The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
In a tertiary maternity hospital, when should a paediatrician be present in the delivery room? Pierre Tourneux, Loriane Pascard, Pascale Daune, Jean Gondry & Cécile Fontaine To cite this article: Pierre Tourneux, Loriane Pascard, Pascale Daune, Jean Gondry & Cécile Fontaine (2017) In a tertiary maternity hospital, when should a paediatrician be present in the delivery room?, The Journal of Maternal-Fetal & Neonatal Medicine, 30:14, 1641-1645, DOI: 10.1080/14767058.2016.1220527 To link to this article: http://dx.doi.org/10.1080/14767058.2016.1220527
Accepted author version posted online: 04 Aug 2016. Published online: 23 Aug 2016. Submit your article to this journal
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Date: 08 November 2017, At: 07:32
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2017; 30(14): 1641–1645 ! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/14767058.2016.1220527
ORIGINAL ARTICLE
In a tertiary maternity hospital, when should a paediatrician be present in the delivery room? Pierre Tourneux1,2*, Loriane Pascard3*, Pascale Daune3, Jean Gondry3,4, and Ce´cile Fontaine1,2
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1
Me´decine Ne´onatale et Re´animation Pe´diatrique, Poˆle Femme–Couple–Enfant, Centre Hospitalier Universitaire d’Amiens, Amiens, France, 2Pe´riTox Pe´rinatalite´ & Risques Toxiques (UMI-01), Faculte´ de Me´decine, Universite´ de Picardie Jules Verne, Amiens, France, 3Ecole de Sage-Femme Michel Vitse, Amiens, France, and 4Gyne´cologie-Obste´trique, Poˆle Femme–Couple–Enfant, Centre Hospitalier Universitaire d’Amiens, Amiens, France
Abstract
Keywords
Objective: 10% of newborns require positive pressure ventilation (PPV) at birth. There are few data on prenatal or early postnatal factors that are predictive of the need for a paediatrician in the delivery room. The study analysed prenatal obstetric and early postnatal factors associated with the requirement for paediatrician assistance in this setting. Methods: Over a three-month period, all consecutive births in a tertiary hospital’s maternity unit were prospectively evaluated with regard to the need for paediatrician assistance (requested either before or after the delivery), the requirement for resuscitation, and transfer to a neonatal intensive care unit (NICU). Results: For a total of 584 consecutive births, paediatrician assistance was requested before delivery in 170 cases (30.5%) and after in 78 cases (13.3%). 78% of the newborns requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring transfer to the NICU matched recently published prenatal criteria for paediatrician assistance. Along with a low Apgar score and a cord blood pH57.20, these criteria covered 95% of the prenatal and early postnatal requests for paediatrician assistance. Conclusions: These criteria for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for paediatrician assistance.
Resuscitation, delivery room, midwife, paediatrician, newborn, infant
Introduction About 10% of newborns will require positive pressure ventilation (PPV) at birth, and 1% will require extensive resuscitation [1–3]. Neonatal resuscitation aims at facilitating the physiological transition from foetal to neonatal live [1–3]. It includes supportive, life-saving interventions that establish or restore ventilation, oxygenation and/or circulation in a compromised newborn [1–3]. The implementation of a neonatal resuscitation team [NRT] is recommended, and use of this resource should be anticipated whenever possible [1–4]. In France, maternity hospitals are classified into three groups. In some hospitals, a paediatrician may be on call but not always on site (especially at night). Even when a paediatrician is on site, he/she may not always be present in the delivery room (i.e. as a part of the NRT).
*Equally contributing authors. Address for correspondence: Pierre Tourneux, Me´decine Ne´onatale et Re´animation Pe´diatrique Polyvalente, CHU d’Amiens, F-80054 Amiens cedex 1, France. Tel: +33 322 087604. Fax: +33 322 089781. E-mail: [email protected]
History Received 17 May 2016 Revised 22 July 2016 Accepted 1 August 2016 Published online 22 August 2016
There are few published data on factors that are predictive of the need for a paediatrician in the delivery room [5]. In a 30-month study of an NRT at a tertiary perinatal centre in Canada, Aziz et al. published a list of antenatal and intrapartum factors that were predictive of an increased need for neonatal resuscitation with PPV [5,6]. Deliveries were characterised as (i) ‘‘high-risk’’ when the foetus was likely to be compromised or if the baby was likely to require admission to the neonatal intensive care unit (NICU) after birth, (ii) ‘‘moderate-risk’’ when the foetus was known to be near-term and likely to be well, and (iii) ‘‘low-risk’’ when the need for neonatal resuscitation was very unlikely [6]. These parameters significantly improved the predicted need for PPV (from 15.7% to 45.7% of the deliveries attended), although 6.8% of near-term babies who required PPV did not have any identifiable risk factors [5]. To the best of our knowledge, Aziz et al.’s study constitutes the only work on these factors, and thus no other data on early postnatal factors for paediatrician assistance in the delivery room have been published. The purpose of the present prospective, observational study was to analyse prenatal obstetric factors and early neonatal factors that prompted a midwife’s request for paediatrician assistance in the delivery room.
