Sixty Golden Minutes

Kimberly Jane Doyle, RN, MSN, NNP-BC, CCRN

Wanda T. Bradshaw, MSN, RN, NNP-BC, PNP, CCRN

T he incidence of pr eter m birth (infants bor n at  and suggests an evidence-based framework to complete the
37 weeks gestation) in the United States for 2009 tasks within 60 minutes.
was 12  percent.1 The Vermont
Oxford Network (VON) reports DELIVERY ROOM
that only 25 percent of prema- Abstract RESUSCITATION
ture infants born at 23 weeks The golden hour concept started in the trauma setting but Infants born before 30 weeks
gestation will sur vive. This is becoming more familiar in the neonatal intensive care gestation generally require some
number increases to 50 percent unit (NICU). For a premature baby, the first hour of life respiratory support after birth to
for those 24 weeks gestation, and can make the difference between a good outcome, a poor ensure adequate ventilation and
75 percent for infants at 25 weeks outcome, and death. The golden hour is 60 minutes of oxygenation.5 Engle reports that
gestation. For those 25 weeks team-oriented and task-driven protocols. The focus is on in infants born at 28 weeks
gestation who survive, up to resuscitation, thermoregulation, early administration of gestation or with birth weight
antibiotics for suspected sepsis, early intravenous parenteral
50 percent will have handicaps, 1,000 g, 80 percent required
nutrition, hypoglycemia management, and completed
such as loss of vision and hearing, mechanical ventilation and 70
admission within one hour of life. To a premature baby, the
cerebral palsy, and developmental first 60 minutes of life are golden and can last a lifetime. percent required surfactant. 6
2
delays. Research shows that what Preterm infants must overcome
happens in the first hour of life of alterations in gas exchange,
a premature infant can lead to both short- and long-term con- surfactant deficiency, inadequately developed lungs, lack of
sequences, affect neurodevelopmental status, and even result respiratory drive, and possible retention of lung fluid.7 The
3
in death. The term golden hour was originally coined in adult goal of delivery room resuscitation is to use the least amount
trauma and intensive care medicine. It was born from the of intervention necessary to support normal gas exchange
idea that the first hour of care was critical to and had a direct while minimizing lung injury. It is important to identify
effect on patient outcome. Is there any other hour that is more when to intervene and with what support, what equipment
golden to a preterm infant than the first? is needed, how much oxygen to use, and when to administer
In 2009, Reynolds and colleagues designed a golden hour surfactant.8 The American Heart Association (AHA) 2010
checklist for their neonatal intensive care unit (NICU). The 4 guidelines for the Neonatal Resuscitation Program (NRP)
overall goal of these authors was to develop a protocol that provide an evidenced-based approach for the delivery room.9
would decrease long-term sequelae associated with com- The golden hour protocol that is proposed here (see Table 1)
plications from premature birth including intraventricular highlights tasks of each team member in the first 60 minutes
hemorrhage (IVH), chronic lung disease (CLD), and retino- of life in combination with these guidelines. The goal is to
pathy of prematurity (ROP). The infants were to be deliv-
ered, intubated, admitted to the NICU, and have surfactant Continuing Nursing Education (CNE) Credit
administered within the first hour of life in such a way as to A total of 7 contact hours may be earned as CNE credit for reading the
decrease morbidity and mortality. The golden hour should articles in this issue identified as CNE and for completing an online post-test
start in the delivery room and end in the NICU. Key areas of and ­e valuation. To be successful the learner must obtain a grade of at least
80% on the test.
focus are resuscitation, thermoregulation, rapid treatment of
presumed sepsis, timely intravenous protein administration, Disclosure
preventing hypoglycemia, and completed admission to the The author has no relevant financial interest or affiliations with any
­commercial interests related to the subjects discussed within this article.
NICU within one hour of life. The golden hour protocol No commercial support or sponsorship was provided for this educational
developed in this article incorporates all of these components activity.

Accepted for publication March 2012.

