A Randomized Controlled Simulation Trial of a Neonatal Resuscitation Digital Game Simulator for Labour and Delivery Room Staff.

BACKGROUND: Healthcare providers (HCPs) working in labour and delivery rooms need to undergo regular refresher courses to maintain their neonatal resuscitation skills, which are shown to decline over time. However, due to their irregular schedules and limited time, HCPs encounter difficulties in readily accessing refresher programs. RETAIN is a digital game that simulates a delivery room to facilitate neonatal resuscitation training for HCPs. OBJECTIVE: This study aims to ascertain whether participants enjoyed the RETAIN digital game simulator and whether it was at least as good as a video lecture at refreshing and maintaining participants' neonatal resuscitation knowledge. METHODS: In this randomized controlled simulation trial, n = 42 labour and delivery room HCPs were administered a pre-test of neonatal resuscitation knowledge using a manikin. Then, they were randomly assigned to a control or a treatment group. For 20-30 min, participants in the control group watched a neonatal resuscitation lecture video, while those in the treatment group played the RETAIN digital game simulator of neonatal resuscitation scenarios. Then, all participants were administered a post-test identical to the pre-test. Additionally, participants in the treatment group completed a survey of attitudes toward the RETAIN simulator that provided a measure of enjoyment of the RETAIN game simulator. After two months, participants were administered another post-test identical to the pre-test. RESULTS: For the primary outcome (neonatal resuscitation performance), an analysis of variance revealed that participants significantly improved their neonatal resuscitation performance over the first two time points, with a significant decline to the third time point, the same pattern of results across conditions, and no differences between conditions. For the secondary outcome (attitudes toward RETAIN), participants in the treatment condition also reported favourable attitudes toward RETAIN. CONCLUSIONS: Labour and delivery room healthcare providers in both groups (RETAIN simulator or video lecture) significantly improved their neonatal resuscitation performance immediately following the intervention, with no group differences. The findings suggest that participants enjoyed interacting with the RETAIN digital game simulator, which provided a similar boost in performance right after use to the more traditional intervention.

Delivery Room Lung Ultrasound-Feasibility, Normal Patterns, and Predictive Value for Respiratory Support in Term and Near-Term Neonates: A Monocentric Study.

AIM: our study aimed to characterize the lung ultrasound (LUS) patterns noted immediately after delivery in term and near-term neonates, and to investigate whether the LUS scores or patterns observed at that point could anticipate the need for respiratory support in the sample of patients studied. MATERIALS AND METHODS: We performed two ultrasound examinations: one in the delivery room and the second at one hour of age. The anterior and lateral regions of both lungs were examined. We assessed the correlation between the LUS scores or patterns and the gestational age, umbilical arterial blood gases, the need for respiratory support (CPAP or mechanical ventilation), the presence of respiratory distress, and the need for the administration of oxygen. RESULTS: LUS scores were significantly higher in the delivery room examination (8.05 ± 1.95) than at 1 h of age (6.4 ± 1.75) (p < 0.001). There were also statistically significant differences between the LUS patterns observed in different lung regions between the delivery room exam and the exam performed at 1 h of age (p values between 0.001 and 0.017). There were also differences noted regarding the LUS patterns between different lung regions at the exam in the delivery room (the right anterior region LUS patterns were significantly worse than the right lateral LUS patterns (p < 0.004), left anterior LUS patterns (p < 0.001), and left lateral LUS patterns (p < 0.001)). A statistically significant correlation was found between LUS scores and the gestational age of the patients (r = 0.568, p < 0.001-delivery room; r = 4.0443, p < 0.001-one hour of age). There were statistically significant associations between LUS scores, patterns at delivery (p < 0.001) and 1 h of age (p < 0.001), and the need for respiratory support (CPAP or mechanical ventilation). CONCLUSIONS: LUS in the delivery room offers important information regarding lung fluid elimination and aeration of the lungs, and early LUS features are significantly associated with the risk of respiratory distress and the need for respiratory support.

Direct Umbilical Vein Injection of Epinephrine with Cut-Cord Milking in an Ovine Model of Neonatal Resuscitation.