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Materials and methods We considered all consecutive live births between 15 May and 15 August 2012, at the tertiary maternity hospital in Amiens (France). The main exclusion criteria were the medical interruption of pregnancy and foetal death in utero. We then considered Aziz et al.’s criteria for ‘‘high-risk’’ or ‘‘moderate-risk’’ deliveries for which the midwife had requested paediatrician assistance [6]: (i) antepartum factors such as delivery 35 weeks of gestation, multiple pregnancy, the mother’ clinical history/status (gestational diabetes, hypertension, infections, polyhydramnios, oligohydramnios, etc.), major foetal malformations (congenital diaphragmatic hernia, hydrops, etc.); intrauterine growth restriction or minor foetal abnormalities (such as isoimmunization); (ii) intrapartum factors such as breech presentation, the use of general anaesthesia, elective caesarean section or caesarean section for failure to progress at any gestational age, non-reassuring foetal heart rate patterns, meconium-stained fluid (whether thick or thin); a foetal scalp blood pH 7.20; emergency caesarean section, and vacuum or forceps delivery for failure to progress; and (iii) any prospectively recorded, clearly specified postnatal factors (Table 1). The paediatrician was always a senior subspecialist in neonatology, with between 3 and 25 years of experience. The following items of data were prospectively collected from the midwives: Requests for paediatrician assistance (‘‘no requests’’ or ‘‘prenatal requests’’ or ‘‘early postnatal requests’’). The indication for requesting paediatrician assistance. Only one indication was defined for each request (Table 1), with an emphasis on the neonate’s age. For example, a request for a preterm (28 WG) newborn with a non-reassuring foetal heart rate pattern was considered to
Table 1. Intrapartum, peripartum and postnatal criteria for requesting paediatrician assistance in the delivery room.
Intrapartum or peripartum parameters Preterm 35 WG Multiple pregnancy Maternal pathology Major foetal malformation IUGR or a minor foetal abnormality Presentation (breech, etc.) Use of general anaesthesia Elective caesarean section or failure to progress Non-reassuring foetal heart rate Meconium-stained fluid Scalp blood pH 7.2 Emergency caesarean section Vacuum or forceps delivery for failure to progress Postnatal parameters Low Apgar score Cord blood pH 57.20 Hypoglycaemia Other
Prenatal requests (n ¼ 178)
Postnatal requests (n ¼ 78)
61 (34.3%) 12 (6.7%) 6 (3.4%) 5 (2.8%) 3 (1.7%) 5 (2.8%) 0 13 (7.3%)
1 (1.3%) 0 1 (1.3%) 0 1 (1.3%) 0 0 4 (5.1%)
39 (21.9%) 15 (8.4%) 0 18 (10.1%) 1 (0.6%)
0 13 (16.7%) 0 2 (2.6%) 6 (7.7%)
be related to a ‘‘preterm newborn’’, rather than a ‘‘nonreassuring foetal heart rate pattern’’. The time of day (‘‘day’’ was defined as the period between 8 am and 6 pm, when a paediatrician was present with a resident in paediatrics (on duty) in the maternity hospital; ‘‘night’’ was defined as the period between 6 pm and 8 am, when a paediatrician was on call but not present). During the day, the resident in paediatrics was never asked to make a decision on PPV and/or endotracheal intubation. Type of delivery (vaginal delivery, vacuum, forceps, planned caesarean section, emergency caesarean section). Birth term, birth weight, and the Apgar score. The paediatrician’s response (‘‘presence’’ when the paediatrician came to the delivery room, or ‘‘phone advice’’ when the paediatrician did not attend the delivery but gave advice over the ‘‘phone’’). The paediatrician’s action in the delivery room, if present (‘‘clinical examination’’; ‘‘airway suction’’, for any newborn requiring airway suction but no further treatment; ‘‘treatment’’: any newborn requiring oral administration of a medication (such as analgesics, or glucose for hypoglycaemia) but not PPV. The use of PPV (newborns requiring PPV support for a short period but not endotracheal intubation) or endotracheal intubation (in newborn requiring prolonged PPV). The newborn outcome or destination (‘‘maternity’’: no special care; ‘‘2 h of monitoring’’: the requirement for monitoring for the first 2 h of life, followed by transfer to the maternity unit with the mother; ‘‘neonatology’’: the requirement for treatment and/or continuous monitoring for more than 2 h but not respiratory support; ‘‘NICU’’: the requirement for respiratory support (performed in the NICU). Our local protocol stipulates that the paediatrician has to be called when a newborn presents with a specific sign potentially requiring admission to the NICU. Even when a midwife has established that a newborn requires admission to the NICU, he/she calls the paediatrician to discuss the matter. The study was approved by the appropriate local independent ethics committee (Commission d’E´valuation E´thique des Recherches Non Interventionnelles, Amiens, France; reference #142). All study participants (parents, midwives and paediatricians) gave their verbal consent to participation. Data were analysed using StatviewÕ software (version 5.0, SAS Institute Inc., Cary, NC, USA). Intergroup differences were probed with a chi-squared test or an analysis of variance with post-hoc analysis (Fisher’s least significant difference test). The threshold for statistical significance was set to p50.05. The results are expressed as the mean ± standard deviation for continuous variables and as the number (percentage) for categorical variables.
Results 24 13 2 11
(30.7%) (16.6%) (2.6%) (14.1%)
IUGR: intra-uterine growth retardation; WG: weeks of gestation.
