusion of the technique improved the obstetric treatment and the usefulness of ultrasound increases in the delivery room for maternal and fetal care and as method of diagnosis of some obstetric complications. The knowledge of intrapartum ultrasound imaging can be considered useful for the obstetric team, since there is evidence that ultrasound can improve the obstetric management. The mean indications are described: fetal biometry and estimated fetal weight, amniotic fluid volume, fetal situation and presentation, placental localization and anatomy, assessment of size and location of uterine leiomyomas, fetal cardiac activity, evaluation of umbilical cord and fetal cardinal movements intrapartum. Besides, the use of ultrasound is reported in obstetric and postpartum complications. Actually ultrasonography, as a non-invasive, safety and low-cost technique, offers a diagnostic method in particular conditions during labour, delivery and postpartum.     

Use of surfactant in the delivery room

Surfactant supplementation in prevention and treatment of surfactant deficient hyaline membrane disease has been widely studied. This article focuses on the prevention of HMD by preventilatory, tracheal instillation of surfactant in the delivery room.     

The need for delivery room intubation of thin meconium in the low-risk newborn: a clinical trial.

The delivery room management of meconium-stained amniotic fluid remains controversial. We attempted to determine if intubation of the low-risk newborn with thin meconium affects the incidence of respiratory symptoms. Exclusion criterion included moderate or thick meconium, fetal distress, neonatal depression, or prematurity. Eligible infants were randomized to either an intubation (group I) or to a nonintubation group (group II). The outcome was the presence of respiratory symptoms. Patients were studied from May 1994 to June 1997. There were 8967 births during this period: 7.9% (708/8967) were delivered through meconium. Thin meconium was noted in 50.3% (356/708) of all births. 24/356 infants with thin meconium were excluded for medical criterion. One hundred sixty-three infants were medically eligible but could not be randomized due to lack of consent, late arrival of the team, or obstetrician request. These were placed into intubation (group I B) and nonintubation (group II B) groups. Seventy-seven infants were randomized into group I and 92 infants into group II. From the intubation groups I and I B, one required supplemental oxygen and was weaned to room air in 7 hr. From the nonintubation groups II and II B, two infants required oxygen, weaning to room air in 11 and 46 hr. Comparing birth weight, gestational age, sex, mode of delivery and 5-min Apgar, there were no significant differences. However, the intubation groups had significantly lower 1-min Apgar scores. There was no airway morbidity reported in the intubation groups. In the infant with thin meconium and an otherwise low-risk pregnancy, we were unable to demonstrate a difference in respiratory symptoms with intubation and intratracheal suctioning.     

Heat loss prevention for preterm infants in the delivery room.

OBJECTIVE: Preterm infants are prone to hypothermia immediately following birth. Among other factors, excessive evaporative heat loss and the relatively cool ambient temperature of the delivery room may be important contributors. Most infants <29 weeks gestation had temperatures <36.4 degrees C on admission to our neonatal unit (NICU). Therefore we conducted a randomized, controlled trial to evaluate the effect of placing these infants in polyurethane bags in the delivery room to prevent heat loss and reduce the occurrence of hypothermia on admission to the NICU. METHODS: After parental consent was obtained, infants expected to be <29 weeks gestation were randomized to intervention or control groups just prior to their birth. Infants randomized to the intervention group were placed in polyurethane bags up to their necks immediately after delivery before being dried. They were then resuscitated per NRP guidelines, covered with warm blankets, and transported to the NICU, where the bags were removed and rectal temperatures were recorded. Control infants were resuscitated, covered with warm blankets, and transported without being placed in polyurethane bags. Delivery room temperatures were recorded so this potentially confounding variable could be assessed. RESULTS: Intervention patients were less likely than control patients to have temperature < 36.4 degrees C on admission , 44 vs 70% (p<0.01) and the intervention group had a higher mean admission temperature, 36.5 degrees C vs 36.0 degrees C (p<0.003). This effect remained significant (p<0.0001) when delivery room temperature was controlled in analysis. Warmer delivery room temperatures (>/=26 degrees C) were associated with higher admission temperatures in both intervention and control infants, but only the subgroup of intervention patients born in warmer delivery rooms had a mean admission temperature >36.4 degrees C. CONCLUSIONS: Placing infants <29 weeks gestation in polyurethane bags in the delivery room reduced the occurrence of hypothermia and increased their NICU admission temperatures. Maintaining warmer delivery rooms helped but was insufficient in preventing hypothermia in most of these vulnerable patients without the adjunctive use of the polyurethane bags.     

Teamwork and quality during neonatal care in the delivery room.

OBJECTIVE: Experts believe good teamwork among health care providers may improve quality. We sought to measure the frequency of team behaviors during delivery room care and to explore how these behaviors relate to the quality of care. STUDY DESIGN: We video recorded neonatal resuscitation teams then used independent observers to measure teamwork behaviors and compliance with Neonatal Resuscitation Program (NRP) guidelines (a measure of quality of care). RESULTS: Observer agreement was either fair or good for all teamwork behaviors except workload management, vigilance, and leadership, for which agreement was slight. All teams (n=132) exhibited the behaviors information sharing and inquiry, and all but one team exhibited vigilance and workload management. Other behaviors were present less often: assertion in 19.9% of teams, teaching 16.7%, leadership 19.7%, evaluation of plans 12.9%, and intentions stated 9.1%. Factor analysis identified three fundamental components of teamwork: communication (comprised of information sharing and inquiry); management (workload management and vigilance); and leadership (assertion, intentions shared, evaluation of plans, and leadership). All three components were weakly but significantly correlated with independent assessments of NRP compliance and an overall rating of the quality of care. CONCLUSION: Most team behaviors can be reliably observed during delivery room care by neonatal resuscitation teams, and some are infrequently used. We found weak but significant and consistent correlations among these behaviors with independent assessments of NRP compliance and an overall rating of the quality of care. These findings support additional efforts to study team training for delivery room care and other areas of healthcare.     

Twin delivery: a survey of French obstetrical policies

OBJECTIVES: To describe obstetrical policy variations concerning the delivery management in the case of twins, at term. PATIENTS AND METHODS: A mail survey was undertaken among the medical supervisors of the maternity wards belonging to the AUDIPOG Network (N=170). RESULTS: The participating rate was 73.35%. 124 answers were analysed. Elective caesarean was realized by 0.8% of participants for diamniotic twins and by 57% of cases for monamniotic twins An elective caesarean is planned for respectively 74% of answers if first (J1) and second twin (J2) are in a breech presentation, 81% if J1 is in breech and J2 in cephalic presentation, and 68% if J1 is in breech and J2 in transverse presentation. Delivery with J1 in breech and J2 in cephalic presentation had a higher risk than a delivery of a single breech at term. When J1 and J2 had a breech presentation 73% of participants thought that this delivery is more difficult than a delivery of a single breech at term. However, they were only 17.5% to consider that a delivery of twin with J1 in cephalic and J2 in breech presentation had a higher risk than a single breech delivery. DISCUSSION AND CONCLUSION: Medical policy variations are not extensive except for X-ray pelvimetry and the presence for the delivery of one paediatrician and one anaesthesiologist. An elective caesarean policy for twins is infrequent in France.