BACKGROUND: An umbilical venous catheter (UVC) is the preferred route of epinephrine administration during neonatal resuscitation but requires specialized equipment, expertise, and time. HYPOTHESIS: Direct injection of epinephrine into the umbilical vein (UV) followed by milking a ~20 cm segment of cut umbilical cord to flush the epinephrine (DUV + UCM) will lead to a quicker administration and earlier return of spontaneous circulation (ROSC) compared with epinephrine given through a UVC. DESIGN: Eighteen near-term asphyxiated lambs were randomized to receive a low-UVC or DUV + UCM of epinephrine at 0.02 or 0.03 mg/kg doses. OUTCOME MEASURES: A total of 16/18 lambs achieved ROSC with a similar mean (±SEM) time to ROSC [DUV + UCM vs. low-UVC (4.67 ± 0.67 vs. 3.99 ± 0.58 min); p = 0.46]. Two out of ten lambs in the DUV + UCM group required UVC placement for additional epinephrine. The administration of the first dose of epinephrine was similar (DUV + UCM-2.97 ± 0.48 vs. UVC-4.23 ± 0.58 min; p = 0.12). Both methods yielded similar epinephrine concentrations (peak concentrations of 253 ± 63 and 328 ± 80 ng/mL for DUV + UCM and UVC EPI, respectively). CONCLUSIONS: DUV + UCM resulted in a ROSC success of 78% following the first epinephrine dose and showed similar epinephrine concentrations to UVC. Clinical studies evaluating DUV + UCM as an alternate route for epinephrine while intravenous access is being established are warranted.

A stylet use may be beneficial for elective and rescue intubation of prematurely born infants < 30 weeks.

BACKGROUND: Recent studies have reported that using a stylet does not provide any advantages during intubation within a diverse infant population. Our research focuses on the issue, specifically in premature infants who undergo elective or rescue intubation (EI or RI) in the delivery room (DR). METHODS: We conducted a single-center retrospective observational study comparing the number of intubation attempts, the duration of intubation procedure until successful, and the rate of associated desaturations exceeding 20%. We derived outcomes from video recordings and performed statistical analyses. RESULTS: We have analyzed 104 intubation attempts in 70 infants with a mean gestational age and birth weight of 25±1.9 weeks and 736±221 grams, respectively; 39 of these attempts involved stylet use, and 65 did not. 75% of infants requiring intubation were less than 26 weeks of gestational age. The use of a stylet increased the rate of successful initial attempts [OR (95% CI) 4.3 (1.3-14.8), P=0.019], reduced the duration of the intubation procedure [median (IQR) seconds: 43 (30-72) vs 140 (62-296), P<0.001], and decreased the occurrences of desaturation exceeding 20% (13% vs 50%, P=0.003). CONCLUSION: The benefits of using a stylet during rescue and elective intubations of premature infants in the delivery room outweigh the potential harms. Its use may be advantageous in settings where proactive approaches are implemented for periviable infants.

Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants?

BACKGROUND: Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence. METHODS: An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity). DISCUSSION: The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION: The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database.

OBJECTIVE: To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine. STUDY DESIGN: We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR. RESULTS: In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine. CONCLUSIONS: This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Birth outcomes associated with a natural delivery approach in a perinatal center: A comparative retrospective study.

OBJECTIVES: At our center, natural home-like delivery settings have been established in or near conventional labor wards, for the care of pregnant women who prefer little or no medical intervention during labor and birth. We compared obstetrical and neonatal outcomes of women in active spontaneous labor, between those who chose to deliver in a natural-delivery setup and those who chose a conventional setting. METHODS: This retrospective study included low-risk women who delivered at term between March 1, 2020 and December 31, 2022, in a single tertiary university affiliated medical center. Birth outcomes were compared between 124 women who delivered by natural birth (the study group) and 244 who gave birth in a conventional setting (the control group). RESULTS: No cesarean deliveries were performed in the study group, compared to 18 (7.4%) of the control group, p = 0.004. Intrapartum fever, postpartum hemorrhage, and uterotonic administration were similar between the groups. For the study compared to the control group, breastfeeding was more common (71.3% vs. 12.3%, p < 0.001), analgesia administration within 48 h delivery was lower (4.1% vs. 10.7%, p = 0.033), and maternal and neonatal length of hospitalization were shorter. Of the women initially admitted to the natural-delivery room, 14 (11.5%) were transferred to a conventional-delivery room. CONCLUSIONS: Birth in a hospital natural-delivery setting was associated with increased likelihood of vaginal birth, increased immediate breastfeeding and breastfeeding at discharge, and lower postpartum pain.

