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Timelines from birth to arrival at the resuscitation bay, assessment of initial heart rate, and initiation of positive pressure ventilation for apnoeic or inadequately breathing newborns. The boxes represent the median, first and third quartile and the whiskers represent the range without outliers. Values in headings are shown as median (IQR).
Source publication
Objective:
Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate complia...
Contexts in source publication
Context 1
... these, 22/62 (35%) had the initial HR assessed and 22/62 (35%) PPV initiated within the first 60 s of birth. The timelines from birth to arrival at the resuscitation bay, initial assessment of HR, and initiation of PPV are shown in Figure 1. The time from arrival at the resuscitation bay to the first assessment of HR and initiation of PPV was 23 (10-46) and 22 (12-42) s. ...
Context 2
... these, 22/62 (35%) had the initial HR assessed and 22/62 (35%) PPV initiated within the first 60 s of birth. The timelines from birth to arrival at the resuscitation bay, initial assessment of HR, and initiation of PPV are shown in Figure 1. The time from arrival at the resuscitation bay to the first assessment of HR and initiation of PPV was 23 (10-46) and 22 (12-42) s. ...
Similar publications
Background
The quality of neonatal resuscitation after delivery needs to be improved to reach the Sustainable Development Goals 3.2 (reducing neonatal deaths to <12/1,000 live newborns) by the year 2030. Studies have emphasized the importance of correctly performing the basic steps of resuscitation including stimulation, heart rate assessment, vent...
Citations
... Fourteen studies addressed this comparison. 18,[23][24][25][26][28][29][30]32,33,[41][42][43][44] There were three RCTs including 187 newborns and eleven observational studies including 452 newborns (Table 2). In all observational studies, both ECG and pulse oximetry were used for all newborns, hence each infant served as its own control. ...
... Observational studies: This was reported in 6 studies including 265 infants. 23,25,28,29,32,44 Pulse oximetry was slower than ECG from device placement (HR PO was 57 s slower, 95% CI (13 s slower to 101 s slower), p < 0.05). The evidence was of low certainty, downgraded for RoB and imprecision. ...
... Observational studies: This was reported in 6 studies including 321 infants. 23,24,26,31,33,44 Pulse oximetry was slower than ECG (HR PO 52 s slower, 95% CI (9 s slower to 94 s slower), p < 0.05). The evidence was of low certainty, downgraded for RoB and imprecision. ...
Aim
To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth.
Methods
A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.
Results
Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes.
Limitations
Certainty of evidence was low or very low for most comparisons.
Conclusion
If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.
... Several studies have shown a wide variation in compliance with guidelines with regard to time from birth to initiation of PPV. [20][21][22] This suggests that healthcare providers find it challenging to promptly identify newborns in need of PPV. In the present study, the proportion of newborns who required PPV increased when bradycardia persisted at 1 min after birth. ...
Objective
To determine the prevalence of bradycardia in the first minute after birth and association with positive pressure ventilation (PPV).
Method
A population-based cross-sectional study was conducted from June 2019 to December 2021 at Stavanger University Hospital, Norway. Parents consented to participation during pregnancy, and newborns ≥28 weeks’ gestation were included at birth. Heart rate (HR) was captured immediately after birth and continuously for the first minute(s). Time of birth was registered on a tablet. Provision of PPV was captured using video.
Results
Of 4876 included newborns, 164 (3.4%) did not breathe (two-thirds) or breathed ineffectively (one-third) and received PPV at birth. HR in the first minute had a wide distribution. The prevalence of first measured HR <100 and <60 beats/minute at median 16 s was 16.3% and 0.6%, respectively. HR increased in most cases. At 60 s, 3.7% had HR <100 beats/minute, of which 82% did not require PPV. In total, 25% of newborns had some registered HR <100 beats/minute during the first minute, of which 95% did not require PPV. Among newborns who received PPV, 76% and 62% had HR ≥100 beats/minute at 60 s and at start PPV, respectively.
