Assistência ao parto pélvico / Breech birth assistance

É imprescindível retomar o ensino da versão cefálica externa e das manobras tocúrgicas no parto pélvico vaginal, tanto em litotomia quanto na posição vertical. A adoção de protocolos rígidos para o parto pélvico vaginal planejado correlaciona-se com taxa de sucesso de aproximadamente 70% e taxas de resultados adversos inferiores a 7%. A morbimortalidade fetal e neonatal é semelhante à de cesárea planejada. Gestantes elegíveis para o parto pélvico vaginal devem concordar com a via de parto, possuir baixo risco de complicações e ser assistidas por profissionais com experiência em parto vaginal de apresentações anômalas e suas manobras obstétricas. Cesariana prévia e prematuridade entre 32 e 36 semanas não são contraindicações absolutas ao parto pélvico vaginal, devendo ser individualmente avaliadas na decisão da via de parto. Neonatologistas devem estar presentes no nascimento de fetos pélvicos, e um exame neonatal completo deve ser realizado. A rotação posterior do dorso fetal, o prolapso de cordão umbilical, a deflexão dos braços e/ou do polo cefálico e o encarceramento da cabeça derradeira são as principais distocias relacionadas à assistência ao parto pélvico por via vaginal. Todo profissional que assiste parto pélvico vaginal deve estar capacitado para a resolução adequada desses eventos. No parto pélvico vaginal em litotomia, as principais manobras para o auxílio ao desprendimento da pelve fetal são a tração inferior bidigital na prega inguinal e a manobra de Pinard; para o desprendimento do tronco fetal, as de Rojas, Deventer-Miler e Pajot; e para o desprendimento da cabeça derradeira, as de Mauriceau, Bracht, Champetier de Ribes e Praga e o parto vaginal operatório com o fórcipe de Piper. As posições não litotômicas no parto pélvico vaginal se associam à redução dos períodos de dilatação e expulsão, da taxa de cesariana, da necessidade de manobras para extração fetal e da taxa de lesões neonatais. No parto pélvico vaginal assistido na posição de quatro apoios, os aspectos a serem observados durante o desprendimento do corpo fetal incluem o tônus dos membros inferiores fetais, a rotação correta do tronco fetal (abdome fetal voltado para o dorso materno), o ingurgitamento vascular do cordão umbilical, a presença dos cotovelos e das pregas do tórax fetal e a dilatação anal materna. No parto pélvico vaginal assistido na posição de quatro apoios, mais da metade dos fetos se desprendem sem a necessidade de nenhuma manobra. Habitualmente, apenas duas manobras podem ser necessárias: uma para auxílio à saída dos ombros ("rotação 180°-90°") e outra para desprendimento da cabeça fetal ("Frank nudge").

Implementation of less invasive surfactant administration in clinical practice-Experience of a mid-sized country.

OBJECTIVE: There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level. METHODS: A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform. RESULTS: Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated "easy/very easy" vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with "RAM" cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes. CONCLUSIONS: The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.

Educational Perspectives: Anesthesia 101: What the Neonatologist Needs to Know About Anesthesiology.

As the complexity of medicine increases, so too do the challenges with multidisciplinary communication and coordinated patient care. Anesthesiology represents a field for which there is no required study for medical students, pediatric residents, or neonatal-perinatal medicine fellows in the United States, so a neonatologist may have never received any formal training in anesthesiology (and vice versa for pediatric anesthesiologists in neonatology). In this review, we address frequently asked questions of neonatologists to anesthesiologists to better frame common issues. These topics include thermal regulation, fluid management, airway management, and the field of regional anesthesiology. Finally, collaborative efforts between the surgical and medical fields, such as the American College of Surgeons Children's Surgery Verification Quality Improvement Program, and the American Academy of Pediatrics NICU Verification Program, are ongoing and robust; these programs represent important opportunities to significantly improve the perioperative care of infants. Our hope is that this summary can serve as a primer and reference for those caring for neonatal patients during any perioperative period, including seasoned neonatologists and those early in their training. It is our further desire that this review will lead to improved communication and collegiality between the specialties.

The wake project: Improving safe sleep practices in a neonatal intensive care unit.

BACKGROUND: Every year, about 50 babies in New York City die from a sleep-related injury. The Bronx County ranked second highest rate of sleep-related infant deaths (SRID) at 0.5 per 1000 among the other boroughs. The highest rate was among blacks and the rate of SRID cases were highest in our population at 0.97 (zip code 10466) among all other Bronx neighborhoods which comprises 77% of non-Hispanic black population. Further, Bronx has the highest preterm birth rate at 9.5%. This quality improvement (QI) project aimed to develop and implement an educational initiative on infant safe sleep (SS) to improve "Safe Sleep Practices (SSP) in a level III neonatal intensive care unit (NICU) for one of the highest risk populations in the country. METHODS: Baseline data was collected prior to initiating the QI project. Multiple plan-do-study-act (PDSA) cycles were completed over a 12 month period. Run charts were utilized to identify improvement and guide interventions. These interventions included education for nurses, crib cards, posters, feedback forms, grand rounds and small group discussions. RESULTS: Approximately 600 crib checks (CC) were performed over the duration of this project. At baseline, 7% of infants were placed in a SS position in the NICU. Following the QI project, SS position increased to 96% of infants. CONCLUSION: Multifactorial interventions significantly improved SS compliance among NICU nurses. Cultivating personal motivation among nurses, consistent empowerment and dedication to culture change by the entire team was crucial for the sustainability of the project.