Healing Architecture in Birthing Rooms: A Scoping Review.

AIM: The purpose of this scoping review is to map the knowledge about the multisensory birthing room regarding the birth experience and birth outcomes. BACKGROUND: The concept of multisensory birthing rooms is relatively novel, making it relevant to explore its impact. METHODS: Five databases were searched. The search was limited to articles in English, Danish, Norwegian, and Swedish. There were no time limitations. Fourteen relevant articles were identified providing knowledge about multisensory birthing rooms. RESULTS: Eight articles focused on birth experience, six articles focused on birth outcome, and one on the organization of the maternity care. Seven of the studies identified that sensory birthing rooms have a positive impact on the birth experience and one qualitative study could not demonstrate a better overall birth experience. Five articles described an improvement for selected birth outcomes. On the other hand, a randomized controlled trial study could not demonstrate an effect on either the use of oxytocin or birth outcomes such as pain and cesarean section. The definition and description of the concept weaken the existing studies scientifically. CONCLUSIONS: This scoping review revealed that multisensory birthing rooms have many definitions and variations in the content of the sensory exposure; therefore, it is difficult to standardize and evaluate the effect of its use. There is limited knowledge concerning the multisensory birthing room and its impact on the birth experience and the birth outcome. Multisensory birthing rooms may have a positive impact on the birth experience. Whereas there are conflicting results regarding birth outcomes.

Positive Pressure Ventilation in Preterm Infants in the Delivery Room: A Review of Current Practices, Challenges, and Emerging Technologies.

BACKGROUND: A major proportion of preterm neonates require positive pressure ventilation (PPV) immediately after delivery. PPV may be administered through a face mask (FM) or nasal prongs. Current literature indicates that either of these are associated with similar outcomes. SUMMARY: Nonetheless, FM remains the most utilized and the best choice. However, most available FM sizes are too large for extremely preterm infants, which leads to mask leak and ineffective PPV. Challenges to providing effective PPV include poor respiratory drive, complaint chest wall, weak thoracic muscle, delayed liquid clearance, and surfactant deficiency in preterm infants. Mask leak, airway obstruction, poor technique, and inappropriate size are correctable causes of ineffective PPV. Visual assessment of chest rise is often used to assess the efficacy of PPV. However, its accuracy is debatable. Though end tidal CO2 may adjudge the effectiveness of PPV, clinical studies are limited. The compliance of a preterm lung is highly dynamic. The inflating pressure set on T-piece is constant throughout the resuscitation, but the lung volume and dynamics changes with every breath. This leads to huge fluctuations of tidal volume delivery and can trigger inflammatory cascade in preterm infants leading to brain and lung injury. Respiratory function monitoring in the delivery room has potential for guiding and optimizing delivery room resuscitation. This is, however, limited by high costs, complex information that is difficult to interpret during resuscitation, and absence of clinical trials. KEY MESSAGES: This review summarizes the existing literature on PPV in preterm infants, the various aspects related to it such as the pathophysiology, interfaces, devices utilized to deliver it, appropriate technique, emerging technologies, and future directions.

The effect of fathers' birth attendance on paternal attachment and the perception of parental role: a randomised controlled trial.

