Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review
  • Published:

Neonatal resuscitation for the preterm infant: evidence versus practice

Journal of Perinatology volume 30, pages S57–S66 (2010)Cite this article

Subjects

Abstract

In an effort to determine the actual conduct of neonatal resuscitation and the errors that may be occurring during this process, we developed a method of video recording neonatal resuscitations as an ongoing quality assurance project. We initiated video recordings of resuscitations using simple video recorders attached to an overhead warmer and reviewed the resultant tapes during biweekly quality improvement meetings. We also added the continuous recording of analog information such as heart rate, oximeter values, fraction of inspired oxygen and airway pressure. We subsequently developed a checklist that includes a preresuscitation briefing and a postresuscitation debriefing, all of which are reviewed at the same time as the video recording. We have examined the use of oxygen in the very preterm infant, the effectiveness of bag and mask ventilation, including the detection of airway obstruction during such ventilation, intubation in the delivery area and environment. In addition, we have trained our teams and leaders using Crew Resource Management and focused on improved communication. The availability of a dedicated room for resuscitation allows an increased ambient environment and the ability to provide a user-friendly setting similar to the neonatal intensive care unit to optimize performance. There are numerous opportunities for improving team and leader performance and outcomes following neonatal resuscitation. Further prospective studies are required to evaluate specific interventions.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2

Similar content being viewed by others

References

  1. US Census Bureau. International Population Reports WP/02, Global Population Profile: 2002, US Government Printing Office: Washington DC, 2004.

  2. Lawn JE, Cousens S, Zupan J . 4 million neonatal deaths: when? Where? Why? Lancet 2005; 365: 891–900.

    Article  PubMed  Google Scholar 

  3. Wass V, Van der Vleuten C, Shatzer J, Jones R . Assessment of clinical competence. Lancet 2001; 357: 945–949.

    Article  CAS  PubMed  Google Scholar 

  4. Carbine DN, Finer NN, Knodel E, Rich W . Video recording as a means of evaluating neonatal resuscitation performance. Pediatrics 2000; 106 (4): 654–658.

    Article  CAS  PubMed  Google Scholar 

  5. MacKenzie CF, Jeffries NJ, Hunter WA, Bernhard WN, Xiao Y, and the LOTAS group. Comparison of self-reporting of deficiencies in airway management with video analysis of actual performance. Hum Factors 1996; 38: 623–635.

    Article  CAS  PubMed  Google Scholar 

  6. Oakley E, Stocker S, Staubli G, Young S . Using video recording to identify management errors in pediatric trauma resuscitation. Pediatrics 2006; 117: 658–664.

    Article  PubMed  Google Scholar 

  7. Kattwinkel J (ed). Neonatal Resuscitation Textbook, 5th edn, American Academy of Pediatrics: Elk Grove Village, IL, 2006.

    Google Scholar 

  8. Leone TA, Rich W, Finer NN . A survey of delivery room resuscitation practices in the United States. Pediatrics 2006; 117 (2): e164–e175.

    Article  PubMed  Google Scholar 

  9. Vento M, Asensi M, Sastre J, Lloret A, García-Sala F, Viña J . Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen. J Pediatr 2003; 142: 240–246.

    Article  CAS  PubMed  Google Scholar 

  10. Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD . Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res 1993; 34 (6): 809–812.

    Article  CAS  PubMed  Google Scholar 

  11. Saugstad OD, Rootwelt T, Aalen O . Resuscitation of asphyxiated newborn infants with room air or oxygen: An international controlled trial: the Resair 2 study. Pediatrics 1998; 102 (1): E11–E17.

    Article  Google Scholar 

  12. Saugstad OD, Ramji S, Irani SF, El-Meneza S, Hernandez EA, Vento M . Resuscitation of newborn infants with 21 or 100% oxygen: follow-up at 18 to 24 months. Pediatrics 2003; 112: 296.

    Article  PubMed  Google Scholar 

  13. Saugstad OD, Ramji S, Vento M . Resuscitation of depressed newborn infants with ambient air or pure oxygen: a meta-analysis. Biol Neonate 2005; 87 (1): 27–34.

    Article  PubMed  Google Scholar 

  14. Tan A, Schulze A, O’Donnell CPF, Davis PG . Air versus oxygen for resuscitation of infants at birth. The Cochrane Database of Systematic Reviews 2005, Issue 3. Art. no.: CD002273..