Improving Infant Vaccination Status in a Level IV Neonatal Intensive Care Unit.

BACKGROUND AND OBJECTIVES: Infants in NICUs are at risk for underimmunization. Adherence to the routine immunization schedule recommended by the Advisory Committee for Immunization Practices minimizes the risk of contracting vaccine-preventable illnesses in this vulnerable population. From January 2015 to June 2017, only 56% (419 of 754) of the infants in our Mayo Clinic level IV NICU were fully up to date for recommended immunizations at the time of discharge or hospital unit transfer. We aimed to increase this rate to 80% within 6 months. METHODS: Using the quality improvement methodology of Define, Measure, Analyze, Improve, Control, we analyzed baseline data, including provider and nursing surveys using a fishbone diagram, the 5 Whys, and a Pareto chart. We identified 3 major root causes of the quality gap: lack of provider knowledge of the routine immunization schedule, failure of providers to order vaccines when due, and hesitancy of parents toward vaccination. Using plan-do-study-act cycles, 5 improvement interventions were implemented. These included an intranet resource for NICU providers on the routine immunization schedule, an Excel-based checklist to track when immunizations were due, and provider education on parental vaccine hesitancy and vaccine safety. RESULTS: During the 19-month improve and control phases of the project, the fully immunized rate at the time of NICU discharge or transfer rose from a baseline of 56% (419 of 754) to 93% (453 of 488), with a P value <.001. CONCLUSIONS: Our NICU significantly improved infant immunization rates with a small number of interventions. These interventions may be generalizable to other NICUs with low infant immunization rates.

Point of care ultrasound in the neonatal unit: Applications, training and accreditation.

Point-of-care, or clinician-performed ultrasound (CPU), is increasingly utilised within neonatology as a valuable adjunct to clinical examination. The ability to perform and interpret rapid, real-time, serial assessment of patient physiology at the bedside has seen the potential uses of CPU expand, with an evolving list of clinical and research applications. Benefits of functional assessment of neonatal haemodynamics in particular have been described across a range of gestational ages and disease states. Devising suitable curricula for trainees and ensuring robust processes for the training and credentialing of clinicians performing CPU is essential. Challenges to universal implementation of CPU in the neonatal intensive care setting exist, and regional differences in training and accreditation are well described. Appropriate integration into clinical decision-making and ensuring competency-based locally appropriate training programs, which build on an expanding evidence base, are key priorities in ensuring newborns receive optimal benefit from the modality.

Point of care ultrasound (POCUS) in Canadian neonatal intensive care units (NICUs): where are we?

OBJECTIVES: Despite increased evidence that point-of-care ultrasound (POCUS) has the potential to improve patient care in many clinical areas, the extent of use and training in POCUS in Canadian neonatal intensive care units (NICUs) has not been described in the literature. In this study, we aimed to explore the extent to which POCUS is being used and the need for a formal curriculum with defined POCUS competencies in the field of Neonatal-Perinatal Medicine (NPM). METHODS: We sent a cross-sectional electronic survey to all NPM program directors and fellows in Canada. All 13 Canadian NPM programs were invited to participate. Data were analyzed using descriptive statistics and qualitative content analysis. RESULTS: The response rate was 69% (n = 9) from program directors (PDs) and 29% (n = 25) from NPM fellows. Most respondents indicated regular use of POCUS in clinical practice and ready access to a portable ultrasound machine. The most common use for POCUS was targeted assessment of patent ductus arteriosus (PDA) and persistent pulmonary hypertension (PPHN). Only six PDs reported that POCUS skills are taught to trainees in their centers and only two PDs reported that a structured program existed. Barriers to POCUS structured training include a lack of trained personnel as well as insufficient time in the busy NPM curriculum. CONCLUSION: POCUS is widely used in Canadian NICUs. However, a formal curriculum and assessment of competencies in this area of neonatal clinical care are lacking.

Neonatologists less frequently discuss long term complications: A simulation-based study of prenatal consults beyond the threshold of viability.

