Neonatal Vital Sign Trajectories and Risk Factors During Transport Within a Regional Care Network

OBJECTIVE

The aim of this study was to characterize vital sign abnormalities, trajectories, and related risk factors during neonatal transport.

METHODS

We performed a retrospective analysis of neonates transported within a US regional care network in 2020 to 2021. Demographic and clinical data were collected from electronic records. Group-based trajectory modeling was applied to identify groups of neonates who followed distinct vital sign trajectories during transport. Patients with conditions likely to impact the assessed vital were excluded. Risk factors for trajectories were examined using modified Poisson regression models.

RESULTS

Of the 620 neonates in the study, 92% had one abnormal systolic blood pressure (SBP) measure, approximately half had an abnormal heart rate (47%) or temperature (56%), and 28% had an abnormal oxygen saturation measure during transport. Over half (53%) were in a low and decreasing SBP trajectory, and 36% were in a high and increasing heart rate trajectory. Most infants ≤ 28 weeks postmenstrual age had 2 or more concerning vital sign trajectories during transport.

CONCLUSION

Abnormal vital signs were common during neonatal transport, and potentially negative trajectories in heart rate and SBP were more common than temperature or oxygen saturation. Transport teams should be trained and equipped to detect concerning trends and respond appropriately while en route.

Mother's Bed Incline and Desaturation Episodes in Healthy Term Newborns during Early Skin-to-Skin Contact: A Multicenter Randomized Controlled Trial

INTRODUCTION

Early skin-to-skin contact (ESSC) is associated with rare, sudden, unexpected postnatal collapse episodes. Placing the newborn in ESSC closer to an upright position may reduce the risk of airway obstruction and improve respiratory mechanics. This study assessed whether a greater inclination of the mother's bed during ESSC would reduce the proportion of healthy term newborns (HTNs) who experienced episodes of pulse oximeter saturation (SpO2) <91%.

METHODS

We conducted a multicenter randomized controlled trial comparing the effect of the mother's bed incline, 45° versus 15°, on desaturation in HTNs during ESSC. Before delivery on 1,271 dyads, randomization was conducted, and stringent criteria to select healthy mothers and term newborns were monitored until after birth. Preductal SpO2 was continuously monitored between 10 min and 2 h after birth. The primary outcome was the occurrence of at least one episode of SpO2 <91%.

RESULTS

254 (20%) mother-infant dyads were eligible for analysis (45°, n = 126; 15°, n = 128). Overall, 57% (95% confidence interval [CI]: 51%-63%) of newborns showed episodes of SpO2 <91%. The proportion of infants with SpO2 <91% episodes was 52% in 45° and 62% in 15° (relative risk: 0.80; 95% CI: 0.6-1.07).

CONCLUSIONS

We did not show that a high mother bed inclination during ESSC led to significantly fewer HTNs who experienced episodes of SpO2 <91%. Desaturation episodes from 10 min to 2 h after birth occurred in more than half of HTNs.

What is the impact of mother's bed incline on episodes of decreased oxygen saturation in healthy newborns in skin-to-skin contact after delivery: Study protocol for a randomized controlled trial

BACKGROUND

Early mother-child skin-to-skin contact (SSC) in the first 2 h postpartum is highly beneficial for both mother and child. However, cases have been reported of newborns who have experienced apparently life-threatening events (ALTEs) or sudden death during this procedure. The causes of these events are unknown. Newborn's prone position could influence the onset of these events but there is very little evidence to support any recommendation. We hypothesize that newborns' breathing obstruction episodes increase as mothers lie more horizontally. The main objective of this study is to compare the occurrence of desaturation and bradycardia episodes as a function of mother's bed incline. The study is designed as a randomized, controlled, assessor blind, multicenter, superiority trial with two parallel groups and 1:1 allocation ratio.

METHODS

The study participants will be full-term healthy mother-newborn dyads from ten hospitals in Spain. Participants will be randomly assigned to one of two study arms defined by mother's bed inclination (45° or 15°). The planned sample size is 5866. Centralized permuted blocks randomization and assessor blinding will be implemented. The newborns will be monitored remotely with pulse oximetry, from 10 min to 2 h after delivery. We established SO2 and heart rate (HR) limit alarms, as well as an action protocol in the event of alarm activation. The primary outcome is the number of healthy newborns who undergo episodes of SO2 ≤ 90%. Secondary outcomes are the mean SO2 level, the number of newborns who experience episodes of SO2 ≤ 85%, the time to SSC discontinuation due to abnormal SO2 or HR, and episodes of HR < 111 beats per minute (bpm) or > 180 bpm. Subgroups and pooled analysis will be performed to identify if breast-feeding and mother and child positions favor the occurrence of desaturation or bradycardia episodes.