Conclusion
Bradycardia with HR <100 bpm in the first minute of life was frequent, but mostly self-resolved. Among the 4% of newborns that remained bradycardic at 60 s, only 20% received PPV. Two-thirds of resuscitated newborns had HR ≥100 beats/minute at start PPV. None of the ventilated newborns were breathing adequately at start PPV.
Trial registration number
NCT03849781 .
... Continuous monitoring with pulse oximetry (PO) ± electrocardiogram (ECG) has the advantage of providing a more dynamic indication of HR changes and information on the responses to resuscitative interventions [5]. Several studies have shown that ECG presents HR more rapidly than PO, and that PO may underestimate HR in the initial minutes [7][8][9][10][11][12]. The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR) therefore recommend the use of ECG for newborn HR assessment during delivery room resuscitation whenever possible [3,5]. ...
... The PO sig tated based on reviewing a recording of the monitor screen. The time to relia was defined as the time when a continuous pulse wave, HR, and/or saturatio displayed for at least 3 s [7,12,14]. ...
... Similar findings have been reported previously, with a success rate in obtaining saturation measurements varying between 20-100% at one minute after birth [18]. Several studies have found that reliable PO signals are rarely available in the first two minutes after birth [6][7][8]19,20]. A previous study by our team demonstrated that PO signal may be delayed in newborns with low APGAR scores, who represent the group in most need of HR feedback [7]. ...
Background:
European guidelines recommend the use of pulse oximetry (PO) during newborn resuscitation, especially when there is a need for positive pressure ventilation or supplemental oxygen. The objective was to evaluate (i) to what extent PO was used, (ii) the time and resources spent on the application of PO, and (iii) the proportion of time with a useful PO signal during newborn resuscitation.
Methods:
A prospective observational study was conducted at Stavanger University Hospital, Norway, between 6 June 2019 and 16 November 2021. Newborn resuscitations were video recorded, and the use of PO during the first ten minutes of resuscitation was recorded and analysed.
Results:
Of 7466 enrolled newborns, 289 (3.9%) received ventilation at birth. The resuscitation was captured on video in 230 cases, and these newborns were included in the analysis. PO was applied in 222 of 230 (97%) newborns, median (quartiles) 60 (24, 58) seconds after placement on the resuscitation table. The proportion of time used on application and adjustments of PO during ongoing ventilation and during the first ten minutes on the resuscitation table was 30% and 17%, respectively. Median two healthcare providers were involved in the PO application. Video of the PO monitor signal was available in 118 (53%) of the 222 newborns. The proportion of time with a useful PO signal during ventilation and during the first ten minutes on the resuscitation table was 5% and 35%, respectively.
Conclusion:
In total, 97% of resuscitated newborns had PO applied, in line with resuscitation guidelines. However, the application of PO was time-consuming, and a PO signal was only obtained 5% of the time during positive pressure ventilation.
... Takes time to achieve reliable recordings. [198][199][200] Frequently underestimates heart rate. 201 Loss of signals due to contact disturbances or low peripheral circulation. ...
... 201 Loss of signals due to contact disturbances or low peripheral circulation. [198][199][200] Introduction 31 ...