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VOL. 31, NO. 5, SEPTEMBER/OCTOBER 2012 © 2012 Springer Publishing Company 289
http://dx.doi.org/10.1891/0730-0832.31.5.289
meet the needs of the fragile infant while promoting the best
outcomes possible.
When an infant is delivered, the team has 60 seconds to
dry, stimulate, and assess the infant per AHA 2010 ­guidelines.
Traditionally, the infant’s color has been used to guide care
in the delivery room.
Saturation Monitoring
O’Donnell and colleagues evaluated this practice and
­a nalyzed at what saturation providers described an infant
as pink and compared the opinions of each member of the
resuscitation team.10 What they discovered was that most pro-
viders did not agree on when infants were pink, or whether
color alone is a reliable predictor of oxygen saturations. This
study provides evidence that the use of pulse oximeters in the
delivery room allows for more consistent monitoring and a
better standard of care. The probe should be connected to
the infant’s right upper extremity to ensure preductal satura-
tions. For faster results, the probe should be connected to the
infant prior to being connected to the oximeter.9 Research
has demonstrated that in healthy infants, it may take up to
five minutes to reach an oxygen saturation of 80 percent.11
The new AHA recommendations allow for lower preductal
saturation in the first five minutes of life.
Respiratory Support
If respiratory support is required, a pressure-limited device
such as the T-piece (Neopuff; Fisher & Payke Healthcare,
Irvine, California) is preferred because it has been shown to
deliver more consistent pressures than either self-inflating or
flow-inflating bags and is associated with more effective ven-
tilation even with inexperienced providers.12 To use the least
amount of pressure needed, adequate ventilation should be
measured primarily by an improvement in the heart rate, not
chest rise.9 Manual breaths should be avoided because they
have been shown to lead to lung injury.9,12
Oxygen Content
Oxygen is a potent drug, and infants treated with high
amounts of oxygen are at a greater risk for developing CLD.8
The AHA recommends using an oxygen blender in the deliv-
ery room to titrate oxygen delivery in order to reach the
targeted saturation goals outlined by the NRP guidelines.
Snyder and associates state that the “ideal oxygen support is
the least amount of oxygen needed to ensure adequate deliv-
ery of oxygen to the tissues.”8 (p.257) In two clinical trials,
Snyder and colleagues demonstrated that appropriate oxygen
saturations for preterm infants could be achieved during
resuscitation by using as little as 30–40 percent oxygen. 8
Vento and colleagues report that “resuscitation of preterm
neonates with 30 percent oxygen causes less oxidative stress,
inflammation, need for oxygen, and risk of bronchopulmo-
nary dysplasia.”13 (p.439) Use of blenders in the delivery room
allows for titration of oxygen and individualized treatment
of each infant.
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290  SEPTEMBER/OCTOBER 2012, VOL. 31, NO. 5
Surfactant
Surfactant administration can improve survival of prema-
ture infants by reducing respiratory distress and the severity
of CLD.6 Periods of mechanical ventilation, even as brief as
15–30 minutes with a surfactant-deficient lung, have been
shown to result in acute lung injury. This damage can lead
to a decreased response to subsequent surfactant administra-
tion.14 The benefits of giving prophylactic surfactant prior to
the onset of respiratory distress, outweigh the risks for infants
30 weeks gestation.5,14 Hudson and Oddie state that their
goal is to have surfactant administered within five minutes of
delivery for infants 28 weeks gestation.15 Premature infants
may require additional doses of surfactant, known as rescue
doses, to achieve maximum benefit. Suresh and Soll recom-
mend that additional doses be considered when oxygen require-
ments exceed 30 percent for ventilated patients, 40 percent for
other patients, or if the mean airway pressure needed is 7 cm
H2O.14 Engle summarizes that for infants with RDS, surfac-
tant should be administered promptly after intubation.6
Mechanical Ventilation
The goal of respiratory support is to assist the premature
infant in the transition from fetal to neonatal respiration.