  15. Davis PG, Tan A, ODonnell CPF, Schulze A . Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet 2004; 364 (9442): 1329–1333.

    Article  PubMed  Google Scholar 

  16. Ramji S, Saugstad OD . Use of 100% Oxygen or room air in neonatal resuscitation. Neoreviews 2005; 6 (#4): e172.

    Article  Google Scholar 

  17. Saugstad OD, Ramji S, Soll RF, Vento M . Resuscitation of newborn infants with 21 or 100% oxygen: an updated systematic review and meta-analysis. Neonatology 2008; 94 (3): 176–182.

    Article  CAS  PubMed  Google Scholar 

  18. Smith CV, Hansen TN, Martin NE, McMicken HW, Elliott SJ . Oxidant stress responses in premature infants during exposure to hyperoxia. Pediatr Res 1993; 34: 360–365.

    Article  CAS  PubMed  Google Scholar 

  19. Frank L, Sosenko IR . Development of lung antioxidant enzyme system in late gestation: Possible implications for the prematurely born infant. J Pediatr 1987; 110: 9–14.

    Article  CAS  PubMed  Google Scholar 

  20. Walther FJ, Wade AB, Warburton D, Forman HJ . Ontogeny of antioxidant enzymes in the fetal lamb lung. Exp Lung Res 1991; 17: 39–45.

    Article  CAS  PubMed  Google Scholar 

  21. Frank L, Sosenko IR . Failure of premature rabbits to increase antioxidant enzymes during hyperoxic exposure: Increased susceptibility to pulmonary oxygen toxicity compared with term rabbits. Pediatr Res 1991; 29: 292–296.

    Article  CAS  PubMed  Google Scholar 

  22. Silvers KM, Gibson AT, Russell JM, Powers HJ . Antioxidant activity, packed cell transfusions, and outcome in premature infants. Arch Dis Child 1998; 78 (3): F214–F219.

    Article  CAS  Google Scholar 

  23. Lakshminrusimha S, Russell JA, Steinhorn RH, Ryan RM, Gugino SF, Morin III FC et al. Pulmonary arterial contractility in neonatal lambs increases with 100% oxygen resuscitation. Pediatr Res 2006; 59: 137–141.

    Article  PubMed  Google Scholar 

  24. Kumar VH, Nielsen LC, Bevilacqua B, Wynn KA, Wang H, Morin FC et al. Resuscitation in room air compared to 100% oxygen lowers oxidative stress without increasing metabolic acidosis in term newborn lambs. PAS 2005; 57: 37.

    Google Scholar 

  25. Wang CL, Anderson C, Leone TA, Rich W, Govindaswami B, Finer NN . Resuscitation of preterm neonates by using room air or 100% oxygen. Pediatrics 2008; 121: 1083–1089.

    Article  PubMed  Google Scholar 

  26. Escrig R, Arruza L, Izquierdo I, Villar G, Saenz P, Gimeno A et al. Achievement of targeted saturation values in extremely low gestational age neonates resuscitated with low or high oxygen concentrations: a prospective, randomized trial. Pediatrics 2008; 121: 875–881.

    Article  PubMed  Google Scholar 

  27. Rabi Y, Nettel-Aguirre A, Singhal N . Room air versus oxygen administration during resuscitation of preterm infants (ROAR Study). EPAS 2008; 5127.5.

  28. Vento M, Moro M, Escrig R, Arruza L, Villar G, Izquierdo I et al. Preterm resuscitation with low oxygen causes less oxidative stress, inflammation, and chronic lung disease. Pediatrics 2009; 124: e439–e449.

    Article  PubMed  Google Scholar 

  29. Harling AE, Beresford MW, Vince GS, Bates M, Yoxall CW . Does use of 50% oxygen at birth in preterm infants reduce lung injury? Arch Dis Child Fetal Neonatal Ed 2005; 90: F401–F405.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Ezaki S, Suzuki K, Kurishima C, Miura M, Weilin W, Hoshi R et al. Resuscitation of preterm infants with reduced oxygen results in less oxidative stress than resuscitation with 100% oxygen. J Clin Biochem Nutr 2009; 44 (1): 111–118.

    Article  PubMed  Google Scholar 

  31. Finer N, Saugstad O, Vento M, Barrington K, Davis P, Duara S et al. Use of oxygen for resuscitation of the extremely low birth weight infant. Pediatrics 2010; 125 (2): 389–391.