Background: An estimated 0.7 million newborns die due to perinatal asphyxia each year, most are born at or near term. The major burden of preventable newborn deaths occur in low-resourced settings. A self-inflating bag is the most used and available equipment to save newborn lives globally. To aerate the lungs is key to survival. Expired CO2 (ECO2) may be an indicator for lung aeration, and positive end-expiratory pressure (PEEP) may facilitate aeration of the lungs. Research aiming to improve ventilation in term and near-term newborns using a self-inflating bag is needed. Aims: To investigate interpretation of ECO2 measured during bag-mask ventilation in the immediate newborn period, and assess whether this can be used as a marker for lung aeration, effective ventilation technique and prognosis. To study the effects of PEEP during bag-mask ventilation at or near term. Methods: Two observational studies and one randomized clinical trial were performed at Haydom Lutheran Hospital in Tanzania. Data were collected using direct observation, side-stream CO2-monitoring, respiratory function monitoring and dry-electrode ECG. In the randomized trial, newborns in need of ventilation were assigned in blocks based on weeks to receive ventilations by self-inflating bag with or without a PEEP-valve. Results: ECO2 during bag-mask ventilation at birth was significantly associated with both ventilation factors and clinical factors. Tidal volumes of 10-14 ml/kg and a low ventilation frequency of around 30 inflations/minute were associated with the fastest rise and highest levels of ECO2. ECO2 increased before heart rate, and measured levels of ECO2 during resuscitation could, similar to heart rate, predict 24-hours survival. Adding a PEEP-valve to the self-inflating bag did not improve heart rate, ECO2 or outcomes in term and near-term newborns despite delivery of an adequate PEEP. Conclusions: ECO2 may be seen as a combined marker for lung aeration, airway patency and pulmonary circulation at birth. Tidal volumes of 10-14 ml/kg and ventilation frequencies of around 30 inflations/minute may be favorable to achieve a fast lung aeration. We found no clinical benefit of adding a PEEP-valve during bag-mask ventilation at birth in term and near-term newborns, and our study does not support routine use.
... Open access (by stethoscope or palpation) was 70 s (47-118) and preceded initiation of PPV at 78 s (42-118), despite the newborns being placed at the resuscitaire 48 s (22-68) after birth. 7 Assessment of HR may delay starting PPV, and existing technology of standard three-lead ECG and pulse oximetry (PO) has made it difficult to obtain accurate and continuous HR measurements during the first minutes of life when important decisions are made on whether to initiate resuscitation or not. 3 NeoBeat newborn HR metre (Laerdal Global Health, Stavanger, Norway) was developed for immediate and continuous feedback on HR to guide newborn resuscitation. NeoBeat is a reusable, wireless, low-cost dry electrode ECG device that can rapidly be applied around the newborn's thorax or upper abdomen without prior drying of the skin. ...
Introduction
3%–8% of newborns need positive pressure ventilation (PPV) after birth. Heart rate (HR) is considered the most sensitive indicator of the newborns’ condition and response to resuscitative interventions. According to guidelines, HR should be assessed and PPV initiated within 60 s after birth in non-breathing newborns. Dry electrode ECG can provide accurate feedback on HR immediately after birth and continuously during resuscitation. The impact of early and continuous HR feedback is unknown.
Method and analysis
This single-centre randomised controlled trial seeks to determine if HR feedback by dry electrode ECG immediately after birth and continuously during newborn resuscitation results in more timely initiation of PPV, improved ventilation and short-term outcomes compared with standard HR assessment.
In all newborns≥34 gestational weeks, the dry electrode ECG sensor is placed on the upper abdomen immediately after birth as an additional modality of HR assessment. The device records and stores HR signals. In intervention subjects, the HR display is visible to guide decision-making and further management, in control subjects the display is masked. Standard HR assessment is by stethoscope, gel-electrode ECG and/or pulse oximetry (PO).
Time of birth is registered in the Liveborn app. Time of initiation and duration of PPV is calculated from video recordings. Ventilation parameters are retrieved from the ventilation monitor, oxygen saturation and HR from the PO and gel-electrode ECG monitors.
The primary endpoint is proportion of resuscitated newborns who receive PPV within 60 s after birth. To detect a 50% increase with power of 90% using an overall significance level of 0.05 and 1 interim analysis, 169 newborns are needed in each group.
Ethics and dissemination
Approval by the Norwegian National Research Ethics Committee West (2018/338). Parental consent is sought at routine screening early in pregnancy. The results will be published in peer-reviewed journal and presented at conferences.
Trial registration number
NCT03849781 .
... Our hospital has a long tradition and culture for simulation training. 8,19,20 Other hospitals without a similar simulation culture might experience institutional challenges introducing simulation training. 21,22 Thus, we are currently testing our simulation training curriculum in a nation-wide study in Norway. ...