Proper lung inflation is the first step in this transition. The
infant must establish functional residual capacity (FRC) by
recruiting lung volume.8 Snyder and associates report that
attempting to ventilate a poorly inflated lung can lead to
CLD.8 Providing the infant with surfactant and continuous
positive airway pressure (CPAP) allows for recruitment of
lung alveoli and more effective gas exchange.8 Wiswell and
Srinivasan discuss the “INSURE” approach for premature
infants.16 This includes intubation, surfactant administra-
tion, and rapid extubation to nasal continuous positive airway
pressure (NCPAP). Dunn and associates compared several
approaches to the initial respiratory management of premature
infants.5 They were able to conclude that infants who received
early CPAP had similar outcomes to those who were intu-
bated. The AHA recommends that each infant should have an
individualized treatment plan because current research shows
similar outcomes for both CPAP and ventilated infants.9
Being prepared and able to anticipate that most premature
infants will require some respiratory support in the delivery
room is the first step to a successful resuscitation. The AHA
guidelines recommend for the least amount of support and
oxygen required to meet appropriate saturation goals. The
proposed golden hour protocol (see Table 1) uses a team
approach in an organized and timely manner to provide the
best possible patient outcomes.
THERMOREGULATION
Hypothermia in a premature infant can precipitate a cascade
of events that may lead to increased morbidity and mortality.
Despite advances in technology, extremely low birth weight
(ELBW) infants continue to be hypothermic upon admission
to the NICU and for the first 12 hours of life.17 Not only are
premature infants at a higher risk for heat loss but also the
effects of cold stress can last a lifetime. The AHA addresses
thermoregulation in the 2010 NRP guidelines. The first step
in reducing infant hypothermia is adjusting the temperature of
the delivery room. It is recommended that the room tempera-
ture be set to 80°F (26.7°C). The radiant warmer should be
turned on prior to delivery. Blankets and hats should also be
prewarmed. The AHA recommends the use of polyethylene
bags to prevent heat loss in ELBW infants.9 The infant should
be placed in the bag up to the neck and a hat placed on the
head. Reynolds and associates layered two hats in their golden
hour protocol to decrease heat loss.4 New research shows that
woolen hats may help improve infant temperatures more effi-
ciently than the currently used cotton or stockinet caps.18 In
addition, by placing plastic wrap under the woolen hat, heat loss
may be minimized even further.18 The infant should be trans-
ported in a prewarmed incubator, and if needed, may be placed
on an activated chemical mattress. Regulation of environmen-
tal temperatures is the first step to thermoregulation, but to
prevent evaporative heat loss, humidity must also be used.
Incubator humidity when maintained at 50 percent or
higher is associated with improved infant body temperatures
and fluid and electrolyte balance.18 When incubator doors are
opened, a percentage of humidity is lost despite air shields,
and the infant’s body temperature can drop as much as 1.8°F
(1°C) within five minutes.17 To account for this rapid fluc-
tuation, Knobel and Holditch-Davis proposed that incuba-
tor humidity be initiated at 80 percent.17 This allows for the
relative humidity to remain above 60 percent even when the
doors are opened briefly.
In the proposed golden hour protocol, the infant is admit-
ted and settled into the incubator within 60 minutes of birth.