DISCUSSION

A simple intervention such as modifying mother's bed angle of inclination while in SSC with her child during the first 2 h postpartum could favor newborn's hemodynamic and respiratory stabilization and thus contribute to reducing the onset of ALTEs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02585492 . Registered on 22nd October 2015.

PROTOCOL VERSION

2 (30th June 2015).

Factors Affecting the Target Oxygen Saturation in the First Minutes of Life in Preterm Infants

BACKGROUND

The aim of this study was to describe the effect of factors on time to reach a pulse oxygen saturation (SpO2) level of 90% in preterm infants in the delivery room.

METHODS

Preterm (<35 gestational age) infants who did not require supplemental oxygen were included in the study. Continuous recordings were taken by pulse oximetry during the first 15 min of life.

RESULTS

Of 151 preterm infants, 79 (52.3%) were female and 126 (83.5%) were delivered by cesarean section. Target saturation level (≥90%) was achieved faster in preductal measurements. Mean times taken to have a preductal and postductal SpO2 level of 90% were significantly lower in preterm babies born by vaginal delivery, with umbilical arterial pH ≥ 7.20 and whose mothers were non-smokers during pregnancy.

CONCLUSIONS

Differences in achievement of target saturation level were influenced by multiple factors (birth way, probe location, maternal smoking and umbilical blood gas pH) in the delivery room during resuscitation of preterm babies.

Performance of Two Different Pulse Oximeters in Neonatal Transition

OBJECTIVE

To evaluate the performance of two different pulse oximeter technologies by comparing the time taken to achieve reliable oxygen saturation readings during neonatal transition.

METHODS

This cross-sectional study was done to compare the performance of two pulse oximeter technologies - Signal Extraction Technology (SET), and Resistor Calibration (RCAL) technology on 150 inborn, term neonates at birth. Probes of both pulse oximeters were connected to the pre-ductal limb and the time taken to obtain a reliable reading was recorded. Sequential saturation values were recorded every minute till ten minutes of life. Statistical analysis was done with Mann-Whitney U test and intraclass correlation coefficient was calculated.

RESULTS

Pulse oximeter with SET recorded reliable readings faster than RCAL technology - Median (IQR) 32 (21-60)s vs. 45 (21.75-105)s, p = 0.021. There was a significant difference in the time to record first saturation readings of the two pulse oximeters when used in normal deliveries [RCAL vs. SET-Median (IQR) 50s (25-120.75) vs. 32.5s (21.75-58.25), p = 0.004] but no such difference was observed in Lower Segment Cesarean section (LSCS) [RCAL vs. SET Median (IQR) 35.5s (18.25-70.75) vs. 31s (20-69.75), p = 0.968]. Sequential saturation readings for every minute for the first 10 min of life were higher with SET vs. RCAL technology. The intraclass correlation coefficient between both pulse oximeters, for each minute, was poor (r < 0.80).

CONCLUSIONS

The SET pulse oximeter picked up first saturation values faster than the RCAL technology pulse oximeters. Studies are needed to evaluate effect of this on decisions made during neonatal resuscitation.

Oxygen therapy and oximetry in the delivery room

Pulse oximetry is increasingly being used in the delivery room. Expert recommendations state that oxygen therapy during newborn resuscitation should be guided by pulse oximetry. Obtaining accurate and stable oxygen saturation and heart rate information from a pulse oximeter in the delivery room can be challenging. Understanding the properties of this device is important in overcoming these challenges. This article describes several aspects of pulse oximetry use in the delivery room ranging from technical issues with the device itself to clinical applications of the technology.

Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants

AIM

To compare heart rate (HR) measurements from Masimo and Nellcor pulse oximeters (POs) against HR measured via a three lead electrocardiograph (ECG) (HRECG ). We also compared peripheral oxygen saturation (SpO2 ) measurements between Nellcor and Masimo oximeters.

