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OBJECTIVE: To determine the proportion of infants who had the tasks recommended in the neonatal resuscitation guidelines performed within 30 and 60 seconds of birth, and the time taken to perform each task. STUDY DESIGN: From video recordings in delivery rooms, we determined the time from birth and arrival on a resuscitation table to warm, assess heart rate (HR), attach an oximeter, and provide respiratory support for each infant. We determined the proportion of infants who had these tasks completed by 30 and 60 seconds, and the median time taken to perform each task. RESULTS: We reviewed and analyzed data from 189 infants (median gestational age, 29 weeks [IQR, 27-34 weeks]; median birth weight, 1220 g [IQR, 930-2197 g]). Twelve infants (6%) were not on the resuscitation table within 30 seconds of birth. Less than 10% of infants were placed in polyethylene bags or had their HR determined by 30 seconds. By 60 seconds, 48% were in polyethylene bags, 33% had their HR determined, 38% received respiratory support, and 60% had an oximeter attached. The median time taken to perform all tasks was greater than that recommended in the guidelines. CONCLUSION: Most newborns were not managed within the time frame recommended in resuscitation guidelines. The recommended 30- and 60-second intervals may be too short.

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OBJECTIVE: To investigate whether infants < 29 weeks gestation who receive positive pressure ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation (SpO2) measurements at 5 minutes than infants ventilated with a self inflating bag (SIB). STUDY DESIGN: Randomized, controlled trial of T-piece or SIB ventilation in which SpO2 was recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with air. RESULTS: Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB. At 5 minutes after birth, there was no significant difference between the median (interquartile range) SpO2 in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to 67%]; P = .27). More infants in the T-piece group received oxygen during delivery room resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room. CONCLUSION: There was no significant difference in SpO2 at 5 minutes after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this study.

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We reviewed videos of 61 extremely preterm infants taken immediately after birth. The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are not apneic at birth.

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OBJECTIVE: To determine the accuracy of heart rate obtained by pulse oximetry (HR(PO)) relative to HR obtained by 3-lead electrocardiography (HR(ECG)) in newborn infants in the delivery room. STUDY DESIGN: Immediately after birth, a preductal PO sensor and ECG leads were applied. PO and ECG monitor displays were recorded by a video camera. Two investigators reviewed the videos. Every two seconds, 1 of the investigators recorded HR(PO) and indicators of signal quality from the oximeter while masked to ECG, whereas the other recorded HR(ECG) and ECG signal quality while masked to PO. HR(PO) and HR(ECG) measurements were compared using Bland-Altman analysis. RESULTS: We attended 92 deliveries; 37 infants were excluded due to equipment malfunction. The 55 infants studied had a mean (+/-standard deviation [SD]) gestational age of 35 (+/-3.7) weeks, and birth weight 2399 (+/-869) g. In total, we analyzed 5877 data pairs. The mean difference (+/-2 SD) between HR(ECG) and HR(PO) was -2 (+/-26) beats per minute (bpm) overall and -0.5 (+/-16) bpm in those infants who received positive-pressure ventilation and/or cardiac massage. The sensitivity and specificity of PO for detecting HR(ECG) <100 bpm was 89% and 99%, respectively. CONCLUSION: PO provided an accurate display of newborn infants' HR in the delivery room, including those infants receiving advanced resuscitation.

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OBJECTIVES: To assess interobserver variability of Apgar scores assigned with video recordings of neonatal resuscitation (AS(video)) and compare the scores assigned by observers of videos to the Apgar score given by staff attending the delivery (AS(del)). STUDY DESIGN: Ten-second clips of 30 newborns taken at 5 minutes were shown to observers. Infants were 23 to 40 weeks' gestation, received varying degrees of resuscitation, and were monitored with pulse oximetry. Forty-two observers (neonatal/obstetric medical/nursing staff) scored infants' respiratory effort, muscle tone, reflex irritability, and color. The value for heart rate was assigned from the oximeter, which was masked in all clips. All 42 AS(video) and the AS(del) were represented graphically for each infant. Interobserver reliability was assessed by use of a variance components model. RESULTS: AS(video) varied widely between observers. Variability was large for all 4 elements of the score observers assigned and was seen irrespective of the infant's level of illness. AS(del) was greater than AS(video) in most cases, on average by 2.4 points. There was no evidence that the level of discrepancy was substantially different between groupings of staff. CONCLUSION: The Apgar score has poor interobserver reliability. More objective and precise measures of newborns' condition are required.

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OBJECTIVE: Because the optimal concentration of oxygen (FiO2) required for stabilization of the newly born infant has not been established, the FiO2 is commonly adjusted according to the infant's oxygen saturation (SpO2). We aimed to determine the range of pre-ductal SpO2 in the first minutes of life in healthy newborn infants. STUDY DESIGN: We applied an oximetry sensor to the infant's right palm or wrist of term and preterm deliveries immediately after birth. Infants who received any resuscitation or supplemental oxygen were excluded. SpO2 was recorded at 60 second intervals for at least 5 minutes and until the SpO2 was >90%. RESULTS: A total of 205 deliveries were monitored; 30 infants were excluded from the study. SpO2 readings were obtained within 60 seconds of age from 92 of 175 infants (53%). The median (interquartile range) SpO2 at 1 minute was 63% (53%-68%). There was a gradual rise in SpO2 with time, with a median SpO2 at 5 minutes of 90% (79%-91%). CONCLUSION: Many newborns have an SpO2 <90% during the first 5 minutes of life. This should be considered when choosing SpO2 targets for infants treated with supplemental oxygen in the delivery room.

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Application of the sensor to newly born infants before connection to a pulse oximeter increases the reliability and speed with which data are displayed. Data are available in most infants within 90 seconds of birth. Oximetry may be useful in guiding interventions during resuscitation.

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Clinical assessment and end-tidal carbon dioxide (ETCO2) detectors are used to verify tracheal intubation in newborn infants. A case is presented in which an ETCO2 detector was misleading in determining endotracheal tube (ETT) position but useful in determining the efficacy of ventilation in an extremely preterm infant.

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A monochorionic twin pregnancy had normal male karyotype on chorionic villous sampling. At delivery, one twin presented as morphologically normal, the other as trisomy 21. A twinning event and chromosome division error shortly after conception resulted in monozygotic twins with discordant tissue karyotypes and blood chromosome chimerism for trisomy 21.

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