One difficulty in meeting this goal may be encountered during
the unpredictable time needed to place, confirm, and secure
umbilical catheters. When an infant is under sterile drapes for
procedures such as umbilical catheter placement, the amount of
heat that can reach the body surface is ­limited.17 To minimize
the time when an infant may be more prone to hypothermia,
it is recommended that only skilled practitioners place umbili-
cal catheters.15,19 During the placement of umbilical catheters,
the admission nurse is responsible for keeping track of the
temperature and vital signs of the infant as well as the time
that has elapsed since delivery. When delivery is approaching,
intravenous fluid tubing can be primed and placed in the warm
incubator.17 To maximize infection control precautions, this
should be a sterile procedure and the connections are main-
tained as sterile as possible. Ventilator equipment also plays a
role in thermoregulation; therefore, it is prudent to include
this in the discussion. Infant temperatures have been shown to
decrease by up to 1.8°F (1°C) when ventilator heater tempera-
tures fall below 93.2°F (34°C). Changes in lung function can
be seen even after short periods of inadequate humidification
of the preterm airway.20 This demonstrates the importance of
not only prewarmed respiratory equipment but also the crucial
role of the respiratory therapist. Although the use of heated
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VOL. 31, NO. 5, SEPTEMBER/OCTOBER 2012  291
and humidified gas is a standard of care in the NICU, it is
generally not used in the delivery room. Research demon-
strated a positive effect on admission temperatures of infants
when heated and when humidified gas was used in the deliv-
ery room and during transport to the NICU.20 During this
study, respiratory heaters were able to reach 98.6°F (37°C) in
less than three minutes. These fragile patients rely on each
member of the team for prevention of hypothermia. To help
reduce morbidity and mortality of the premature population,
optimal thermal care is a necessity.17
SEPSIS
Early onset sepsis (EOS), bloodstream infections within
72 hours of life, remains a major cause of morbidity and mor-
tality among premature infants. Premature birth has been cor-
related with sepsis and the risk is inversely proportional to birth
weight.21 Early goal-directed therapy (EGDT) is a concept that
was introduced by Rivers and associates in 2001 for the treat-
ment of sepsis in an adult setting.22 A 16 percent reduction in
mortality was demonstrated related to the early administration
of antimicrobial therapy. Kumar and associates used EGDT
to demonstrate that for every hour when antibiotic adminis-
tration was delayed for adult patients with early-onset sepsis,
there was a decrease in survival of almost 8 percent.23 EGDT
is the basis for the Surviving Sepsis Campaign and resulting
recommendations. The 2008 guidelines consist of ten strate-
gies for the management of sepsis.24 The main recommenda-
tion is that broad-spectrum antimicrobial therapy should be
started within the first hour when sepsis is suspected.
In the neonatal population, the clinical presentation of
sepsis may be subtle, in part because of the immature immune
system. The premature infant with sepsis may present with
a change in vital signs, hypoglycemia, temperature insta-
bility, or a change in behavior.21 Blood cultures should be
obtained prior to the administration of antibiotics if possible,
but therapy should not be delayed.25 Labenne and associates
maintain that in the neonatal population, antibiotics must be
started promptly after birth to reduce long-term morbidities
and mortalities related to sepsis.26 The golden hour protocol
proposed here (see Table 1) recommends that antibiotics be
given within the first 60 minutes of life.
NUTRITION
Nutritional management plays a large role in optimizing
growth, preventing metabolic shock, and promoting the best
neurodevelopmental outcomes.27 Taylor and associates rec-
ommend that for best practice and preventing hypoglycemia,
very low birth weight (VLBW) infants should have glucose
infusing within 30 minutes of birth.28 Early administration
of parenteral protein prevents protein catabolism, a decrease
in growth-regulating factors, and both hypoglycemia and
hypokalemia.27 The VON advocates for intravenous protein to
be infusing within two hours of delivery for VLBW infants.29
To meet the recommended time frames of infusion for glucose
and protein, both Adamkin and Taylor and associates advocate
TABLE 1  n  Golden Hour Flowsheet Starting at Delivery

Time – mins NNP Admitting RN in Delivery Room RT Helper RN at Bedside

210 Fill out preprinted Set delivery room temperature Check intubation and suction Be sure admitting bed is
admission orders. at 80°F. Ensure delivery bed is supplies. Ensure oxygen is ready. Prime intravenous
warm; ensure warm blankets, humidified and warmed. lines with warmed stock
hat, and plastic body bag are Delegate for vent or parenteral fluids. Delegate
available. Ensure transport other needed respiratory tasks needed.
incubator is warmed and equipment at bedside.
available.