METHOD

Term infants born via elective caesarean section were studied. ECG leads were placed on the infant's chest and abdomen. Masimo and Nellcor PO sensors were randomly allocated to either foot. The monitors were placed on a trolley, and data from each monitor screen captured by a video camera. HR, SpO2 measurements and signal quality were extracted. Bland-Altman analysis was used to determine agreement between HR from the ECG and each oximeter, and between SpO2 from the oximeters.

RESULTS

We studied 44 infants of whom 4 were resuscitated. More than 8000 pairs of observations were used for each comparison of HR and SpO2. The mean difference (±2SD) between HRECG and HRN ellcor was -0.8 (±11) beats per minute (bpm); between HRECG and HRM asimo was 0.2 (±9) bpm. The mean (±2SD) difference between SpO2Masimo and SpO2Nellcor was -3 (±15)%. The Nellcor PO measured 20% higher than the Masimo PO at SpO2 <70%.

CONCLUSION

Both oximeters accurately measure HR. There was good agreement between SpO2 measurements when SpO2 ≥70%. At lower SpO2 , agreement was poorer.

Oxygen saturation of healthy term neonates during the first 30 minutes of life

BACKGROUND

The purpose of this study was to document the oxygen saturation (SpO(2) ), general physical signs and laboratory characteristics during the first 30 min of life.

METHODS

Forty healthy singleton full-term neonates delivered vaginally (n = 33) or by cesarean section (n = 7) were included in this prospective observational study. After delivery, the SpO(2) levels of the upper (right hand; 'preductal') and lower (dorsum of the right foot; 'postductal') extremities of the neonates lying on the servo-controlled radiant heater in the delivery room were measured simultaneously with oximeter probes (Oxiprobe BM-270) placed at 1, 5, 10, 15, 20, 25, and 30 min. The correlation between pre- and postductal SpO(2) level and different variables (vital signs, capillary refill time recorded at 1 and 15 min, cord pH and hemoglobin values, and Apgar scores at 1 and 5 min) was examined.

RESULTS

The 1 min pre- and postductal SpO(2) were 82.3 ± 7.34% and 79.08 ± 8.16% (P > 0.05), respectively. The preductal values at 5, 10, and 15 min were statistically higher than the postductal values (89.73 ± 6.01%, 93.43 ± 4.06%, and 94.53 ± 3.19% vs 85.53 ± 6.92%, 89.9 ± 4.91%, 92.83 ± 3.92%, respectively). SpO(2) was the same regardless of the mode of delivery. No correlations were found between pre- and postductal SpO(2) and other variables.

CONCLUSIONS

Oxygen saturation was not affected by mode of delivery, was independent of Apgar score, cord hemoglobin, cord pH, vital signs, and capillary refill time in the first few minutes of life, and did not reach 90% in the first 5 min of life in healthy full-term neonates.

Correlation of pulse oximetry and apgar scoring in the normal newborns

CONTEXT

Apgar score (AS) is routinely used for assessment of newborns immediately after birth. Within acceptable limits, low saturations at birth are normal in vigorous newborn babies. Various studies have questioned the reliability of AS.

AIMS

To detect whether AS is an accurate indicator of hypoxemia and to study the correlation of different components of AS with the arterial oxygenation saturation (SpO2) levels of normal newborns in the delivery room.

SETTINGS AND DESIGN

A prospective cross-sectional observational study on normal healthy neonates delivered vaginally in a tertiary level referral medical college.

MATERIALS AND METHODS

SpO2 levels were monitored continuously in the newborns with a pulse oximeter and serial recording of SpO2 levels was done at 5 min intervals starting at 1 min of life until 30 min after birth. Simultaneously, AS was recorded in these newborns at 1 and 5 min of life.

STATISTICAL ANALYSIS

Data was analyzed using the Mann-Whitney-U test.

RESULTS

AS at 1 and 5 min of life didn't correlate with the changes in SpO2 of newborns. In AS; though respiratory efforts and muscle tone were significantly correlated with SpO2 of the newborns, body color did not have significant correlation with simultaneously recorded SpO2.

CONCLUSIONS

A revised AS in which evaluation of color is replaced by pulse oximetry monitoring would prove to be a better tool for neonatal evaluation in the immediate postnatal period.