BACKGROUND: Fathers' birth attendance is associated with support for mothers in infant care, positive child health outcomes, and parental well-being. OBJECTIVE: This study was conducted in a randomised controlled experimental design to investigate the effect of fathers' birth attendance on paternal-infant attachment and the perception of parental role. METHODOLOGY: Pregnant women during the childbirth process and their husbands were included in the study and were randomised according to fathers' birth attendance. The data were collected with the Information Form (IF), Paternal Antenatal Attachment Questionnaire (PAAQ), Self-Perception of Parental Role Scale (SPPRS), Postnatal Paternal-Infant Attachment Questionnaire (PPAQ), and Edinburgh Postnatal Depression Scale (EPDS). The IF data were obtained from women before birth, and the EPDS data were obtained from women 15 days after birth. RESULTS: Individual characteristics of mothers and fathers in the groups, and prenatal PAAQ and SPPRS scores of the fathers were similar (p > 0.05). In the postnatal period, a significant difference was found in favour of the intervention group in the PPAQ total (p < 0.01), Patience and Tolerance (p < 0.05) and Pleasure in Interaction (p < 0.01) sub-dimensions. The within-group variation of the SPPRS scores of fathers in the intervention and control groups was analysed. The postnatal Competence (p < 0.01) and Integration (p < 0.05) sub-dimension scores statistically significantly increased in both the intervention and control groups compared to the antenatal period. CONCLUSION: While husbands' accompanying their wives in the delivery room positively affects paternal-infant attachment, its effect on the perception of parental role is an issue that needs to be further investigated.

Predicting post-traumatic stress disorder: The complex relationship between burnout, intentions to leave and emotional support among health care professionals.

BACKGROUND: Health care professionals working in delivery rooms often encounter stressful situations. Understanding their challenges and the support they receive is essential for improving their well-being and consequently patient care. PURPOSE: Examining the relationship between burnout, intentions to leave, post-traumatic stress disorder (PTSD) symptoms, and complex PTSD among health care professionals, and identifying their predictors. METHODS: A mixed methods design, including a survey among 196 midwives and gynecologists assessing burnout, intentions to leave, exposure to negative work experiences and PTSD, as well as 15 semi-structured interviews. DISCUSSION: Most participants experienced multiple difficult events in the delivery room, reporting insufficient emotional support. Burnout and lack of emotional support were significant predictors of PTSD symptoms. Participants expressed a need for emotional support to cope with complex situations. CONCLUSION: Burnout among midwives must be addressed through prevention and intervention programs. Emotional support is essential in mitigating PTSD symptoms among midwives and gynecologists, enhancing their resilience and well-being.

A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units.

(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.

Delivery room resuscitation intensity and associated neonatal outcomes of 24+0-31+6 weeks' preterm infants in China: a retrospective cross-sectional study.

BACKGROUND: The aim of this study was to review current delivery room (DR) resuscitation intensity in Chinese tertiary neonatal intensive care units and to investigate the association between DR resuscitation intensity and short-term outcomes in preterm infants born at 24+0-31+6 weeks' gestation age (GA). METHODS: This was a retrospective cross-sectional study. The source population was infants born at 24+0-31+6 weeks' GA who were enrolled in the Chinese Neonatal Network 2019 cohort. Eligible infants were categorized into five groups: (1) regular care; (2) oxygen supplementation and/or continuous positive airway pressure (O2/CPAP); (3) mask ventilation; (4) endotracheal intubation; and (5) cardiopulmonary resuscitation (CPR). The association between DR resuscitation and short-term outcomes was evaluated by inverse propensity score-weighted logistic regression. RESULTS: Of 7939 infants included in this cohort, 2419 (30.5%) received regular care, 1994 (25.1%) received O2/CPAP, 1436 (18.1%) received mask ventilation, 1769 (22.3%) received endotracheal intubation, and 321 (4.0%) received CPR in the DR. Advanced maternal age and maternal hypertension correlated with a higher need for resuscitation, and antenatal steroid use tended to be associated with a lower need for resuscitation (P < 0.001). Severe brain impairment increased significantly with increasing amounts of resuscitation in DR after adjusting for perinatal factors. Resuscitation strategies vary widely between centers, with over 50% of preterm infants in eight centers requiring higher intensity resuscitation. CONCLUSIONS: Increased intensity of DR interventions was associated with increased mortality and morbidities in very preterm infants in China. There is wide variation in resuscitative approaches across delivery centers, and ongoing quality improvement to standardize resuscitation practices is needed.

Back vs. chest ECG electrode placement in neonatal resuscitation: A pilot randomized controlled trial.