    Article  PubMed  Google Scholar 

  32. Sendak MJ, Harris AP, Donham RT . Use of pulse oximetry to assess arterial oxygen saturation during newborn resuscitation. Crit Care Med 1986; 14 (8): 739–740.

    Article  CAS  PubMed  Google Scholar 

  33. Maxwell LG, Harris AP, Sendak MJ, Donham RT . Monitoring the resuscitation of preterm infants in the delivery room using pulse oximetry. Clin Pediatr 1987; 26 (1): 18–20.

    Article  CAS  Google Scholar 

  34. Reddy VK, Holzman IR, Wedgwood JS . Pulse oximetry saturations in the first 6 h of life in normal term infants. Clin Pediatr 1999; 38 (2): 87–92.

    Article  CAS  Google Scholar 

  35. Meier-Stauss P, Bucher HU, Hurlimann R, Konig V, Huch R . Pulse oximetry used for documenting oxygen saturation and right-to-left shunting immediately after birth. Eur J Pediatr 1990; 149: 135.

    Article  Google Scholar 

  36. Harris AP, Sendak MJ, Donham RT . Changes in arterial oxygen saturation immediately after birth in the human neonate. J Pediatr 1986; 109 (1): 117–119.

    Article  CAS  PubMed  Google Scholar 

  37. Saugstad OD . Oxygen saturations immediately after birth. J Pediatr 2006; 148 (5): 569–570.

    Article  PubMed  Google Scholar 

  38. Dawson JA, Kamlin CO, Wong C, Te Pas A, O’Donnell CP, Donath SM et al. Oxygen saturation and heart rate during delivery room resuscitation of infants <30 weeks gestation with air or 100% oxygen. Arch Dis Child Fetal Neonatal Ed 2009; 94 (2): F87–F91.

    Article  CAS  PubMed  Google Scholar 

  39. Nijland R, Jongsma HW, Nijhuis JG, van den Berg PP, Oeseburg B . Arterial oxygen saturation in relation to metabolic acidosis in fetal lambs. Am J Obstet Gynecol 1995; 172: 810–819.

    Article  CAS  PubMed  Google Scholar 

  40. Dildy GA, van den Berg PP, Katz M, Clark SL, Jongsma HW, Nijhuis JG et al. Intrapartum fetal pulse oximetry: fetal oxygen saturation trends during labor and relation to delivery outcome. Am J Obstet Gynecol 1994; 171: 679–684.

    Article  CAS  PubMed  Google Scholar 

  41. Sendak MJ, Harris AP, Donham RT . Use of pulse oximetry to assess arterial oxygen saturation during newborn resuscitation. Crit Care Med 1986; 14: 739–740.

    Article  CAS  PubMed  Google Scholar 

  42. Maxwell LG, Harris AP, Sendak MJ, Donham RT . Monitoring the resuscitation of preterm infants in the delivery room using pulse oximetry. Clin Pediatr 1987; 26: 18–20.

    Article  CAS  Google Scholar 

  43. Reddy VK, Holzman IR, Wedgwood JF . Pulse oximetry saturations in the first 6 h of life in normal term infants. Clin Pediatr 1999; 38: 87–92.

    Article  CAS  Google Scholar 

  44. Meier-Stauss P, Bucher HU, Hurlimann R, Konig V, Huch R . Pulse oximetry used for documenting oxygen saturation and right-to-left shunting immediately after birth. Eur J Pediatr 1990; 149: 851–855.

    Article  CAS  PubMed  Google Scholar 

  45. Harris AP, Sendak MJ, Donham RT . Changes in arterial oxygen saturation immediately after birth in the human neonate. J Pediatr 1986; 109: 117–119.

    Article  CAS  PubMed  Google Scholar 

  46. House JT, Schultetus RR, Gravenstein N . Continuous neonatal evaluation in the delivery room by pulse oximetry. J Clin Monit 1987; 3: 96–100.

    Article  CAS  PubMed  Google Scholar 

  47. Dimich I, Singh PP, Adell A, Hendler M, Sonnenklar N, Jhaveri M . Evaluation of oxygen saturation monitoring by pulse oximetry in neonates in the delivery system. Can J Anaesth 1991; 38: 985–988.

    Article  CAS  PubMed  Google Scholar 

  48. Toth B, Becker A, Seelbach-Gobel B . Oxygen saturation in healthy newborn infants immediately after birth measured by pulse oximetry. Arch Gynecol Obstet 2002; 266: 105–107.

