Elsevier

Early Human Development

Volume 87, Issue 11, November 2011, Pages 749-753
Early Human Development

Preterm resuscitation I: Clinical approaches to improve management in delivery room

https://doi.org/10.1016/j.earlhumdev.2011.08.019Get rights and content

Abstract

Delivery room (DR-) management has a great potential to optimise quality of long term outcome in extremely preterm infants. However, a new conceptual framework that focuses on an individualised ‘support of transition’ rather than on ‘resuscitation’ is necessary.

Video-recordings of DR-management represent a valuable tool to improve care. Recording combined with a structured feed-back should be introduced in step-wise approach in clinical routine.

To describe the postnatal condition of groups of infants or to compare interventions in a research setting, a numerical score – representing the sum of several objective findings – is required. The conventional Apgar-Score has severe limitations that restrict its applicability. The Specified-Apgar allows an assessment of infant's condition independent of interventions and regardless of gestational age. The Expanded-Apgar quantifies the interventions needed to achieve the condition described by the Specified-Apgar.

In summary, beside a new conceptual framework an individualised monitoring and an objective assessment of DR-management are required.

Introduction

More than half a century ago, Virginia Apgar started her seminal paper as follows: “Resuscitation of infants at birth has been the subject of many articles. Seldom have there been such imaginative ideas, such enthusiasm, and dislikes, and such unscientific observations and study about one clinical picture. There are outstanding exceptions to these statements, but the poor quality and lack of precise data of the majority of papers concerned with infant resuscitation are interesting.” [1].

Whereas only a few clinical studies upon delivery room management were performed in the years thereafter, scientific interest in the first minutes of life increased during the last decade. Data from several research groups provide the scientific basis for an evidence based approach on delivery room management. Subsequently, the European Scientific Collaboration for neonatal Resuscitation Research (ESCNR) was founded. The aim of our group is an intensive scientific collaboration to combine expertise and to formulate and answer important questions on DR-management.

Over the last years, different aspects of DR-management have been studied in detail, such as: evaluation of infant's condition, monitoring, respiratory support, including surfactant administration, oxygen supplementation, and improvement in early maternal attachment. Some of these aspects will be discussed by Morley et al. in this issue. The present article focuses on a clinical framework that increases awareness of neonatologists on special needs of extremely preterm infants during the period of postnatal transition. Management of this vulnerable population in the delivery room has to be individualised. To do so, a critical appraisal of the infant's need is necessary, requiring a new approach on the assessment of postnatal condition and response to clinical interventions.

Section snippets

Changes in DR-management as a chance to improve outcome of preterm infants

The outcome of preterm infants has improved significantly during the end of the last century. Mortality decreased and quality of survival increased mainly due to new interventions, such as surfactant administration, new drugs and changes in therapeutic strategies. Results of large randomised controlled trials allow an evidence-based treatment of many problems commonly associated with prematurity.

In contrast to these significant achievements of the past, there was only small improvement during

An individualised monitoring of DR-management

Prerequisite for adapting DR-management to the individual needs of extremely preterm infants is a critical assessment of medical care provided in the context of the postnatal transition process.

Different methods are available to assess medical care that is provided [12]. Clinician surveys are tested tools that enable a rigorous assessment of various interventions. These tools are based on self-report. However, individual's perception may differ from behaviour observed by others. Furthermore,

A standardised assessment of DR-management

The detailed analysis and description of the postnatal condition and performed interventions represent a good way to improve the care of an individual infant. However, this method is not applicable to describe the postnatal condition of groups of infants or to compare effects of intervention in a research setting. A numerical score – representing the sum of several objective findings – will be more appropriate for that purpose.

Conflict of interest

Nicole Braun and Mario Rüdiger received a grant from the Else Kröner-Fresenius-Stiftung to perform TEST-APGAR study. The other authors have no conflict of interest to disclose.

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