A total of 584 consecutive births were considered during the study period, with 383 trouble-free vaginal deliveries, 56 vacuum-assisted deliveries, 19 forceps deliveries, 55 elective caesarean sections or caesarean sections for failure to progress, and 71 emergency caesarean sections. 500 of the
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DOI: 10.1080/14767058.2016.1220527
deliveries were at term (37 WG), 33 occurred between 35 and 36 WG, and 51 occurred at 535 WG or earlier. 295 (50.5%) births occurred during the day and 289 occurred at night (49.5%). In all, 178 (30.5%) deliveries triggered a prenatal request for paediatrician assistance, 78 (13.3%) triggered a postnatal request and 328 (56.2%) did not prompt a request. Prenatal requests were significantly more frequent during the day (n ¼ 106; 59.6%) than during the night (n ¼ 72; 40.4%; p50.01). The same was true for postnatal requests (day: n ¼ 45; 57.7%; night: n ¼ 33; 42.3%; p50.01). When the paediatrician was called during the day, he/she attended the delivery room in 91.4% of cases and gave ‘‘phone advice’’ in 8.6% of cases. Attendance was significantly more likely at night, with values of 95.3% and 4.7%, respectively (p50.001). Preterm birth 35 WG, a non-reassuring foetal heart rate, meconium stained fluid and emergency caesarean section were the most common indications for a prenatal request (Table 1). For some newborns, the paediatrician was called before the delivery (depending on the study protocol). If the newborn infant’s status was good at birth, the newborn was cared for by the midwife alone (in order to promote the relationship between the parents and the newborn and decrease stress). All the newborns in this specific situation were then transferred to the maternity ward. The parents’ first consultation with a paediatrician took place within 12 h of arrival maternity ward and when the newborn infant was awake. When considering the 78 deliveries that triggered a postnatal request for paediatrician assistance, we found that 28 (35.9%) of the neonates also met one or more criteria for a prenatal request; however, the midwife had run out of time and was only able to request assistance after the delivery (Table 1). The most indications for a postnatal request were a low Apgar score, cord blood pH57.20 and meconium stained fluid (Table 1). Eleven newborns were classified as meeting ‘‘other’’ criteria for a postnatal request: a suspected neonatal infection (n ¼ 3), collar bone fracture (n ¼ 1), tremor (n ¼ 1), skin wounds during a caesarean section (n ¼ 1), petechiae (n ¼ 1), a suspected umbilical cord abnormality (n ¼ 1), neonatal B hepatitis (n ¼ 1), neonatal apnoea (n ¼ 1) and a suspected congenital abnormality of the hip (n ¼ 1). The gestational age and birth weight were lower in the ‘‘prenatal request’’ group than in the two other groups (Table 2, p50.01). Neonates in the ‘‘prenatal request’’ and ‘‘postnatal request’’ groups had a lower Apgar score, cord blood pH and lactate level than neonates in the ‘‘no request’’ group (Table 1, p50.001 for all). When considering the nature of the paediatrician’s intervention in the delivery room, a simple clinical examination was performed in 452 cases (77.4%), with airway suction in 26 cases (4.5%), oral administration of a medication in 18 cases (3.1%), PPV in 41 cases (7.0%) and endotracheal intubation in 47 cases (8.0%; Table 3). Paediatrician assistance had been requested prenatally for 32 of the 41 neonates (78.0%) requiring PPV and 45 of the 47 neonates (95.8%) requiring endotracheal intubation (Table 3). After the delivery, 449 (76.9%) newborns went with their mother to the maternity ward, 40 (6.9%) newborns were monitored for 2 h in the delivery room before joining their mother in the maternity ward, 34 (5.8%) were transferred to
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Table 2. Clinical status at birth in the ‘‘prenatal request’’, ‘‘postnatal request’’ and ‘‘no request’’ groups.
Term (WG) Birth weight (g) 1-min Apgar score 5-min Apgar score 10-min Apgar score Arterial cord blood pH Venous cord blood pH Arterial cord blood lactate (mmol/L) Venous cord blood lactate (mmol/L)
No request (n ¼ 328)
Prenatal request (n ¼ 178)
Postnatal request (n ¼ 78)
39.3 ± 1.3 3362 ± 458 9.91 ± 0.46 9.97 ± 0.16 9.99 ± 0.12 7.26 ± 0.08 7.33 ± 0.07 3.08 ± 1.37
36.6 ± 3.8*,** 2673 ± 869*,** 8.32 ± 2.41* 9.12 ± 1.62* 9.57 ± 1.07* 7.22 ± 0.10* 7.28 ± 0.09* 4.10 ± 2.27*
39.2 ± 1.3 3471 ± 523 8.73 ± 1.86* 9.48 ± 1.07* 9.65 ± 0.85* 7.20 ± 0.09* 7.27 ± 0.09* 4.31 ± 2.22*
2.91 ± 1.27
3.85 ± 2.05*
4.04 ± 2.13*
Results are expressed as mean ± SD. WG: weeks of gestation. *p50.001 versus the ‘‘no request’’ group; **p50.05 versus the ‘‘postnatal request’’ group.
Table 3. Details of the paediatrician’s intervention in the delivery room and the type of care/transfer in the ‘‘prenatal request’’, ‘‘postnatal request’’ and ‘‘no request’’ groups.
No request (n ¼ 328) Clinical examination Treatment Airway suction Positive pressure ventilation Endotracheal intubation Maternity ward 2 h of monitoring Neonatology department Neonatal intensive care unit
328 (100%) 0 0 0 0 328 (100%) 0 0 0
Prenatal request (n ¼ 178) 71 7 23 32 45 75 21 25 57
(39,9%) (3.9%) (12.9%) (18.0%) (25.3%) (42.1%) (11.8%) (14.1%) (32.0%)
Postnatal request (n ¼ 78) 53 11 3 9 2 46 19 9 4
(68.0%) (14.1%) (3.8%) (11.5%) (2.6%) (59.0%) (24.4%) (11.5%) (5.1%)
the neonatology department and 61 (10.4%) were transferred to the NICU. A paediatrician had been present before delivery for 82 (86.3%) of the 95 newborns requiring further treatment in the neonatology department or the NICU (Table 3).