0–10 Assess infant. Place infant in plastic body Manage airway; secure ETT if Sterile set up of umbilical
Evaluate need for bag and hats on head; pulse needed. catheter insertion supplies.
intubation. Assign oximeter on right hand or
Apgar scores. extremity.
10–15 Stabilize for Stabilize for transport to NICU. Stabilize for transport to NICU. Stabilize for transport to
transport to NICU.
NICU.
15–20 Scrub, gown, Assess, weigh infant, obtain Connect to vent or NCPAP; Chart, assist admitting RN,
and glove for measurements, vital signs, connect Neopuff or bag and have lab tubes ready
umbilical catheter administer vitamin K, and and mask at bedside; set for blood specimens.
placement. secure for umbilical catheter oxygen limits and titrate as
placement with sterile body needed.
bag in place.
20–30 Start placing Assist NNP for umbilical catheter Obtain and warm appropriate Prepare antibiotics.
umbilical placement; monitor infant dose of surfactant.
catheters (arterial temperature and vital signs.
first).
30–35 Obtain blood for Put blood in lab tubes and label Transport blood gas and Send lab specimens; call for
labs. appropriately. return results to bedside. x-ray.
35–45 Insert UVC Assist with x-ray Be prepared to adjust ETT if Chart.
needed, and surf infant
when sterile drapes are
removed.
45–55 Interpret x-ray; Administer antibiotics, connect Chart. Chart; assist with IV pumps if
adjust and IV fluids to infant, and begin not already running.
secure umbilical infusion once placement
catheters. of umbilical catheters are
confirmed.
55–60 Interpret labs; write Close incubator, ensure humidity Administer surfactant if Assist admitting RN.
additional orders. is on and set point, remove ordered.
plastic bag, bridge and secure
umbilical lines, give eye
prophylaxis, and nest infant.
60 Chart. Tidy up bed space in preparation Chart. Assist admitting RN.
for family.
Post Update family. Orient family to NICU. Chart. Monitor respiratory status and Chart.
prepare to wean vent.

Note: Team effort also includes a unit secretary to put infant data in the computer system, enters orders, get lab slips, infant identification stickers/
tags, and prepare newborn screening form. Ampicillin, gentamicin, and standard total parenteral nutrition (TPN) must be available on unit and
be able to be obtained before orders are entered. Fluids are hung while delivery team is at delivery or just prior to delivery if possible. Allow
for fluids to be at room temperature or warmed prior to infusion. If a family has an impending premature delivery, update the family and get
consents ahead of delivery if possible. Explain what the golden hour is and that the team will be using that time to stabilize their infant and that
the family may visit after that hour. RN 5 registered nurse; NNP 5 neonatal nurse practitioner; RT 5 respiratory therapist; ETT 5 endotracheal
tube; NCPAP 5 nasal continuous positive airway pressure; UVC 5 umbilical venous catheter; IV 5 intravenous.

that a standard stock parenteral nutrition to be available on
the unit.27,28 This fluid should either be room temperature or
prewarmed to comply with the thermoregulation guidelines
set in the protocol. This stock solution should be composed of
10 percent dextrose concentration with 4 percent amino acids,
which is appropriate for either central or peripheral venous
access and would provide approximately 2 g/kg protein.27 The
best practice is to have glucose infusing within 30 minutes
after birth.28 Ideally, this infusion will be via umbilical cath-
eters that will take time to place and confirm via radiologic
studies. By using the proposed golden hour protocol, intrave-
nous parenteral nutrition is infusing as soon as venous access is
established and within the first 60 minutes of life, which will
promote positive long-term outcomes.

