EXTREME PRETERM INFANTS

DELIVERY MANAGEMENT
dr. Lily Rundjan, SpA(K)
dr. Christopher Khorazon

INDONESIAN PICU NICU UPDATE – 2020/2021

 Background
Extremely Preterm Infants
(EPI: <28 weeks gestation)
have greater risk of death or
severe neurodevelopmental
outcome

Strategies to minimize the risk:

• In-utero transfer to Tertiary hospital
• Antenatal steroids/MgSO4 coverage
• Infection treated
• Optimal timing for termination of pregnancy
• Optimal delivery management

Manfy A. Delivery Room Emergencies: Seminars in Fetal & Neonatal. Elsevier. 2019. Vol 24: 3-4
Queensland Clinical Guidelines. Perinatal care of the extremely preterm baby.
INDONESIAN PICU NICU UPDATE – 2020/2021
 Preparation
(Outline)
1. Maternal & fetal information
2. Neonatal resuscitation team:
• Minimum 3 qualified staffs + 1 recorder
• Ideally 7 persons for resuscitation team
(Leader, airway, breathing, circulation, medication, access, recorder)

3. Tools & Equipment

Thermoregulation, airway, breathing, circulation, drugs, monitoring, PPE

4. Location:
Delivery room (DR) is ideally co-located with NICU.

INDONESIAN PICU NICU UPDATE –

Sawyer T, et al. Anticipation and preparation for every delivery room resuscitation. Seminars in Fetal and Neonatal Medicine. 2018 (23):312-320 2020/2021
 Preparation:
Maternal & Fetal Information
Maternal Fetal

• Antenatal Care • Gestational age

• Serology (Hep B, HIV, Rubella; etc) • Gestational weight
• Low vaginal swab, Urine MCS • Plurality (single, twin, etc)
• Genetic investigation • Presentation
• Substance use/ smoking in pregnancy • Antenatal/morphology scan
• Medications in pregnancy • Doppler - Fetal growth restriction
• Maternal diseases: • CTG monitoring - Foetal distress
Diabetes, Hypertension, Pre-eclampsia, Hypothyroidism; • Meconium
etc • Scalp lactate
• Maternal fever, PPROM, Chorioamnionitis
• MgSO4
• Antenatal steroids
• Oligohydramnios/Polyhydramnios
• Antepartum haemorrhage
• Analgesia during birth/labour

INDONESIAN PICU NICU UPDATE – 2020/2021

 Preparation:
Neonatal Resuscitation Team
Team briefing: decides roles that responsible for
airway (A), breathing (B) and circulation (C) and other roles.

Positioning of personnel and equipment:

• Head (A): manages airway and perform PPV
• Right (B): Turns on Apgar timer, respiratory management,
monitors for chest rise with ventilation, place the pulse
oximetry, helps PPV and intubation if needed
• Left (C): assesses heart rate, place EKG leads and provide
chest compressions if needed.

Other team member roles:

• Leader: leads resuscitation, directs other team members,
call additional help if needed
• Recorder: keeps time, documents resuscitation, assist
code leader
• Medication: prepares and administer medications
• Access: places emergency umbilical vessel catheter if
needed.

Sawyer T, et al. Anticipation and preparation for every delivery room resuscitation. Seminars in Fetal and Neonatal Medicine. 2018 (23):312-320 INDONESIAN PICU NICU UPDATE – 2020/2021
 Preparation:
Neonatal Resuscitation Team – Roles
Nurse (Delivery Room)

Doctor / Team Leader q Check TABCD, resuscitation kit

q Set room temperature 24-260C
Ø Inform consultant of impending delivery q Activate infant warmer and set to pre warm
*Delay caesarean if consultant not yet present
Ø Assign roles mode à manual mode
Ø Discuss plan and expectation q Prepare plastic wrap, hat, heated mattress
Ø Discuss maternal and infant conditions q Set T piece resuscitator 25/5 in 30% FiO2
Ø Confirm all tools and equipment are ready q Check saturation monitor and probe availability
Ø Confirm TABCD q Prepare CPAP circuit and humidifier
q Warm surfactant in isolette
q Prepare adrenaline 1:10000
q Prepare infant transport (including ventilator)

Nurse (NICU)
Prepare NICU equipment setting (central/peripheral
access, lipids, ventilator, etc)

Extremely Preterm early management flow chart. The first 72 hours for infants <28 weeks of gestation and/or EFW <1000 g. INDONESIAN PICU NICU UPDATE – 2020/2021
 Delivery
Decision to terminate pregnancy:
Mother/Fetal life is in danger.

Three possible delivery scenarios:

1. Emergency: SC CITO + full neonatal
resuscitation
2. Planned: Semi-elective SC + full
neonatal resuscitation
3. Palliative: comfort care, treatment
focused on mother
David AL, Soe A. Extreme prematurity and perinatal management. The Royal College of Obstetrician & Gynaecologists. 2018 (20): 109-117
Sawyer T, et al. Anticipation and preparation for every delivery room resuscitation. Seminars in Fetal and Neonatal Medicine. 2018 (23):312-320 INDONESIAN PICU NICU UPDATE – 2020/2021
Wyckoff M, Ringer, S, Escobedo, M, Ades, A, Colby, C, Eichenwald, EC, et all Textbook of Neonatal Resuscitation (NRP) 7 ed. USA: American Academy of Pediatrics and American Heart Association. ; 2016
.
 Active Management of EPI in DR

OUTLINE:
• Thermoregulation
• Delayed Cord Clamping
• Respiratory Management
• Monitoring
• Neonatal Transport
• Developmental care