    Article  CAS  PubMed  Google Scholar 

  49. Mariani G, Brener P, Ezquer A, Aguirre A, Esteban ML, Perez C et al. Pre-ductal and post-ductal O-2 saturation in healthy term neonates after birth. J Pediatr 2007; 150: 418–421.

    Article  PubMed  Google Scholar 

  50. Rabi Y, Yee W, Chen SY, Singhal N . Oxygen saturation trends immediately after birth. J Pediatr 2006; 148: 590–594.

    Article  PubMed  Google Scholar 

  51. Kamlin COF, O’Donnell CPF, Davis PG, Morley CJ . Oxygen saturation in healthy infants immediately after birth. J Pediatr 2006; 148: 585–589.

    Article  PubMed  Google Scholar 

  52. Kelm M, Proquitté H, Schmalisch G, Roehr CC . Reliability of two common PEEP-generating devices used in neonatal resuscitation. Klin Padiatr 2009; 221 (7): 415–418.

    Article  CAS  PubMed  Google Scholar 

  53. Hoskyns EW, Milner AD, Hopkin IE . A simple method of face mask resuscitation at birth. Arch Dis Child 1987; 62 (4): 376–378.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Tracy M, Downe L, Holberton J . How safe is intermittent positive pressure ventilation in preterm babies ventilated from delivery to newborn intensive care unit? Arch Dis Child Fetal Neonatal Ed 2004; 89 (1): F84–F87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Leone TA, Lange A, Rich W, Finer NN . Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during noninvasive mask ventilation. Pediatrics 2006; 118 (1): e202–e204.

    Article  PubMed  Google Scholar 

  56. Finer NN, Rich W, Wang C, Leone T . Airway obstruction during mask ventilation of very low birth weight infants during neonatal resuscitation. Pediatrics 2009; 123 (3): 865–869.

    Article  PubMed  Google Scholar 

  57. Garey D, Rich W, Leone T, Finer N . Supplemental training to improve neonatal resuscitation skills in pediatric residents. E-PAS 2009; 4322.48. http://www.abstracts2view.com/pasall/view.php?nu=PAS09L1_2698.

  58. de Oliveira Filho GR . The construction of learning curves for basic skills in anesthetic procedures: an application of the cumulative sum method. Anesth Analg 2002; 95: 411–416.

    PubMed  Google Scholar 

  59. Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law JA, Pytka S et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98: 23–27.

    Article  PubMed  Google Scholar 

  60. Konrad C, Schüpfer G, Wietlisbach M, Gerber H . Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86: 635–639.

    Article  CAS  PubMed  Google Scholar 

  61. Kelly MA, Finer NN . Nasotracheal intubation in the neonate: physiologic responses and effects of atropine and pancuronium. J Pediatr 1984; 105 (2): 303–309.

    Article  CAS  PubMed  Google Scholar 

  62. Finer NN, Rich W . Neonatal resuscitation: toward improved performance. Resuscitation 2002; 53 (1): 47–51.

    Article  PubMed  Google Scholar 

  63. Leone TA, Rich W, Finer NN . Neonatal intubation: success of pediatric trainees. J Pediatr 2005; 146 (5): 638–641.

    Article  PubMed  Google Scholar 

  64. Carbine DN, Finer NN, Knodel E, Rich W . Video recording as a means of evaluating neonatal resuscitation performance. Pediatrics 2000; 106 (4): 654–658.

    Article  CAS  PubMed  Google Scholar 

  65. Lane B, Finer NN, Rich W . Duration of intubation attempts during neonatal resuscitation. J Pediatr 2004; 145 (1): 67–70.

    Article  PubMed  Google Scholar 

  66. O’Donnell CP, Kamlin CO, Davis PG, Morley CJ . Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics 2006; 117 (1): e16–e21.

    Article  PubMed  Google Scholar 

  67. Bosma J . Anatomy of the Infant Head. The John Hopkins University Press: Baltimore, USA, 1985, pp 25.

    Google Scholar 

  68. Fishman RA, Pashley NR . A study of the premature neonatal airway. Otolaryngol Head Neck Surg 1981; 89 (4): 604–607.

    Article  CAS  PubMed  Google Scholar 

  69. Schild JA . Relationship of laryngeal dimensions to body size and gestational age in premature neonates and small infants. Laryngoscope 1984; 94 (10): 1284–1292.