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EVALUATING GOLDEN HOUR PROTOCOLS
Despite the limitation that there is a lack of well-powered ran-
domized controlled trials, many NICUs practice some compo-
nents or variation of the golden hour.18 Premature infants can
be very unstable and do not tolerate stress well, so even in the
absence of a written protocol labeled golden hour, it is known
to be the best practice to complete the admission as quickly
as possible.15 To create the golden hour protocol illustrated
here (Table 1), several NICU protocols were reviewed. Inova
Fairfax Hospital in Virginia has a First Hour of Life Pathway.30
Their pathway begins five minutes before delivery and allows
ten minutes in the delivery room. In the NICU, the bedside
nurse sets up the umbilical catheter trays in a sterile manner, so
the practitioner may begin placing umbilical catheters almost
immediately upon admission to the NICU. They also identify
and include the unit secretary as an integral part of the team
required to complete an admission within 60 minutes. The
secretary is responsible for entering the infant into the system,
putting in orders, printing identification bands, and is the first
person a parent will encounter in the NICU.
In the Bradford Teaching Hospital, Hudson and Oddie state
their goal for golden hour protocol as, “We aim to stabilise,
admit, and put lines into the most vulnerable babies within
an hour of admission and then leave them as undisturbed as
possible.”15(p.1) Their 60 minutes begin after resuscitation and
upon admission to the NICU.15(p.12) The protocols are very
specific including what laboratory studies, intravenous fluids,
radiologic studies, and procedures are to be done.15 Although
what is expected to occur in the first hour is clear, the respon-
sibility of each team member is not defined.
Reynolds and associates start their unit golden hour pro-
tocol in the delivery room.4 Their checklist includes resusci-
tation, surfactant, and admission to the NICU. They address
hypothermia and respiratory distress, but not umbilical cath-
eter placement, antibiotics, fluids, or radiographic studies. It
is also unclear which team member is responsible for which
task. They used simulation-based learning to increase the skills
and comfort level of their staff prior to the implementation
of the protocol. A video recorder is activated in the delivery
room to allow the team to view and critique the resuscitation
process. The recording is meant to be educational and allow
the unit to improve on their skills as a team.
The NICU in Franklin Square Hospital Center in Baltimore
has a golden hour protocol that starts 48 hours before delivery.
Their team attempts to get parental consent for procedures and
treatment of the infant prior to delivery if possible. They incor-
porated a multidisciplinary team approach to creating and imple-
menting the current protocol. A three-page laminated checklist
is at every delivery bed and outlines when and who is responsible
for each task, including the unit secretary. After every admission,
the team is debriefed to identify where improvements could have
been made. By educating the staff on long-term outcomes of the
premature infant, each member of the team was able to identify
how each person made a difference and allowed for the staff to
take ownership of the new protocol.31
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VOL. 31, NO. 5, SEPTEMBER/OCTOBER 2012  293
The success of any golden hour protocol starts with an
effective team in the delivery room. Not only can each
member of the team make a difference, but also a great team
can perform at a level that exceeds the skills of any one mem-
ber.3 Research demonstrates that communication, teamwork,
experience, and practice improve patient outcomes. 3 The
golden hour protocol proposed here outlines the roles of each
team member in the first 60 minutes after delivery.
CONCLUSION
Despite astounding advances over the past ten years, pre-
mature births remain the second leading cause of neonatal
mortality in the United States.18 “In complex environments
such as the NICU, the appropriate timing of every action
may be the most important consideration and can change the
outcome of a life.”19(p.62) Interdisciplinary training, effective
communication, and team development are important factors
in promoting positive outcomes.32 Key areas of the golden
hour are resuscitation, thermoregulation, rapid treatment of
sepsis, timely parenteral nutrition administration, euglyce-
mia, and completed admission within 60 minutes of deliv-
ery. It takes a well-organized and skilled group with effective
communication skills to meet these goals within one hour.
The proposed golden hour protocol outlines a road map that
starts in the delivery room with consistent care derived from
evidenced-based research and will ideally reduce morbidity
and mortality in the premature population. Defining the
tasks for each person can empower each to take ownership
of his or her role and make a commitment to provide the
best outcomes possible. Advantages of the proposed protocol
are clear expectations of each team member and a guideline
for time management. For a premature infant, the first 60
minutes of life are golden and last a lifetime.