Discussion In a prospective study of 584 consecutive deliveries, 170 (30.5%) triggered a prenatal request for paediatrician assistance (according to the criteria published by Aziz et al. [6] and 78 (13.3%) triggered a postnatal request. Prenatal requests were significantly more frequent during the day than during the night (p50.01), and newborns in the ‘‘prenatal request’’ group had a lower gestational age and a lower birth weight than those in the two other groups. Paediatrician assistance was requested before delivery for the great majority of newborns requiring PPV (78%), endotracheal intubation (95.8%) or further treatment in the neonatology department or the NICU (86.3%). We confirmed that the ante- and intra-partum factors described by Aziz et al. [6] accurately predicted the need for paediatrician attendance in general and neonatal resuscitation (PPV and/or endotracheal ventilation) in particular. A number of studies have focussed on the need for paediatrician
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attendance in specific situations (such as the observation of meconium-stained amniotic fluid [7] or elective caesarean sections [4,8–12]. Even though these situations are very common (especially in tertiary hospital units), few studies have examined a broad range of risk factors [5,7,13–16]. To the best of our knowledge, no prospective studies have attempted to validate Aziz et al.’s criteria in other centres. The characteristics of the newborns in the ‘‘prenatal request’’ group were correlated with the high incidence of preterm deliveries, which is partly predictable [5,6,17]. About 40% of the newborns in the ‘‘prenatal request’’ group required only a clinical examination and were then able to stay with their mother in the maternity ward. In the first ever population-based study of the development and implementation of a multidisciplinary NRT, 19.0% of the 2944 newborns attended to by the team required PPV or further treatment [5]. Even though 40% of the newborns in the present study did not require neonatal resuscitation, an assessment of ante- and intra-partum risk factors predicted the majority (78%) of deliveries requiring PPV. These findings are similar to those initially reported by Aziz et al. (in which 85% of the requirements for PPV were predicted) [5]. In contrast, Mitchell et al. stated that most requirements for resuscitation cannot be accurately predicted [18]. The ‘‘postnatal request’’ and ‘‘no request’’ groups did not differ significantly in terms of the birth weight or gestational age, as they were mostly term deliveries. Only 14.0% of the newborns in the ‘‘postnatal request’’ group required PPV and/ or endotracheal intubation, and 16.7% required transfer to the neonatology department or the NICU. The indications for requesting paediatrician attendance in the ‘‘postnatal request’’ group were much more heterogeneous than in the ‘‘prenatal request’’ group. Even though 28 (35.9%) of the 78 newborns in the ‘‘postnatal request’’ group also met the criteria for a prenatal request, the indication was clearly postnatal in the 50 (64.1%) other newborns. Paediatrician assistance was often required for diagnosis or medication but not for acute resuscitation. The number of postnatal requests could therefore be reduced further by reinforcing checks for hypoglycaemia or suspected neonatal infections. The present study had some limitations, since only 584 newborns were included. However, all the inclusions were consecutive, and data were recorded prospectively. We clearly obtained a good level of agreement with the original criteria established in Aziz et al.’s population-based study [6]. The success of neonatal resuscitation is related not only to the implementation of a multidisciplinary NRT but also to anticipation and communication with a transport team [5,17,19]. Smith et al. demonstrated that prospective risk assessment improved efficiency and human resource use [20]. Our results support the recommendation whereby at least one practitioner with expertise in neonatal resuscitation should be present in the delivery room team when a risk factor has been identified [21]. In conclusion, we found that the criteria adapted from Aziz et al. [6] enabled a prenatal request for paediatrician assistance in 78% of deliveries requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring further treatment in the neonatology department or the NICU. With completed with ‘‘low Apgar score’’ and
J Matern Fetal Neonatal Med, 2017; 30(14): 1641–1645
‘‘cord pH57.20’’, these criteria predicted the prenatal or early postnatal need for paediatrician assistance in 95% of cases. We believe that considering these criteria in procedures and guidelines for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for an NRT.
Acknowledgements The authors would like to thank the staff in the maternity unit, all the parents having participated in this study, Jean-Xavier Fontaine and Ariane Tourneux for advice in data analysis and David Fraser for carefully reviewing the English and improving the manuscript.
Declaration of interest None of the authors has any potential conflict of interest.
References 1. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2015;132:S204–41. 2. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S543–60. 3. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2015;95:e169–201. 4. Eidelman AI, Schimmel MS, Bromiker R, Hammerman C. Pediatric coverage of the delivery room: an analysis of manpower utilization. J Perinatol 1998;18:131–4. 5. Aziz K, Chadwick M, Downton G, et al. The development and implementation of a multidisciplinary neonatal resuscitation team in a Canadian perinatal centre. Resuscitation 2005;66: 45–51. 6. Aziz K, Chadwick M, Baker M, Andrews W. Ante- and intrapartum factors that predict increased need for neonatal resuscitation. Resuscitation 2008;79:444–52. 7. Maayan-Metzger A, Leibovitch L, Schushan-Eisen I, et al. Meconium-stained amniotic fluid and the need for paediatrician attendance. Acta Paediatr 2013;102:e8–12. 8. Ozlu F, Yapicioglu H, Ulu B, et al. Do all deliveries with elective caesarean section need paediatrician attendance? J Matern Fetal Neonatal Med 2012;25:2766–8. 9. de Almeida MF, Guinsburg R, da Costa JO, et al. Non-urgent caesarean delivery increases the need for ventilation at birth in term newborn infants. Arch Dis Child Fetal Neonatal Ed 2010;95: F326–30. 10. Gordon A, McKechnie EJ, Jeffery H. Pediatric presence at cesarean section: justified or not? Am J Obstet Gynecol 2005; 193:599–605. 11. Atherton N, Parsons SJ, Mansfield P. Attendance of paediatricians at elective Caesarean sections performed under regional anaesthesia: is it warranted? J Paediatr Child Health 2006;42:332–6. 12. Jacob J, Pfenninger J. Cesarean deliveries: when is a pediatrician necessary? Obstet Gynecol 1997;89:217–20. 13. de Almeida MF, Guinsburg R, da Costa JO, et al. Resuscitative procedures at birth in late preterm infants. J Perinatol 2007;27: 761–5. 14. Vain NE, Szyld EG, Prudent LM, et al. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet 2004;364:597–602. 15. Molkenboer JF, Vencken PM, Sonnemans LG, et al. Conservative management in breech deliveries leads to similar results compared
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with cephalic deliveries. J Matern Fetal Neonatal Med 2007;20: 599–603. 16. Hogston P. Is a paediatrician required at caesarean section? Eur J Obstet Gynecol Reprod Biol 1987;26:91–3. 17. Chabernaud JL, Gilmer N, Lode N, et al. [Delivery room management: what’s new in 2010 recommendations?]. Arch Pediatrie 2011;18:604–10. 18. Mitchell A, Niday P, Boulton J, et al. A prospective clinical audit of neonatal resuscitation practices in Canada. Adv Neonatal Care 2002;2:316–26.