    Article  CAS  PubMed  Google Scholar 

  70. Westhorpe RN . The position of the larynx in children and its relationship to the ease of intubation. Anaesth Intensive Care 1987; 15 (4): 384–388.

    Article  CAS  PubMed  Google Scholar 

  71. Albert DM, Mills RP, Fysh J, Gamsu H, Thomas JN . Endoscopic examination of the neonatal larynx at extubation: a prospective study of variables associated with laryngeal damage. Int J Pediatr Otorhinolaryngol 1990; 20 (3): 203–212.

    Article  CAS  PubMed  Google Scholar 

  72. Woody NC, Woody HB . Direct digital intratracheal intubation for neonatal resuscitation. J Pediatr 1968; 73 (6): 903–905.

    Article  CAS  PubMed  Google Scholar 

  73. Moura JH, da Silva GA . Neonatal laryngoscope intubation and the digital method: a randomized controlled trial. J Pediatr 2006; 148 (6): 840–841.

    Article  PubMed  Google Scholar 

  74. Thorington J . Refraction of the Human Eye and Methods of Estimating the Refraction. Blakiston: Philadelphia, 1930.

    Google Scholar 

  75. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA . Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anesth 2005; 52 (2): 191–198.

    Article  PubMed  Google Scholar 

  76. Vanderhal AL, Berci G, Simmons Jr CF, Hagiike M . A videolaryngoscopy technique for the intubation of the newborn: preliminary report. Pediatrics 2009; 124 (2): e339–e346.

    Article  PubMed  Google Scholar 

  77. Vento M, Aguar M, Leone TA, Finer NN, Gimeno A, Rich W et al. Using intensive care technology in the delivery room: a new concept for the resuscitation of extremely preterm neonates. Pediatrics 2008; 122 (5): 1113–1116.

    Article  PubMed  Google Scholar 

  78. Vohra S, Frent G, Campbell V, Abbott M, Whyte R . Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. J Pediatr 1999; 134 (5): 547–551.

    Article  CAS  PubMed  Google Scholar 

  79. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B . Heat loss prevention (HeLP) in the delivery room: a randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr 2004; 145 (6): 750–753.

    Article  PubMed  Google Scholar 

  80. Cramer K, Wiebe N, Hartling L, Crumley E, Vohra S . Heat loss prevention: a systematic review of occlusive skin wrap for premature neonates. J Perinatol 2005; 25 (12): 763–769.

    Article  PubMed  Google Scholar 

  81. Helmreich R, Merritt A, John A . The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol 1999; 9 (1): 19–32.

    Article  CAS  PubMed  Google Scholar 

  82. Cooper S, Wakelam A . Leadership of resuscitation teams: ‘Lighthouse Leadership’. Resuscitation 1999; 42 (1): 27–45.

    Article  CAS  PubMed  Google Scholar 

  83. Finer NN, Rich W . Neonatal resuscitation: toward improved performance. Resuscitation 2002; 53 (1): 47–51.

    Article  PubMed  Google Scholar 

  84. Cooper GE, White MD, Lauber JK . Resource Management on the Flightdeck: Proceedings of a NASA/Industry Workshop (NASA CP-2120). NASA-Ames Research Center: Moffett Field, CA, 1980.

    Google Scholar 

  85. Lockyer J, Singhal N, Fidler H, Weiner G, Aziz K, Curran V . The development and testing of a performance checklist to assess neonatal resuscitation megacode skill. Pediatr 2006; 118: e1739–e1744.

    Article  Google Scholar 

  86. Schmölzer GM, Kamlin OC, Dawson JA, te Pas AB, Morley CJ, Davis PG . Respiratory monitoring of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 2010; 95 (4): F295–F303.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California San Diego Medical Center and School of Medicine, San Diego, CA, USA

    N Finer & W Rich

Authors
  1. N Finer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. W Rich
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N Finer.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Additional information

This paper resulted from the Evidence vs. Experience in Neonatal Practices Conference, 19–20 June 2009, sponsored by Dey LP.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Finer, N., Rich, W. Neonatal resuscitation for the preterm infant: evidence versus practice. J Perinatol 30 (Suppl 1), S57–S66 (2010). https://doi.org/10.1038/jp.2010.115

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2010.115

Keywords

This article is cited by

Search

Advanced search

Quick links