References
  1. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2008.
National Vital Statistics Reports. 2010;58(16). Centers for Disease
Control and Prevention Web site. http://www.cdc.gov/nchs/data/nvsr/
nvsr58/nvsr58 16.pdf. Accessed February 19, 2011.
  2. Jajczyk S. NICQ 2007 process record cover sheet. Vermont Oxford
Network. 2007:29–30. http://esjh.org/nicu/images/stories/
nicuplaybook.pdf. Accessed February 19, 2011.
  3. Annibale DJ, Bissinger RL. The golden hour.Adv Neonatal Care. 2010;10(5):
221–223. http://dx.doi.org/10.1097/ANC0b013e3181e9e244.
  4. Reynolds RD, Pilcher J, Ring A, Johnson R, McKinley P. The golden
hour: care of the LBW infant during the first hour of life one unit’s
experience. Neonatal Netw. 2009;28(4):211–219.
  5. Dunn MS, Kaempf J, de Klerk A, et al. Randomized trial comparing 3
approaches to the initial respiratory management of preterm neonates.
Pediatrics. 2011;128(5):e1069–e1076. http://dx.doi.org/10.1542/peds.
2010-3848.
  6. Engle WA. Surfactant-replacement therapy for respiratory distress in the
preterm and term neonate. Pediatrics. 2008;121(2):419–432. http://
dx.doi.org/10.1542/peds.2007-3283.
  7. Rabi Y, Singhal N, Nettel-Aguirre A. Room-air versus oxygen administration
for resuscitation of preterm infants: the ROAR study. Pediatrics.
2011;128(2):e374–e381. http://dx.doi.org/10.1542/peds.2010-3130.
  8. Snyder T, Walker W, Clark R. Establishing gas exchange and improving 26. Labenne M, Michaut F, Gouyon B, Ferdynus C, Gouyon J. A population-
oxygenation in the delivery room management of the lung. Adv based observational study of restrictive guidelines for antibiotic therapy
Neonatal Care. 2010;10(5):256–260. http://dx.doi.org/doi: 10.1097/ in early-onset neonatal infections. Pediatr Infect Dis J. 2007;26(7):593–
ANC.0b013e3181f0836d. 599. http://dx.doi.org/10.1097/INF.0b013e318068b656.
  9. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 27. Adamkin DH. Nutrition management of the very low-birthweight infant:
2010 American Heart Association Guidelines for Cardiopulmonary I. Total parenteral nutrition and minimal enteral nutrition. NeoReviews.
Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 2006;7:e602–607. http://dx.doi.org/10.1542/neo.7-12-e602.
122(18)(suppl 3):S909 –S919. 28. Taylor SN, Kiger J, Finch C, Bizal D. Fluid, electrolytes, and nutrition:
10. O’Donnell CP, Kamlin CO, Davis PG, Carlin JB, Morley CJ. Clinical minutes matter. Adv Neonatal Care. 2010;10(5):248–255. http://
assessment of the infant colour at delivery. Arch Dis Child Fetal Neonatal Ed. dx.doi.org/10.1097/ANC.0b013e3181f0823e.
2007;92(6):F465–F467. http://dx.doi.org/10.1136/adc.2007.120634. 29. Vermont Oxford Network NICQ. Neonatal nutrition initiative 2009–
11. Nuntnarumit P, Rojnueangnit K, Tangnoo A. Oxygen saturation 2010. http://www.vtoxford.org. Accessed May 1, 2010.
trends in preterm infants during the first 15 min after birth. J Perinatol. 30. Inova Fairfax Hospital for Children. First hour of life pathway. Falls
2010;30(6):399–402. http://dx.doi.org/10.1038/jp.2009.178. Church, VA: ReLi Committee; 2011.
12. Te Pas AB, Walther FJ. A randomized, controlled trial of delivery- 31. Wood C. Golden hour. Paper presented at: National Neonatal Nurses
room respiratory management in very preterm infants. Pediatrics. Conference; September 2011; Washington, DC.