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19. McNamara PJ, Mak W, Whyte HE. Dedicated neonatal retrieval teams improve delivery room resuscitation of outborn premature infants. J Perinatol 2005;25:309–14. 20. Smith MA, Brix KA, Heaton CJ. The influence of work on the outcome of low-risk pregnancies. J Am Board Fam Pract 1988;1: 167–74. 21. Noblett KE, Meibalane R. Respiratory care practitioners as primary providers of neonatal intubation in a community hospital: an analysis. Respir Care 1995;40:1063–7.
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
In a tertiary maternity hospital, when should a paediatrician be present in the delivery room? Pierre Tourneux, Loriane Pascard, Pascale Daune, Jean Gondry & Cécile Fontaine To cite this article: Pierre Tourneux, Loriane Pascard, Pascale Daune, Jean Gondry & Cécile Fontaine (2017) In a tertiary maternity hospital, when should a paediatrician be present in the delivery room?, The Journal of Maternal-Fetal & Neonatal Medicine, 30:14, 1641-1645, DOI: 10.1080/14767058.2016.1220527 To link to this article: http://dx.doi.org/10.1080/14767058.2016.1220527
Accepted author version posted online: 04 Aug 2016. Published online: 23 Aug 2016. Submit your article to this journal
Article views: 87
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [Duke University Medical Center]
Date: 08 November 2017, At: 07:32
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2017; 30(14): 1641–1645 ! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/14767058.2016.1220527
ORIGINAL ARTICLE
In a tertiary maternity hospital, when should a paediatrician be present in the delivery room? Pierre Tourneux1,2*, Loriane Pascard3*, Pascale Daune3, Jean Gondry3,4, and Ce´cile Fontaine1,2
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1
Me´decine Ne´onatale et Re´animation Pe´diatrique, Poˆle Femme–Couple–Enfant, Centre Hospitalier Universitaire d’Amiens, Amiens, France, 2Pe´riTox Pe´rinatalite´ & Risques Toxiques (UMI-01), Faculte´ de Me´decine, Universite´ de Picardie Jules Verne, Amiens, France, 3Ecole de Sage-Femme Michel Vitse, Amiens, France, and 4Gyne´cologie-Obste´trique, Poˆle Femme–Couple–Enfant, Centre Hospitalier Universitaire d’Amiens, Amiens, France
Abstract
Keywords
Objective: 10% of newborns require positive pressure ventilation (PPV) at birth. There are few data on prenatal or early postnatal factors that are predictive of the need for a paediatrician in the delivery room. The study analysed prenatal obstetric and early postnatal factors associated with the requirement for paediatrician assistance in this setting. Methods: Over a three-month period, all consecutive births in a tertiary hospital’s maternity unit were prospectively evaluated with regard to the need for paediatrician assistance (requested either before or after the delivery), the requirement for resuscitation, and transfer to a neonatal intensive care unit (NICU). Results: For a total of 584 consecutive births, paediatrician assistance was requested before delivery in 170 cases (30.5%) and after in 78 cases (13.3%). 78% of the newborns requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring transfer to the NICU matched recently published prenatal criteria for paediatrician assistance. Along with a low Apgar score and a cord blood pH57.20, these criteria covered 95% of the prenatal and early postnatal requests for paediatrician assistance. Conclusions: These criteria for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for paediatrician assistance.
Resuscitation, delivery room, midwife, paediatrician, newborn, infant
Introduction About 10% of newborns will require positive pressure ventilation (PPV) at birth, and 1% will require extensive resuscitation [1–3]. Neonatal resuscitation aims at facilitating the physiological transition from foetal to neonatal live [1–3]. It includes supportive, life-saving interventions that establish or restore ventilation, oxygenation and/or circulation in a compromised newborn [1–3]. The implementation of a neonatal resuscitation team [NRT] is recommended, and use of this resource should be anticipated whenever possible [1–4]. In France, maternity hospitals are classified into three groups. In some hospitals, a paediatrician may be on call but not always on site (especially at night). Even when a paediatrician is on site, he/she may not always be present in the delivery room (i.e. as a part of the NRT).