Objective
Metric based virtual reality simulation training may enhance the capability of interventional neuroradiologists (INR) to perform endovascular thrombectomy. As pilot for a national simulation study we examined the feasibility and utility of simulated endovascular thrombectomy procedures on a virtual reality (VR) simulator.
Methods
Six INR and four residents participated in the thrombectomy skill training on a VR simulator (Mentice VIST 5G). Two different case-scenarios were defined as benchmark-cases, performed before and after VR simulator training. INR performing endovascular thrombectomy clinically were also asked to fill out a questionnaire analyzing their degree of expectation and general attitude towards VR simulator training.
Results
All participants improved in mean total procedure time for both benchmark-cases. Experts showed significant improvements in handling errors (case 2), a reduction in contrast volume used (case 1 and 2), and fluoroscopy time (case 1 and 2). Novices showed a significant improvement in steps finished (case 2), a reduction in fluoroscopy time (case 1), and radiation used (case 1). Both, before and after having performed simulation training the participating INR had a positive attitude towards VR simulation training.
Conclusion
VR simulation training enhances the capability of INR to perform endovascular thrombectomy on the VR simulator. INR have generally a positive attitude towards VR simulation training. Whether the VR simulation training translates to enhanced clinical performance will be evaluated in the ongoing Norwegian national simulation study.
... To obtain rapid and reliable heart rate monitoring during newborn resuscitation is challenging. Comparative studies show that electrocardiogram (ECG) provide feedback of heart rate earlier than pulse oximetry, and pulse oximetry can underestimate initial heart rate [4][5][6][7][8][9]. The International Liaison Committee on Resuscitation (ILCOR) suggests using ECG for accurate estimation of heart rate during newborn resuscitation, and emphasizes the importance of speed and reliablity [3,10]. ...
Objective
To compare the accuracy of heart rate detection properties of a novel, wireless, dry-electrode electrocardiogram (ECG) device, NeoBeat®, to that of a conventional 3-lead gel-electrode ECG monitor (PropaqM®) in newborns.
Results
The study population had a mean gestational age of 39 weeks and 2 days (1.5 weeks) and birth weight 3528 g (668 g). There were 950 heart rate notations from each device, but heart rate was absent from the reference monitor in 14 of these data points, leaving 936 data pairs to compare. The mean (SD) difference when comparing NeoBeat to the reference monitor was -0.25 (9.91) beats per minute (bpm) ( p = 0.44). There was a deviation of more than 10 bpm in 7.4% of the data pairs, which primarily (78%) was attributed to ECG signal disturbance, and secondly (22%) due to algorithm differences between the devices. Excluding these outliers, the correlation was equally consistent (r ² = 0.96) in the full range of heart rate captured measurements with a mean difference of − 0.16 (3.09) bpm. The mean difference was less than 1 bpm regardless of whether outliers were included or not.
... 24 However, failing to initiate proper ventilation within the first minute and applying suboptimal PPV are also common in high-resource settings. [25][26][27] Specifically, a study from a tertiary hospital in Norway reports a median time from arriving to the table to initiation of PPV of 42 s and 56% of neonates received PPV, with a 60% ventilation fraction during the first 30 s. 25 The time to initiation of PPV was considerably longer in our study and does not commence within the recommended golden minute after birth. However, primarily due to logistical reasons, the time from birth to resuscitation was significantly longer for neonates in the labour ward. ...
Background
Neonatal mortality, often due to birth asphyxia, remains stubbornly high in sub-Saharan Africa. Guidelines for neonatal resuscitation, where achieving adequate positive pressure ventilation (PPV) is key, have been implemented in low-resource settings. However, the actual clinical practices of neonatal resuscitation have rarely been examined in these settings. The primary aim of this prospective observational study was to detail the cumulative proportion of time with ventilation during the first minute on the resuscitation table of neonates needing PPV at the Mulago National Referral Hospital in Kampala, Uganda.