BACKGROUND: The recent Neonatal Resuscitation Program advises the early utilization of an electrocardiogram (ECG) for non-vigorous newborns in the delivery room. However, placing ECG electrodes on the chest may delay obtaining a reliable heart rate (HR) and could interfere with chest compressions. Our previous study showed that preset ECG electrodes, attached to the back of the newborn, are quicker than a pulse oximeter (POX) for detecting HR. AIM: To compare time to detect a reliable HR using back-placed ECG electrodes versus standard front placement. METHODS: Infants were randomly assigned to back (n = 85) or chest (n = 89) electrode placement. Time measurement began upon placing infants on a Panda warmer ResusView. Failure was defined as no HR detected within 5 minutes. Intention-to-treat analysis compared HR signal acquisition time between groups. RESULTS: Both groups showed similar proportions of detectable HR within the first minute. Median (IQR) time to obtain HR was 26 (13,38) seconds for the chest group and 21 (12,54) seconds for the back group (p = 0.91). A large number of vigorous infants were included. In the chest group, these vigorous infants had shorter HR acquisition times than non-vigorous infants (Mean ± SD of 34 ± 48 seconds vs. 50 ± 44 seconds respectively; p = 0.049). Failure rates and time to acquire a HR for infants who were non-vigorous and required advanced resuscitation were similar between the back and chest groups (p = 0.51). CONCLUSION: Preset back ECG electrodes have shown encouraging results in neonates requiring advanced resuscitation. Further studies are needed to enhance guidance during neonatal resuscitation.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis.

AIM: To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS: Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS: DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS: DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Variation in delivery room management of preterm infants across Europe: a survey of the Union of European Neonatal and Perinatal Societies.

The aim of the present study, endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Italian Society of Neonatology (SIN), was to analyze the current delivery room (DR) stabilization practices in a large sample of European birth centers that care for preterm infants with gestational age (GA) < 33 weeks. Cross-sectional electronic survey was used in this study. A questionnaire focusing on the current DR practices for infants < 33 weeks' GA, divided in 6 neonatal resuscitation domains, was individually sent to the directors of European neonatal facilities, made available as a web-based link. A comparison was made between hospitals grouped into 5 geographical areas (Eastern Europe (EE), Italy (ITA), Mediterranean countries (MC), Turkey (TUR), and Western Europe (WE)) and between high- and low-volume units across Europe. Two hundred and sixty-two centers from 33 European countries responded to the survey. At the time of the survey, approximately 20,000 very low birth weight (VLBW, < 1500 g) infants were admitted to the participating hospitals, with a median (IQR) of 48 (27-89) infants per center per year. Significant differences between the 5 geographical areas concerned: the volume of neonatal care, ranging from 86 (53-206) admitted VLBW infants per center per year in TUR to 35 (IQR 25-53) in MC; the umbilical cord (UC) management, being the delayed cord clamping performed in < 50% of centers in EE, ITA, and MC, and the cord milking the preferred strategy in TUR; the spotty use of some body temperature control strategies, including thermal mattress mainly employed in WE, and heated humidified gases for ventilation seldom available in MC; and some of the ventilation practices, mainly in regard to the initial FiO2 for < 28 weeks' GA infants, pressures selected for ventilation, and the preferred interface to start ventilation. Specifically, 62.5% of TUR centers indicated the short binasal prongs as the preferred interface, as opposed to the face mask which is widely adopted as first choice in > 80% of the rest of the responding units; the DR surfactant administration, which ranges from 44.4% of the birth centers in MC to 87.5% in WE; and, finally, the ethical issues around the minimal GA limit to provide full resuscitation, ranging from 22 to 25 weeks across Europe. A comparison between high- and low-volume units showed significant differences in the domains of UC management and ventilation practices.    Conclusion: Current DR practice and ethical choices show similarities and divergences across Europe. Some areas of assistance, like UC management and DR ventilation strategies, would benefit of standardization. Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs. What is Known: • Delivery room (DR) support of preterm infants has a direct influence on both immediate survival and long-term morbidity. • Resuscitation practices for preterm infants often deviate from the internationally defined algorithms. What is New: • Current DR practice and ethical choices show similarities and divergences across Europe. Some areas of assistance, like UC management and DR ventilation strategies, would benefit of standardization. • Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs.