*Equally contributing authors. Address for correspondence: Pierre Tourneux, Me´decine Ne´onatale et Re´animation Pe´diatrique Polyvalente, CHU d’Amiens, F-80054 Amiens cedex 1, France. Tel: +33 322 087604. Fax: +33 322 089781. E-mail: [email protected]
History Received 17 May 2016 Revised 22 July 2016 Accepted 1 August 2016 Published online 22 August 2016
There are few published data on factors that are predictive of the need for a paediatrician in the delivery room [5]. In a 30-month study of an NRT at a tertiary perinatal centre in Canada, Aziz et al. published a list of antenatal and intrapartum factors that were predictive of an increased need for neonatal resuscitation with PPV [5,6]. Deliveries were characterised as (i) ‘‘high-risk’’ when the foetus was likely to be compromised or if the baby was likely to require admission to the neonatal intensive care unit (NICU) after birth, (ii) ‘‘moderate-risk’’ when the foetus was known to be near-term and likely to be well, and (iii) ‘‘low-risk’’ when the need for neonatal resuscitation was very unlikely [6]. These parameters significantly improved the predicted need for PPV (from 15.7% to 45.7% of the deliveries attended), although 6.8% of near-term babies who required PPV did not have any identifiable risk factors [5]. To the best of our knowledge, Aziz et al.’s study constitutes the only work on these factors, and thus no other data on early postnatal factors for paediatrician assistance in the delivery room have been published. The purpose of the present prospective, observational study was to analyse prenatal obstetric factors and early neonatal factors that prompted a midwife’s request for paediatrician assistance in the delivery room.
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Materials and methods We considered all consecutive live births between 15 May and 15 August 2012, at the tertiary maternity hospital in Amiens (France). The main exclusion criteria were the medical interruption of pregnancy and foetal death in utero. We then considered Aziz et al.’s criteria for ‘‘high-risk’’ or ‘‘moderate-risk’’ deliveries for which the midwife had requested paediatrician assistance [6]: (i) antepartum factors such as delivery 35 weeks of gestation, multiple pregnancy, the mother’ clinical history/status (gestational diabetes, hypertension, infections, polyhydramnios, oligohydramnios, etc.), major foetal malformations (congenital diaphragmatic hernia, hydrops, etc.); intrauterine growth restriction or minor foetal abnormalities (such as isoimmunization); (ii) intrapartum factors such as breech presentation, the use of general anaesthesia, elective caesarean section or caesarean section for failure to progress at any gestational age, non-reassuring foetal heart rate patterns, meconium-stained fluid (whether thick or thin); a foetal scalp blood pH 7.20; emergency caesarean section, and vacuum or forceps delivery for failure to progress; and (iii) any prospectively recorded, clearly specified postnatal factors (Table 1). The paediatrician was always a senior subspecialist in neonatology, with between 3 and 25 years of experience. The following items of data were prospectively collected from the midwives: Requests for paediatrician assistance (‘‘no requests’’ or ‘‘prenatal requests’’ or ‘‘early postnatal requests’’). The indication for requesting paediatrician assistance. Only one indication was defined for each request (Table 1), with an emphasis on the neonate’s age. For example, a request for a preterm (28 WG) newborn with a non-reassuring foetal heart rate pattern was considered to
Table 1. Intrapartum, peripartum and postnatal criteria for requesting paediatrician assistance in the delivery room.
Intrapartum or peripartum parameters Preterm 35 WG Multiple pregnancy Maternal pathology Major foetal malformation IUGR or a minor foetal abnormality Presentation (breech, etc.) Use of general anaesthesia Elective caesarean section or failure to progress Non-reassuring foetal heart rate Meconium-stained fluid Scalp blood pH 7.2 Emergency caesarean section Vacuum or forceps delivery for failure to progress Postnatal parameters Low Apgar score Cord blood pH 57.20 Hypoglycaemia Other
Prenatal requests (n ¼ 178)
Postnatal requests (n ¼ 78)
61 (34.3%) 12 (6.7%) 6 (3.4%) 5 (2.8%) 3 (1.7%) 5 (2.8%) 0 13 (7.3%)
1 (1.3%) 0 1 (1.3%) 0 1 (1.3%) 0 0 4 (5.1%)
39 (21.9%) 15 (8.4%) 0 18 (10.1%) 1 (0.6%)
0 13 (16.7%) 0 2 (2.6%) 6 (7.7%)
be related to a ‘‘preterm newborn’’, rather than a ‘‘nonreassuring foetal heart rate pattern’’. The time of day (‘‘day’’ was defined as the period between 8 am and 6 pm, when a paediatrician was present with a resident in paediatrics (on duty) in the maternity hospital; ‘‘night’’ was defined as the period between 6 pm and 8 am, when a paediatrician was on call but not present). During the day, the resident in paediatrics was never asked to make a decision on PPV and/or endotracheal intubation. Type of delivery (vaginal delivery, vacuum, forceps, planned caesarean section, emergency caesarean section). Birth term, birth weight, and the Apgar score. The paediatrician’s response (‘‘presence’’ when the paediatrician came to the delivery room, or ‘‘phone advice’’ when the paediatrician did not attend the delivery but gave advice over the ‘‘phone’’). The paediatrician’s action in the delivery room, if present (‘‘clinical examination’’; ‘‘airway suction’’, for any newborn requiring airway suction but no further treatment; ‘‘treatment’’: any newborn requiring oral administration of a medication (such as analgesics, or glucose for hypoglycaemia) but not PPV. The use of PPV (newborns requiring PPV support for a short period but not endotracheal intubation) or endotracheal intubation (in newborn requiring prolonged PPV). The newborn outcome or destination (‘‘maternity’’: no special care; ‘‘2 h of monitoring’’: the requirement for monitoring for the first 2 h of life, followed by transfer to the maternity unit with the mother; ‘‘neonatology’’: the requirement for treatment and/or continuous monitoring for more than 2 h but not respiratory support; ‘‘NICU’’: the requirement for respiratory support (performed in the NICU). Our local protocol stipulates that the paediatrician has to be called when a newborn presents with a specific sign potentially requiring admission to the NICU. Even when a midwife has established that a newborn requires admission to the NICU, he/she calls the paediatrician to discuss the matter. The study was approved by the appropriate local independent ethics committee (Commission d’E´valuation E´thique des Recherches Non Interventionnelles, Amiens, France; reference #142). All study participants (parents, midwives and paediatricians) gave their verbal consent to participation. Data were analysed using StatviewÕ software (version 5.0, SAS Institute Inc., Cary, NC, USA). Intergroup differences were probed with a chi-squared test or an analysis of variance with post-hoc analysis (Fisher’s least significant difference test). The threshold for statistical significance was set to p50.05. The results are expressed as the mean ± standard deviation for continuous variables and as the number (percentage) for categorical variables.