2007;120(2):322–329. http://dx.doi.org/10.1542/peds.2007-0114. 32. Soll RF, Pfister RH. Evidence-based delivery room care of the very low
13. Vento M, Moro M, Escrig R, et al. Preterm resuscitation with low oxygen birthweight infant. Neonatology. 2011;99(4):349–354. http://dx.doi.
causes less oxidative stress, inflammation, and chronic lung disease. Pediatrics. org/10.1159/000326844.
2009;124(3):e439–e449. http://dx.doi.org/10.1542/peds.2009-0434.
14. Suresh GK, Soll RF. Pharmacologic Adjuncts II. In: Goldsmith JP,
Karotkin EH, eds. Assisted Ventilation of the Neonate. 5th ed. Philadelphia, About the Author
PA: Saunders; 2011:371–388. Kimberly Jane Doyle received her BSN and MSN from Duke
15. Hudson C, Oddie S. The golden hour: resuscitation and early care of University School of Nursing. She is currently works at Riley Hospital
the extremely premature infant. Bradford Teaching Hospitals. http:// for Children in Indianapolis, Indiana.
www.yorkshireneonet.org.uk/guidelines_folder/GoldenHour.htm.
Accessed February 19, 2011. For further information, please contact:
16. Wiswell TE, Srinivasan P. Continuous positive airway pressure. In: Kimberly Jane Doyle, RN, MSN, NNP-BC, CCRN
Goldsmith JP, Karotkin EH, eds. Assisted Ventilation of the Neonate. 4th Riley Hospital for Children
ed. Philadelphia: Saunders; 2003:127–147. 705 Riley Hospital Drive
17. Knobel R, Holditch-Davis D. Thermoregulation and heat loss prevention Indianapolis, IN 46202
after birth and during neonatal intensive-care unit stabilization of extremely E-mail: 2kimdoyle@gmail.com
low-birthweight infants. J Obstet Gynecol Neonatal Nurs. 2007;36:280–
286. http://dx.doi.org/10.1111/J.1552-6902.2007.00149.x
18. Bissinger RL, Annibale DJ. Thermoregulation in very low-birth-
weight infants during the golden hour: results and implications. Adv
Neonatal Care. 2010;10(5):230–238. http://dx.doi.org/10.1097/
ANC.0b013e3181f0ae63.
19. Conway JB, Celenza J, Abraham MR. Advancing patient and family
centered newborn intensive care. In: Horbar JD, Leahy K, Handyside
J, eds. NICQ 2007: Improvement in Action. Burlington, VT: Vermont
Oxford Network; 2010. http://www.vermontoxford.net/quality/
ebook/NICQ_2007.pdf. Accessed February 19, 2011.
20. Te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidified
and heated air during stabilization at birth improves temperature in
preterm infants. Pediatrics. 2010;125(6):e1427–e1432. http://dx.doi.
org/10.1542/peds.2009-2656.
21. Gomella TL, Cunningham MD, Eyal F. Neonatalogy: Management,
Procedures, On-Call Problems, and Drugs. 6th ed. New York, NY:
McGraw Hill; 2009.
22. Rivers E, Nguyen B, Havstad S, et al; and Early Goal-directed Therapy
Collaborative Group. Early goal-directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377.
http://www.nejm.org/doi/full/10.1056/NEJMoa010307. Accessed
February 19, 2011.
23. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before
initiation of effective antimicrobial therapy is the critical determinant of
survival in human septic shock. Crit Care Med. 2006;34(6):1589–1596.
http://dx.doi.org/10.1097/01.CCM.0000217961.75225.E9.
24. Surviving Sepsis Campaign. http://www.survivingsepsis.org/Pages/
default.aspx. Accessed February 27, 2010.
25. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic
shock: 2008. Crit Care Med. 2008;36(1):296–327. http://dx.doi.
org/10.1097/01.CCM.0000298158.12101.41.

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