Delivery Room Management: First Step to the Best Neonatal Outcome

Jin A Lee

doi:10.14734/kjp.2015.26.1.12

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Lee: Delivery Room Management: First Step to the Best Neonatal Outcome

Review Article

Korean J Perinatol 2015;26(1):12-20.

Published online: 20 March 2015

DOI: https://doi.org/10.14734/kjp.2015.26.1.12

Delivery Room Management: First Step to the Best Neonatal Outcome

Jin A Lee, M.D., Ph.D.

Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea

Correspondence to: Jin A Lee, M.D., Ph.D., Department of Pediatrics, Seoul National University Boramae Hospital, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 156-707, Korea Tel: +82-2-870-2364, Fax: +82-2-831-2826 E-mail: ljinna@snu.ac.kr

Received 9 February 2015 Revised 17 March 2015 Accepted 23 May 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Delivery room management is the first step to the intact survival of preterm infants, especially in the first hour of an infant's life following delivery, “a golden hour”. Admission temperature within a range of 36.5°C to 37.4°C, delayed umbilical cord clamping and cord milking, minimal oxygen supplementation, and prophylactic continuous positive airway pressure or surfactant without intubation are the cornerstones of recent delivery room management. Such managements can be supplied only by team approach including obstetrician, neonatologist, and nurses.

Keywords: Delivery room management, Preterm infant

References

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Fig. 1.

Defining the reference range for oxygen saturation for infants after birth (by Dawson et al from reference 15). (A) Term infants ≥37 weeks of gestation. (B) Preterm infants at 32 to 36 weeks of gestation. (C) Preterm infants at <32 weeks of gestation.

Table 1.

Summary of European consensus guideline 2013 by Sweet et al from reference 21

Prenatal care
– Preterm babies at risk of RDS should be born in centres where appropriate care, including MV, is available
– If possible, birth should be delayed to allow the maximum benefit of prenatal corticosteroid therapy
Delivery room stabilization
– Aim to delay cord clamping at birth by at least 60 s
– Stabilize baby in a plastic bag under a radiant warmer to prevent heat loss
– Stabilize gently, avoiding excessive tidal volumes and exposure to 100% oxygen, using pulse oximetry as a guide provided there is an adequate heart rate response
– For extremely preterm infants, consider intubation in delivery suite for prophylactic surfactant administration if antenatal steroids have not been given; for most babies, CPAP should be initiated early
Respiratory support and surfactant
– Natural surfactants should be used and given as early as possible in the course of RDS
– Repeat doses of surfactant may be required if there is ongoing evidence of RDS
– More mature babies can often be extubated to CPAP or NIPPV immediately following surfactant, and a judgement needs to be made as to whether an individual baby will tolerate this
– For those who require MV, aim to ventilate for as short a time as possible, avoiding hyperoxia, hypocarbia and volutrauma
– Caffeine therapy should be used to minimize need for and duration of ventilation
– Babies should be maintained on CPAP or NIPPV in preference to ventilation if possible
Supportive care
– Antibiotics should be started until sepsis has been ruled out unless the risk of infection is low, for example after an elective caesarean section
– Maintain body temperature in the normal range
– Careful fluid balance is required with early aggressive nutritional support using parenteral nutrition whilst enteral feeding is being established
– Blood pressure should be monitored regularly, aiming to maintain normal tissue perfusion, if necessary using inotropes
– Consideration should be given to whether pharmacological closure of the ductus arteriosus is indicated
Abbreviations: RDS, respiratory distress syndrome; CPAP, continuous positive airway pressure; NIPPV, nasal intermittent positive pressure ventilation, MV, mechanical ventilation.

Table 2.

Initial respiratory approach in delivery room for extremely low birth weight infants by Lista et al from reference 34

GA (weeks)	Intubation in DR	N-CPAP in DR	Surfactant
22.0–23.6	Elective	Not applicable	Prophylaxis
24.0–24.6	Only for severely depressed infants	Immediately at birth (valid alternative to intubation)	Early (<2–3h of life)
25.0–27.6	Only for severely depressed infants	Immediately at birth (valid alternative to intubation)	Early (<2–3h of life) and if possible as an INSURE procedure
More than 28	Only for severely depressed infants	Early, in the case of respiratory failure	As rescue if worsening of respiratory failure and if possible as an INSURE procedure

Abbreviations: GA, gestational age; DR, delivery room; N-CPAP, nasal-continuous positive airway pressure; INSURE, intubation, surfactant administration, extubation.

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