Results 24 13 2 11
(30.7%) (16.6%) (2.6%) (14.1%)
IUGR: intra-uterine growth retardation; WG: weeks of gestation.
A total of 584 consecutive births were considered during the study period, with 383 trouble-free vaginal deliveries, 56 vacuum-assisted deliveries, 19 forceps deliveries, 55 elective caesarean sections or caesarean sections for failure to progress, and 71 emergency caesarean sections. 500 of the
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DOI: 10.1080/14767058.2016.1220527
deliveries were at term (37 WG), 33 occurred between 35 and 36 WG, and 51 occurred at 535 WG or earlier. 295 (50.5%) births occurred during the day and 289 occurred at night (49.5%). In all, 178 (30.5%) deliveries triggered a prenatal request for paediatrician assistance, 78 (13.3%) triggered a postnatal request and 328 (56.2%) did not prompt a request. Prenatal requests were significantly more frequent during the day (n ¼ 106; 59.6%) than during the night (n ¼ 72; 40.4%; p50.01). The same was true for postnatal requests (day: n ¼ 45; 57.7%; night: n ¼ 33; 42.3%; p50.01). When the paediatrician was called during the day, he/she attended the delivery room in 91.4% of cases and gave ‘‘phone advice’’ in 8.6% of cases. Attendance was significantly more likely at night, with values of 95.3% and 4.7%, respectively (p50.001). Preterm birth 35 WG, a non-reassuring foetal heart rate, meconium stained fluid and emergency caesarean section were the most common indications for a prenatal request (Table 1). For some newborns, the paediatrician was called before the delivery (depending on the study protocol). If the newborn infant’s status was good at birth, the newborn was cared for by the midwife alone (in order to promote the relationship between the parents and the newborn and decrease stress). All the newborns in this specific situation were then transferred to the maternity ward. The parents’ first consultation with a paediatrician took place within 12 h of arrival maternity ward and when the newborn infant was awake. When considering the 78 deliveries that triggered a postnatal request for paediatrician assistance, we found that 28 (35.9%) of the neonates also met one or more criteria for a prenatal request; however, the midwife had run out of time and was only able to request assistance after the delivery (Table 1). The most indications for a postnatal request were a low Apgar score, cord blood pH57.20 and meconium stained fluid (Table 1). Eleven newborns were classified as meeting ‘‘other’’ criteria for a postnatal request: a suspected neonatal infection (n ¼ 3), collar bone fracture (n ¼ 1), tremor (n ¼ 1), skin wounds during a caesarean section (n ¼ 1), petechiae (n ¼ 1), a suspected umbilical cord abnormality (n ¼ 1), neonatal B hepatitis (n ¼ 1), neonatal apnoea (n ¼ 1) and a suspected congenital abnormality of the hip (n ¼ 1). The gestational age and birth weight were lower in the ‘‘prenatal request’’ group than in the two other groups (Table 2, p50.01). Neonates in the ‘‘prenatal request’’ and ‘‘postnatal request’’ groups had a lower Apgar score, cord blood pH and lactate level than neonates in the ‘‘no request’’ group (Table 1, p50.001 for all). When considering the nature of the paediatrician’s intervention in the delivery room, a simple clinical examination was performed in 452 cases (77.4%), with airway suction in 26 cases (4.5%), oral administration of a medication in 18 cases (3.1%), PPV in 41 cases (7.0%) and endotracheal intubation in 47 cases (8.0%; Table 3). Paediatrician assistance had been requested prenatally for 32 of the 41 neonates (78.0%) requiring PPV and 45 of the 47 neonates (95.8%) requiring endotracheal intubation (Table 3). After the delivery, 449 (76.9%) newborns went with their mother to the maternity ward, 40 (6.9%) newborns were monitored for 2 h in the delivery room before joining their mother in the maternity ward, 34 (5.8%) were transferred to
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Table 2. Clinical status at birth in the ‘‘prenatal request’’, ‘‘postnatal request’’ and ‘‘no request’’ groups.
Term (WG) Birth weight (g) 1-min Apgar score 5-min Apgar score 10-min Apgar score Arterial cord blood pH Venous cord blood pH Arterial cord blood lactate (mmol/L) Venous cord blood lactate (mmol/L)
No request (n ¼ 328)
Prenatal request (n ¼ 178)
Postnatal request (n ¼ 78)
39.3 ± 1.3 3362 ± 458 9.91 ± 0.46 9.97 ± 0.16 9.99 ± 0.12 7.26 ± 0.08 7.33 ± 0.07 3.08 ± 1.37
36.6 ± 3.8*,** 2673 ± 869*,** 8.32 ± 2.41* 9.12 ± 1.62* 9.57 ± 1.07* 7.22 ± 0.10* 7.28 ± 0.09* 4.10 ± 2.27*
39.2 ± 1.3 3471 ± 523 8.73 ± 1.86* 9.48 ± 1.07* 9.65 ± 0.85* 7.20 ± 0.09* 7.27 ± 0.09* 4.31 ± 2.22*
2.91 ± 1.27
3.85 ± 2.05*
4.04 ± 2.13*
Results are expressed as mean ± SD. WG: weeks of gestation. *p50.001 versus the ‘‘no request’’ group; **p50.05 versus the ‘‘postnatal request’’ group.