BACKGROUND: Guidelines exist for counseling expectant families of infants at periviable gestational ages (22-25 weeks), but it is much more common for neonatologists to counsel families at gestational ages beyond the threshold of viability when several aspects of these guidelines do not apply. We aimed to develop an understanding of what information is shared with mothers at risk of preterm delivery beyond periviability and to evaluate communication skills of our participants. METHODS: We developed a checklist of elements to include in counseling based on a comprehensive literature review. The checklist was divided into an information sharing section and a connect score. The information sharing list was sub-divided into general information and specific complications. Neonatologists engaged in a simulated prenatal counseling session with a standardized patient. Videotaped encounters were then analyzed for checklist elements. RESULTS: Neonatologists all scored well in communication using our tool and two other validated communication tools - the SEGUE and the analytic global OSCE. There was no difference in scoring based on years of experience or level of training. Information sharing from neonatologists more often discussed general information over specific. Neonatologists also focused more on early outcomes over long-term outcomes. Only 12% of neonatologists quoted the correct survival rate for the case. CONCLUSIONS: Neonatologists generally communicate well but share less information specific to prematurity and the long-term sequelae of prematurity. Our tool may be used to test if other interventions improve information sharing or communication.

Education, training, and accreditation of Neonatologist Performed Echocardiography in Europe-framework for practice.

There is a growing interest worldwide in using echocardiography in the neonatal unit to act as a complement to the clinical assessment of the hemodynamic status of premature and term infants. However, there is a wide variation in how this tool is implemented across many jurisdictions, the level of expertise, including the oversight of this practice. Over the last 5 years, three major expert consensus statements have been published to provide guidance to neonatologists performing echocardiography, with all recommending a structured training program and clinical governance system for quality assurance. Neonatal practice in Europe is very heterogeneous and the proximity of neonatal units to pediatric cardiology centers varies significantly. Currently, there is no overarching governance structure for training and accreditation in Europe. In this paper, we provide a brief description of the current training recommendations across several jurisdictions including Europe, North America, and Australia and describe the steps required to achieve a sustainable governance structure with the responsibility to provide accreditation to neonatologist performed echocardiography in Europe.

Neonatologist training in communication and palliative care.

Neonatologists receive highly varied and largely inadequate training to acquire and maintain communication and palliative care skills. Neonatology fellows often need to give distressing news to families and frequently face unique communication challenges. While several approaches to teaching these skills exist, practice opportunities through simulation and role play will likely provide the most effective learning.

Roadmap to a successful quality improvement project.

Although the benefits of quality improvement initiatives are largely understood by practicing neonatologists and perinatologists, the vast majority have not received any formal training in quality improvement methodology. Even as reporting requirements of quality metrics has increased from a number of outside agencies and public reporting entities, education for physicians regarding how to carry out quality improvement projects has largely remained the individual's responsibility. The first in a series of quality improvement education papers, we focus on the reasons why quality improvement matters and how to develop a team of stakeholders that will be functional and productive in addressing specific quality and safety concerns.

Medical improvisation training to enhance the antenatal counseling skills of neonatologists and neonatal fellows: a pilot study.

INTRODUCTION: Neonatologists must be skilled at providing antenatal counseling to expectant parents of premature infants at the limits of viability. We conducted a medical improvisation workshop with the objective of enhancing antenatal counseling skills. METHODS: Pre- and postworkshop questionnaires were collected to examine the impact of the training. A follow-up survey was distributed 3 months after the workshop to examine the impact of the training on antenatal counseling skills. RESULTS: Nine neonatologists and three neonatal fellows participated in the workshop. Participants reported the skills learned in the workshop could enhance the quality of antenatal counseling. On follow-up survey, 90% of subjects reported improvements in the quality of their antenatal counseling. DISCUSSION: Participation in a medical improvisation workshop resulted in enhancements of self-perceived antenatal counseling skills. Medical improvisation training may provide a feasible and effective method of communication training for neonatologists. Further research into this innovative method are needed.

Comparison of the Educational Needs of Neonatologists and Neonatal Nurses Regarding Palliative Care in Taiwan.

BACKGROUND: Education and training are very critical to development of high-quality neonatal palliative care. However, little investigation has been done into Taiwanese neonatal clinicians' educational needs regarding neonatal palliative care. PURPOSES: The purposes of this study were to characterize and identify neonatal clinicians' educational needs regarding neonatal palliative care. METHODS: A cross-sectional descriptive surveyed method via a self administered questionnaire was used in this research. Thirty neonatologists were recruited by a convenience sampling and 30 nurses were recruited by a randomized sampling. RESULTS: Out of sixty neonatal clinicians' survey, few had received the education in neonatal palliative care. Most reported minimal training in, experience with, and knowledge of neonatal palliative care. For neonatologists, two of twelve most strongly-felt educational needs were "discussing palliative care and ethical decision-making with parents" (70%) and "informing parents the poor progress in neonates" (63.3%). In contrast, neonatal nurses wanted more training regarding pain control (50%). Communication skills, including the discussing poor prognosis, bad news, and code status and talking with neonates about end-of-life care, were the educational need most commonly felt by both neonatologists and nurses. CONCLUSIONS: Survey data from neonatologists and neonatal nurses in Taiwan indicate a need for further training on a range of neonatal palliative care competencies.