Intraventricular Hemorrhage Prevention Guidelines

Introduction
In the first 72 hours of life, infants within the target group [birth gestational age less than 28 weeks or birth weight less
than 1500 grams] are most at risk for developing intraventricular hemorrhage (IVH). These infants become relatively
immune to the development of IVH after postnatal day three due to the stabilization of the germinal matrix. Therefore,
these guidelines should be maintained for 72 hours after birth. After that time, routine NICU developmental care
measures should be implemented. The severity of IVH is based on the presence and amount of blood in the germinal
matrix and lateral ventricles as demonstrated by cranial ultrasound.
o Grade I: Only germinal matrix hemorrhage
o Grade II: Intraventricular hemorrhage filling 10 to 50 percent of the ventricle
o Grade III: Intraventricular hemorrhage filling more than 50 percent of the ventricle
o Grade IV: Hemorrhage in any parenchymal location in addition to a unilateral or bilateral IVH

Equipment
• Cardio-respiratory monitor
• Combination radiant warmer/isolette (if available) or isolette
• “IVH Bundle” sign
• “Minimal Handling” sign
• Developmental positioning aids
• Isolette cover

Implementation
 Verify the practitioner’s orders in the infant's medical record.
 Gather and prepare the appropriate medication and equipment.
 Perform hand hygiene and don personal protective equipment.
 Place the infant into the isolette to avoid the need for additional movement and handling.
 Confirm the infant weight and gestational age to determine eligibility for IVH Prevention Guidelines.
o An infant only needs to meet one of the two criteria for guideline implementation: less than 28 weeks
gestation and/or less than 1500 grams.
o Guideline interventions should be implemented and maintained as soon as possible.
 If it is known in advance that the infant will meet the criteria for IVH Guidelines, neutral head positioning should
be implemented and maintained in the delivery room.
 All infants meeting IVH Guideline criteria should be ICU status during the first 72 hours of life, regardless of
respiratory status.
 Provide calm, quiet environment.
 Use isolette cover when possible.
 If lights are on, cover the infant’s eyes.
 Routine suctioning should be avoided with suctioning performed only when indicated.
 Give intravenous infusion boluses over at least 30 minutes.
 If UAC in place, draw blood samples and flush slowly, using minimal volumes.
 Nasogastric tube placement and nare patency assessment during admission can be deferred; if infant received
PPV or CPAP and requires stomach decompression, an OG tube is acceptable.
 Place “IVH Bundle” and “Minimal Handling” signs at the bedside.
 Positioning guidelines are as follows:
o Maintain the infant in a neutral head positioning to decrease dramatic shifts in cerebral perfusion. Studies
have shown that turning the head to the side affects jugular venous return and may affect intracranial
pressure and cerebral blood flow.
o Elevate the head of the bed thirty degrees. Do not position prone or in trendelenberg.
o Keep head midline (chin in line with umbilical cord) and maintain midline position at all times.
 o Supine positioning is preferred, with additional supports to keep head midline. Partial side positioning is
acceptable, with additional supports to keep head and body midline.
o Kangaroo care may be discussed on a case-by-base basis; if kangaroo care is performed, infant must be
positioned with head midline. Kangaroo care should be discussed during the first 72 hours of life and
encouraged as soon as physiologic stability achieved; however, further research is needed to examine the
impact of kangaroo care.
 Minimal handling guidelines are as follows:
o Minimizing handling will prevent disturbances in cerebral blood flow; studies have shown that reducing
stimulation and gentle caretaking decrease incidence of IVH.
o Assessments and/or procedures should be coordinated with all members of NICU team, and “hands-on” care
can be extended to every 6 hours at the discretion of the nurse.
o Baths should be avoided for 72 hours or longer if physiologically unstable.
o Footprints and handprints should not be obtained.
o If UAC in place and accurately monitoring blood pressure, only one cuff blood pressure should be obtained
per shift.
o Two team members should change linens and developmental positioning aids while maintaining midline
position and holding extremities in a flexed/supported position.
o Change diaper by supporting hips and shifting lower body to the side and sliding diaper beneath infant while
maintaining neutral head position. The hips should be lifted no higher than the shoulder.
 Remove and discard personal protective equipment.
 Perform hand hygiene.

Patient Teaching
 Explain the procedure to the infant’s family (when present) include information regarding possible significant
adverse reactions and discuss any other concerns.

Complications
 IVH causes brain injury in premature infants and is directly associated with negative neurodevelopmental
outcomes. Infants at risk for IVH should be identified early and interventions implemented to assist in reducing
IVH. Dramatic shifts in cerebral perfusion have been linked to IVH and interventions are aimed at decreasing
these shifts.

Documentation
 Document if IVH Guideline is contraindicated or unable to be maintained. Document parent education and
interaction. Note time and date of IVH guideline stop time and include in bedside shift report. All documentation
should occur in the electronic medical record.

References
 Allen, K., (2013). Treatment of intraventricular hemorrhages in premature Infants. Advances in Neonatal Care,
13(2), 127-130. doi:10.1097/ANC.0b013e31828ac82e
 Carteaux, P., (2003). Evaluation and development of potentially better practices for the prevention of brain
hemorrhage and ischemic brain injury in very low birth weight infants. Pediatrics, 111(e489). Retrieved from
http://pediatrics.aappublications.org/content/111/Supplement_E1/e489.full.html
 Crowell, B. & Annibale, D., (2014). Chapter 15: Intraventricular hemorrhage. Golden Hours: Care of the VLBW
Infant. ISBN 978-0-9890198-1-1
 Cucchiara, B., (Last updated 2013). Intraventricular hemorrhage. Kasner, S. & Wilterdink, J., (Eds.). Retrieved from
http://www.uptodate.com/contents/intraventricular-hemorrhage#references
 Malusky, S., & Donze, A., (2011). Neutral head positioning in premature infant for intraventricular hemorrhage
prevention: An evidenced-based review. Neonatal Network, 30(6), 381-396. http://dx.doi.org/10.1891/0730-
0832.30.6.381
 McGrath, J., Diallo, A., Paquette, R., & Samra, H., (2014). Chapter 19: Developmentally Supportive and Family-
Centered Care. Golden Hours: Care of the VLBW Infant. ISBN 978-0-9890198-1-1
 Praveen, B., (2014). Pathogenesis and prevention of intraventricular hemorrhage. Clin Perinatol, 41(1), 47-67.
doi:10.1016/j.clp.2013.09.007
 Schmid, M., Reister, F., Mayer, B., Hopfner, R., & Hummler, D., (2013). Prospective risk factor monitoring reduces
intracranial hemorrhage rates in preterm infants. Dtsch Arztebl Int, 110(29-30), 489-496.
doi:10.3238/arztebl.2013.0489
 Whitelaw, A., (2011). Core concepts: Intraventricular hemorrhage. Neoreviews, 12 (e94). doi:10.1542/neo.12-2-
e94