Table 3. Details of the paediatrician’s intervention in the delivery room and the type of care/transfer in the ‘‘prenatal request’’, ‘‘postnatal request’’ and ‘‘no request’’ groups.
No request (n ¼ 328) Clinical examination Treatment Airway suction Positive pressure ventilation Endotracheal intubation Maternity ward 2 h of monitoring Neonatology department Neonatal intensive care unit
328 (100%) 0 0 0 0 328 (100%) 0 0 0
Prenatal request (n ¼ 178) 71 7 23 32 45 75 21 25 57
(39,9%) (3.9%) (12.9%) (18.0%) (25.3%) (42.1%) (11.8%) (14.1%) (32.0%)
Postnatal request (n ¼ 78) 53 11 3 9 2 46 19 9 4
(68.0%) (14.1%) (3.8%) (11.5%) (2.6%) (59.0%) (24.4%) (11.5%) (5.1%)
the neonatology department and 61 (10.4%) were transferred to the NICU. A paediatrician had been present before delivery for 82 (86.3%) of the 95 newborns requiring further treatment in the neonatology department or the NICU (Table 3).
Discussion In a prospective study of 584 consecutive deliveries, 170 (30.5%) triggered a prenatal request for paediatrician assistance (according to the criteria published by Aziz et al. [6] and 78 (13.3%) triggered a postnatal request. Prenatal requests were significantly more frequent during the day than during the night (p50.01), and newborns in the ‘‘prenatal request’’ group had a lower gestational age and a lower birth weight than those in the two other groups. Paediatrician assistance was requested before delivery for the great majority of newborns requiring PPV (78%), endotracheal intubation (95.8%) or further treatment in the neonatology department or the NICU (86.3%). We confirmed that the ante- and intra-partum factors described by Aziz et al. [6] accurately predicted the need for paediatrician attendance in general and neonatal resuscitation (PPV and/or endotracheal ventilation) in particular. A number of studies have focussed on the need for paediatrician
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attendance in specific situations (such as the observation of meconium-stained amniotic fluid [7] or elective caesarean sections [4,8–12]. Even though these situations are very common (especially in tertiary hospital units), few studies have examined a broad range of risk factors [5,7,13–16]. To the best of our knowledge, no prospective studies have attempted to validate Aziz et al.’s criteria in other centres. The characteristics of the newborns in the ‘‘prenatal request’’ group were correlated with the high incidence of preterm deliveries, which is partly predictable [5,6,17]. About 40% of the newborns in the ‘‘prenatal request’’ group required only a clinical examination and were then able to stay with their mother in the maternity ward. In the first ever population-based study of the development and implementation of a multidisciplinary NRT, 19.0% of the 2944 newborns attended to by the team required PPV or further treatment [5]. Even though 40% of the newborns in the present study did not require neonatal resuscitation, an assessment of ante- and intra-partum risk factors predicted the majority (78%) of deliveries requiring PPV. These findings are similar to those initially reported by Aziz et al. (in which 85% of the requirements for PPV were predicted) [5]. In contrast, Mitchell et al. stated that most requirements for resuscitation cannot be accurately predicted [18]. The ‘‘postnatal request’’ and ‘‘no request’’ groups did not differ significantly in terms of the birth weight or gestational age, as they were mostly term deliveries. Only 14.0% of the newborns in the ‘‘postnatal request’’ group required PPV and/ or endotracheal intubation, and 16.7% required transfer to the neonatology department or the NICU. The indications for requesting paediatrician attendance in the ‘‘postnatal request’’ group were much more heterogeneous than in the ‘‘prenatal request’’ group. Even though 28 (35.9%) of the 78 newborns in the ‘‘postnatal request’’ group also met the criteria for a prenatal request, the indication was clearly postnatal in the 50 (64.1%) other newborns. Paediatrician assistance was often required for diagnosis or medication but not for acute resuscitation. The number of postnatal requests could therefore be reduced further by reinforcing checks for hypoglycaemia or suspected neonatal infections. The present study had some limitations, since only 584 newborns were included. However, all the inclusions were consecutive, and data were recorded prospectively. We clearly obtained a good level of agreement with the original criteria established in Aziz et al.’s population-based study [6]. The success of neonatal resuscitation is related not only to the implementation of a multidisciplinary NRT but also to anticipation and communication with a transport team [5,17,19]. Smith et al. demonstrated that prospective risk assessment improved efficiency and human resource use [20]. Our results support the recommendation whereby at least one practitioner with expertise in neonatal resuscitation should be present in the delivery room team when a risk factor has been identified [21]. In conclusion, we found that the criteria adapted from Aziz et al. [6] enabled a prenatal request for paediatrician assistance in 78% of deliveries requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring further treatment in the neonatology department or the NICU. With completed with ‘‘low Apgar score’’ and
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‘‘cord pH57.20’’, these criteria predicted the prenatal or early postnatal need for paediatrician assistance in 95% of cases. We believe that considering these criteria in procedures and guidelines for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for an NRT.
Acknowledgements The authors would like to thank the staff in the maternity unit, all the parents having participated in this study, Jean-Xavier Fontaine and Ariane Tourneux for advice in data analysis and David Fraser for carefully reviewing the English and improving the manuscript.
Declaration of interest None of the authors has any potential conflict of interest.
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