Is the vacuum extractor really the instrument of first choice?

This study was a retrospective analysis of the pattern of usage of both the forceps and vacuum extractor as well as the neonatal outcome on all the instrumental deliveries conducted in 1995 at the Kandang Kerbau Hospital, Singapore. There were a total of 927 forceps deliveries and 495 vacuum extractions but neonatal data was available for only 481 forceps and 255 vacuum extractor babies. (There were 2 neonatal units which accepted admissions on alternate days; all of the data were collected from 1 of the units only). Demographic data were comparable in most aspects except that vacuum deliveries were significantly associated with higher parity and shorter labours. There was a trend towards using the vacuum extractor in less difficult cases. Almost all the instrumental deliveries were conducted by specialists. Birth trauma was significantly more likely to occur with the vacuum extractor. Almost all the deliveries were conducted with similar expertise in both groups, yet the use of the vacuum extractor resulted in more birth trauma even in the presence of 'easier' cases. This may suggest an inherent risk in using the vacuum extractor.

Differences in immediate and short-term outcome of premature neonates treated with two types of exogenous surfactant preparation.

A retrospective review of the use of 2 types of exogenous surfactants was done to detect any differences in the short-term outcome. A total of 77 babies received surfactant replacement during the 1 year and 6 months under review. Of these, 30 had received a modified natural preparation, Survanta, and 47 had received a synthetic preparation, Exosurf. The median age at which the surfactant had been administered was at 4 hours of life. Twenty-three percent of all infants had received antenatal steroids. The infants who had received Survanta showed a more rapid initial response, with a lowering of oxygen requirements 1 hour after administration and improvements in the alveolar-arterial oxygen ratios. At 4 hours after administration, the mean arterial-alveolar oxygen ratio was 0.25 +/- 0.15 in the group given Survanta compared with 0.17 +/- 0.11 in the group treated with Exosurf (P < 0.05). These differences however did not persist beyond the first 12 hours after therapy. There were no significant differences between the 2 groups of infants in terms of survival, development of bronchopulmonary dysplasia, intraventricular haemorrhage or ventilator days. A haemodynamically significant patent ductus arteriosus was clinically evident significantly earlier in babies who had received Survanta (mean age 1.86 days against 2.38 days, P = 0.04). The modified natural surfactants appeared to have a more rapid onset of action. The haemodynamic consequences of this more rapid onset of action have to be anticipated in such infants.

Does routine gowning reduce nosocomial infection and mortality rates in a neonatal nursery? A Singapore experience.

A 1 year prospective study on routine gowning before entering a neonatal unit was conducted in a maternity hospital in Singapore. This study was done based on previous work by Donowitz, Haque and Chagla and Agbayani et al., as there have been no known studies done in Singapore. The aim of the study was to test the hypothesis that routine gowning before entering a neonatal nursery does not reduce nosocomial infection and mortality rate. A total of 212 neonates from the neonatal intensive care unit (NICU) and 1694 neonates from the neonatal special care unit (NSCU) were studied. Neonates admitted during the 1 year study were assigned to the gowning (control) and no routine gowning (trial) group on every alternate 2 months. The hospital infection control nurse provided data on nosocomial infection. The overall nosocomial infection rate in the NICU was 24% (25 of 104 admissions) during gowning periods compared to 16.6% (18 of 108 admissions) when plastic aprons were not worn before entry. In the NSCU, the overall infection rate was 1.5% (12 of 800 admissions) during gowning periods compared to 2.1% (19 of 894 admissions) when no gown was worn before entry. Results of the study found no significant differences in the incidences of nosocomial infection and mortality in the neonates. The cost of gowns used during the no routine gowning periods was S$2012.8 compared to S$3708 used during the routine gowning procedure. The investigators recommend that routine gowning before entering a neonatal unit is not essential and cost effective for the purpose of reducing infection. Rather the focus should be on adequate handwashing by all hospital personnel and visitors before handling neonates.

Skin disinfection in preterm infants.

Greater care and a more thorough approach to intravenous catheter site disinfection may be important for the prevention of catheter related sepsis, especially with coagulase negative staphylocci in preterm infants. The efficacy of skin disinfection was evaluated in preterm infants using a skin swabbing technique after disinfectant exposure. In the first part of the study, 25 peripheral intravascular catheter sites were quantitatively sampled immediately after routine cannula insertion. Bacterial counts greater than 100 colony forming units/cm2 were observed from 10 (40%) sites. In the second part, sampling for bacterial colony counts was done after skin cleansing with various durations of exposure of chlorhexidine/alcohol swabs or povidone iodine. The overall mean reduction in bacterial colony counts after skin cleansing ranged from 90-99%. Skin sterilisation was achieved in 33-92% of cases. The use of two consecutive 10 second exposures resulted in a significantly improved reduction in colony counts compared with a single 10 second wipe. A longer 30 second exposure also resulted in a greater reduction of bacterial numbers compared with a shorter duration of 5 or 10 seconds. Repopulation of disinfected sites occurred within 48 hours. This effect was delayed by occluding the cleansed site with a semipermeable dressing. There were no significant differences between povidone iodine and the chlorhexidine swabs in reducing bacterial numbers. This study has demonstrated that a brief exposure with a premoistened disinfectant swab is not sufficient for complete elimination of resident skin flora of newborn infants. The use of two consecutive cleanings, or a longer duration of cleansing is recommended for more effective skin sterilisation.

The importance of septic work-up in the febrile neonate.

71 febrile neonates admitted to the Paediatric and Neonatal Department in 1988 and 1989 were studied. Septic work ups were done for 84% of patients & 80% had lumbar puncture. These infants were subdivided into 5 groups in order to identify the significance of the various stages of septic work up. It was found that 48% of patients with significant infections were only diagnosed after some stage of septic work up. 14% had meningitis and diagnosed only after CSF examination. Only in 13% of patients the diagnosis could be made confidently without a septic work up confirming that the diagnosis of infection in the neonate is difficult and often missed without a septic work up. Clinical impression by paediatricians reduced the number of patients requiring unnecessary investigations and receiving empiric therapy. We recommend maintaining our present cautious policy of admitting neonates with pyrexia.