Management in the delivery room

Management at birth                                 

These babies are vulnerable, delicate and bruise easily. They are prone to hypothermia, have a very thin fragile skin and lose heat and fluid trans-epidermally very quickly. They dislike handling and may rapidly “go off” during various manoeuvres e.g. attempts to site lines.  Such babies should not be unnecessarily stressed.  They are at particular risk of IVH, PPHN, etc.

 

If you have time discuss management plan at birth and outcome of extremely premature babies with parents and give them information leaflet. Inform consultant early if possible

Principles of care in the delivery room:

  • Assemble the most experienced team available.
  • Prepare you resuscitaire, equipments for resuscitation and transport system early
  • Meticulous attention to keeping the baby warm (see plastic bag guidelines).
  • Effective resuscitation with early intubation and administration of surfactant ifrequired (see flow chart)
  • Care taken to minimise pressures and oxygen to what is necessary to achieve adequate ventilation without volutrauma.

                                                           

What to do at resuscitation?

Assessment at Birth:

 

  1. Gestation certain – 23+0 to 23+6  weeks

If gestational age is certain at 23+0 – 23+6 (i.e. at 23 weeks) and the fetal heart is heard during labour, a professional experienced in resuscitation should be available to attend the birth. In the best interests of the baby a decision not to start resuscitation is an appropriate approach particularly if the parents have expressed this wish. However, if resuscitation is started with lung inflation using a mask, the response of the heart rate will be critical in deciding whether to continue or to stop and sensitively explain to the parents the futility of further interventions.

 

  1. 24+0 to 24+6  weeks

If gestational age is certain at 24+0 – 24+6 resuscitation should be commenced unless the parents and clinicians have considered that the baby will be born severely compromised. However the response of the heart rate to lung inflation using a mask will be critical in deciding whether to proceed to intensive care. If the baby is assessed to be more immature than expected, deciding not to start resuscitation may be considered in the best interest of the baby.

 

  1. 25 weeks and greater

When gestational age is 25+0 weeks or more, survival is now considerably greater than in 1995. It is appropriate to resuscitate babies at this gestation and, if the response is encouraging, to start intensive care.

 

  1. Uncertain gestation:

If gestational age is uncertain, (i.e. no dating ultrasound scan) but thought to be >23+0 weeks, an ultrasound scan by an experienced sonographer should be carried out if time permits. If the fetal heart is heard during labour, a professional experienced in resuscitation and another clinician (neonatal nurse or trainee paediatrician) should be called to attend birth. A decision should then be made, in the best interests of the baby, as to whether resuscitation should begin with mask ventilation. Once begun, the response of heart rate to lung inflation will be crucial in judging how long to continue resuscitation. If there is any uncertainty about management initiate resuscitation and guidance from more senior staff should be sought urgently.

 

Summary Flowchart on Framework of Practice in babies less than 26 weeks gestation 2008

 

Reference:

1.Wilkinson AR, Ahluwalia J,  Cole A et al. Management of babies born extremely preterm at less than 26 weeks of gestation: a framework for clinical practice at the time of birth. Arch Dis Child Fetal Neonatal Ed 2009;94:25

 

Early Management on NICU