Methods
From November 2015 to January 2016, resuscitations of non-breathing neonates by birth attendants were video-recorded using motion sensor cameras. The resuscitation practices were analysed using the application NeoTapAS and compared between those taking place in the labour ward and those in theatre through Fisher’s exact test and Wilcoxon rank-sum test.
Results
From 141 recorded resuscitations, 99 were included for analysis. The time to initiation of PPV was 66 (42–102) s overall, and there was minimal PPV during the first minute in both groups with 0 (0–10) s and 0 (0–12) s of PPV, respectively. After initiating PPV the overall duration of interruptions during the first minute was 28 (18–37) s. Majority of interruptions were caused by stimulation (28%), unknown reasons (25%) and suction (22%).
Conclusions
Our findings show a low adherence to standard resuscitation practices in 2015–2016. This emphasises the need for continuous educational efforts and investments in staff and adequate resources to increase the quality of clinical neonatal resuscitation practices in low-resource settings.
... (7) ECG may be faster and more reliable than pulse oximetry or auscultation in providing accurate HR assessment, with no technical difficulties in applying the leads. (6,7,53) A study from a local neonatal unit showed that not only was it faster to apply the ECG leads than a pulse oximetry probe (27 seconds vs. 33.5 seconds, p < 0.001), but reliable data acquisition was also faster with ECG (10 seconds vs. 30.5 seconds, p < 0.001). (54) However, ECG cannot replace the need for pulse oximetry to assess oxygenation and perfusion. ...
Neonatal resuscitation is a coordinated, team-based series of timed sequential steps that focuses on a transitional physiology to improve perinatal and neonatal outcomes. The practice of neonatal resuscitation has evolved over time and continues to be shaped by emerging evidence as well as key opinions. We present the revised Neonatal Resuscitation Guidelines for Singapore 2021. The recommendations from the International Liaison Committee on Resuscitation Neonatal Task Force Consensus on Science and Treatment Recommendations (2020) and guidelines from the American Heart Association and European Resuscitation Council were compared with existing guidelines. The recommendations of the Neonatal Subgroup of the Singapore Resuscitation and First Aid Council were derived after the work group discussed and appraised the current available evidence and their applicability to local clinical practice.
... 4 Furthermore, ECG detects heart rate much earlier compared with pulse oximetry. [5][6][7][8] A novel newborn heart rate metre based on dry electrode ECG allows reliable heart rate monitoring at 3-10 s after birth, 9 even earlier than previously achieved by conventional three-lead gel electrode ECG. 4 6 Delayed cord clamping, defined as that occurring beyond 1 min after birth, is increasingly implemented as standard of care worldwide and might result in a smoother newborn transition at birth and less bradycardia. 10 11 The International Liaison Committee on Resuscitation (ILCOR) recently suggested that ECG can be used to provide a rapid and accurate estimation of the heart rate. ...
Objective
To determine heart rate centiles during the first 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping.
Design
Single-centre prospective observational study.
Setting
Stavanger University Hospital, Norway, March–August 2019.
Patients
Term newborns delivered vaginally were eligible for inclusion. Newborns delivered by vacuum or forceps or who received any medical intervention were excluded.
Interventions
A novel dry electrode electrocardiography monitor (NeoBeat) was applied to the newborn’s chest immediately after birth. The newborns were placed on their mother’s chest or abdomen, dried and stimulated, and cord clamping was delayed for at least 1 min.
Main outcome measures
Heart rate was recorded at 1 s intervals, and the 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles were calculated from 5 s to 5 min after birth.
Results
898 newborns with a mean (SD) birth weight 3594 (478) g and gestational age 40 (1) weeks were included. The heart rate increased rapidly from median (IQR) 122 (98–146) to 168 (146–185) beats per minute (bpm) during the first 30 s after birth, peaking at 175 (157–189) bpm at 61 s after birth, and thereafter slowly decreasing. The third centile reached 100 bpm at 34 s, suggesting that heart rates <100 bpm during the first minutes after birth are uncommon in healthy newborns after delayed cord clamping.
Conclusion
This report presents normal heart rate centiles from 5 s to 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping.