Sedation Prior to Intubation at Birth in Infants with Congenital Diaphragmatic Hernia: An International Survey on Current Practices.

INTRODUCTION: Infants with congenital diaphragmatic hernia (CDH) are commonly intubated immediately after birth. Consensus on whether to provide sedation prior to intubation in the delivery room is lacking, although avoidance of stress is especially important in this population with high risk of pulmonary hypertension. We aimed at obtaining an overview of local pharmacological interventions and at providing guidance on delivery room management. METHODS: An electronic survey was sent to international clinicians in referral centres for prenatal and postnatally diagnosed infants with CDH. This survey addressed demographic information, use of sedation and/or muscle relaxant prior to intubation, and use of pain scales in the delivery room. RESULTS: We received 93 relevant responses from 59 centres. Most centres were from Europe (n = 33, 56%), followed by North America (n = 16, 27%), Asia (n = 6, 10%), Australia (n = 2, 3%), and South America (n = 2, 3%). A total of 19% (11/59) of the centres routinely provided sedation prior to intubation in the delivery room, with midazolam and fentanyl being most often used. Methods of administration varied for all medications provided. Only 5 of 11 centres using sedation reported an adequate sedative effect prior to intubation. Muscle relaxants prior to intubation were used in 12% (7/59) of the centres, although not always in combination with sedation. CONCLUSION: This international survey shows a substantial variation in sedation practices in the delivery room and scarce use of both sedative agents and muscle relaxants prior to intubation of CDH infants. We provide guidance on developing protocols for pre-intubation medication in this population.

The Parturient Women's Privacy Preservation in the Delivery Rooms: A Qualitative Study.

Introduction: Parturient women's privacy preservation and respectful maternity care (RMC) in delivery room is an important principle in the high quality of midwifery care to achieve maternal satisfaction and positive childbirth experience. Hence, it is essential to make natural vaginal delivery (NVD) a positive experience and increase the mothers' satisfaction. This study aimed to investigate the privacy preservation of parturient women's in the delivery room. Methods: Using conventional content analysis, this qualitative study was conducted from June 2018 to December 2020 at two hospitals and three health centers in Shahroud, Iran. Purposeful sampling was employed and it was continued till data saturation through in-depth interviews with 37 participants. Results: The results of interviews with 21 women with NVD experience and 16 maternity health service providers resulted in the extraction of four themes including physical, spiritual-mental, informational, and social privacy. Conclusion: Various mechanisms were found to promote the privacy and satisfaction of parturient women in the delivery room. They included the necessity continuous education, monitoring about mother's privacy preservation and intervention to improve effective communication skills among staff in delivery rooms.

Preventing and Treating Torsades de Pointes in the Mother, Fetus and Newborn in the Highest Risk Pregnancies with Inherited Arrhythmia Syndromes.

The number of women of childbearing age who have been diagnosed in childhood with ion channelopathy and effectively treated using beta blockers, cardiac sympathectomy, and life-saving cardiac pacemakers/defibrillators is increasing. Since many of these diseases are inherited as autosomal dominant, offspring have about a 50% risk of having the disease, though many will be only mildly impacted during fetal life. However, highly complex delivery room preparation is increasingly needed in pregnancies with inherited arrhythmia syndromes (IASs). However, specific Doppler techniques show meanwhile a better understanding of fetal electrophysiology. The advent of fetal magnetocardiography (FMCG) now allows the detection of fetal Torsades de Pointes (TdP) ventricular tachycardia and other LQT-associated arrhythmias (QTc prolongation, functional second AV block, T-wave alternans, sinus bradycardia, late-coupled ventricular ectopy and monomorphic VT) in susceptible fetuses during the second and third trimester. These types of arrhythmias can be due to either de novo or familial Long QT Syndrome (LQTS), Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), or other IAS. It is imperative that the multiple specialists involved in the antenatal, peripartum, and neonatal care of these women and their fetuses/infants have the optimal knowledge, training and equipment in order to care for these highly specialized pregnancies and deliveries. In this review, we outline the steps to recognize symptomatic LQTS in either the mother, fetus or both, along with suggestions for evaluation and management of the pregnancy, delivery, or post-partum period impacted by LQTS.