Evidence-based delivery room care of the very low birth weight infant

Recommendations for routine resuscitation of term infants are clearly stated by organizations such as the International Liaison Committee on Resuscitation (ILCOR). However, several assessments, evaluations and interventions that must be made in the first hours of life are not addressed in the ILCOR guidelines. Additionally, recommendations regarding best practices in the preterm newborn are less clearly elucidated. This review, authored by two opinion leaders of the Vermont Oxford Network (VON) Quality Collaborative, discusses some of the evidence-based potentially better practices that might improve outcome of neonatal resuscitation in the first hour of life in high-risk preterm newborns.
In particular, six evidence-based interventions were felt to be important in achieving better outcome in the delivery room. First, the use of a checklist to prepare for all high-risk neonatal resuscitations seems self-evident. In fact, resuscitation of a high-risk neonate is a complex process that requires the coordinated action of all team members. A checklist should address such domains as team functioning and equipment, multiple resources needed for resuscitation, and important medical information. Second, obtaining a pulse oximetry reading by 2 minutes of life and continuously monitoring the heart rate and oxygen saturation is crucial to avoid sub- and excessive exposure to oxygen. Third, the importance of maintaining normal temperature in very low birth weight infants should be stressed, since hypothermia can lead to increased oxygen consumption, difficult resuscitation, abnormal coagulation status, post-delivery acidosis and delayed transition from fetal to newborn circulation. Raising the delivery room temperature may be one of the most direct ways that hypothermia and cold stress can be addressed.
Other simple methods of temperature support include the use of a stockinette cap, skin-to-skin nursing and use of a warming mattress. Fourth, the authors emphasized the importance of administering surfactant as soon as possible after birth for eligible infants. Fifth, avoiding hypocapnia and hypercapnia by monitoring PaCO2 in the delivery room seems supported by a strong rationale. Last, improvements in teamwork and communication in the delivery room should be pursued by use of briefings, debriefings and other methods.
In conclusion, resuscitation of the extremely preterm infant represents one of the most critical moments in neonatal care. Current recommendations regarding the fundamental issues of resuscitation of these infants frequently do not address the specific needs of the preterm infant and do not take note of some of the nuances that might lead to improved outcome. Available evidence suggests that improved organization and teamwork, as well as improved monitoring and respiratory support can potentially improve the outcome of these infants.

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