INDONESIAN PICU NICU UPDATE – 2020/2021

 Thermoregulation
• Target temperature range : 36.5oC to 37.5oC
• Risk of mortality increased by 30% for each
degree below 36.5oC body temp at admission
• Current neonatal resuscitation guidelines à
Strategies to minimize heat loss:
1. Room temp 24oC
2. Occlusive/plastic wrapping
3. Polyethylene caps
4. Exothermic warming mattress
5. Warmed humidified resuscitation gases

Perlman J, Wyllie JP, Kattwinkel J, et al. Circulation 2015;132:S204–41. INDONESIAN PICU NICU UPDATE – 2020/2021
 A Cochrane review to assess the efficacy and safety of interventions to prevent hypothermia in delivery room (2018)
Result:
• Barriers to heat loss
Plastic wrap improved core body temperature and prevent
hypothermia than routine care only
(Mean difference 0.58 C; CI 95% 0.5-0.66; 13 studies; 1633 infants)
• External heat source
Thermal mattress significantly keeps ≤1500 g infants warm
(Mean difference 0.65 C; CI 95% 0.36-0.94)
• Combination
Ø There is no significant difference between
using plastic wrap vs thermal mattress alone
Ø However, plastic wrap + thermal mattress resulted
hyperthermia

McCall EM, et al. Cochrane Database Syst Rev. 2018 INDONESIAN PICU NICU UPDATE – 2020/2021
 Thermoregulation:
Exothermic Mattresses
Exothermic Mattresses (EM) is used to prevent hypothermia in preterm
infants
Activate by
snapping the disc

Metal disc Gel Latent heat

(sodium acetate gel) crystalizes generated

o When activated at room temperature (19-28oC)

38-42oC in 3 minutes

o Works as external heat source for infants through conduction

TransWarmer™ Extothermic Mattress
(placed between plastic blanket [PB] and towel) X= Metal disc containing sodium acetate gel.
Y = Gel crystalizes and produces heat after activation

McCarthy, et al. PEDIATRICS. 2013 (132): e135-141 INDONESIAN PICU NICU UPDATE – 2020/2021
 Thermoregulation:
Exothermic Mattresses
• McCarthy et al (2013):
RCT of 72 infants (<31 weeks) by
comparing PB+EM and PB only
• Results:
Normal Temperature Hyperthermia
PB+EM 41% 46%
PB only 77% 17%

Conclusion:
Using Exothermic Mattress in addition of plastic
blanket resulted more hyperthermia in very
preterm infants May be applied when unable to reach normothermia in
10 minutes of life – as adjunction to polyethylene bag
McCarthy, et al. PEDIATRICS. 2013 (132): e135-141 INDONESIAN PICU NICU UPDATE – 2020/2021
 Thermoregulation:
Warmed Humidified Gases
• Two studies (476 preterm infants <32 weeks
gestation) were enrolled Heating and humidification was achieved by
• The number of infants with more severe adding 30-50 ml of water and turning on the
hypothermia (<35.5◦C) was significantly device prior to expected delivery. The median
reduced (RR 0.32 CI 0.14-0.73) humidifier temperature was 36.5 oC
• EPI (<28 weeks) had significantly less
admission hypothermia (RR 0.61 CI 0.42, 0.90)
• Mortality and measures of respiratory
outcome were not significantly different,
though there was a trend to improvement in all
respiratory measures assessed.
• There were no significant adverse events and
no increase in admission hyperthermia
(>37.5◦C)
Meyer MP, Owen LS, te Pas AB. Front Pediatr. 2018;6(October):1–8. INDONESIAN PICU NICU UPDATE – 2020/2021
 With the used of heated humidified gases in
DR, hypothermia was significantly reduced.

Meyer MP, Owen LS, te Pas AB. Front Pediatr. 2018;6(October):1–8. INDONESIAN PICU NICU UPDATE – 2020/2021
 Delayed cord clamping &
Umbilical cord milking
In Meta-analysis of 10 studies (199 infants),
delayed cord clamping (DCC) > 20 sec and
umbilical cord milking (UCM) 2-3 times before
clamping, improved short term outcomes on EPI
infants:
• Higher blood pressure and Hb on admission
• Reduce number of blood transfusion given
• Reduce number of IVH
• Reduce rates of sepsis
• No significant difference for number of days on
ventilator
• However, more studies needed to prove the
safety and long-term benefit of DCC and UCM

Ghavam S, Batra D, Mercer J, Kugelman A, Hosono S, Oh W, et al. 2014;54(4):1192–8. INDONESIAN PICU NICU UPDATE – 2020/2021
 66 obstetrician departments responded preferred CC Preferred CC Timing for Preterm Infants
timing for preterm infants:
ü 36 out of 66 (54%) answered DCC
§ 20% = 1-2 min 10%
§ 8% = 2-3 min
36%
§ 5% = 4-10 min
§ 21% = wait until cord pulsation had ceased
54%
DCC was recommended in preterm without
needing resuscitation as it could reduce:
o RDS
o IVH Early Cord Clamping (<1 min)
o Circulatory instability Delayed Cord Clamping (max 10 min / cord pulsation stopped)
o Anemia No defined time
Boere et al. Neonatology. 2015 (107):50-55 INDONESIAN PICU NICU UPDATE – 2020/2021
 Umbilical cord blood gas =
Most objective determinant of foetal metabolic condition at birth

pH, base deficit/excess, lactate levels è markers of metabolic acidosis

Foetal lactate = direct end-product of NICU management plan:

anaerobic metabolism • Do gas in 30 minutes
vIf accumulated in fetus (capillary/venous/arterial)
àDepletes buffer system • Repeat gas until lactate normalised
àMetabolic acidemia (pH ↘) • Investigate signs of multi-organ
àPoor neonatal outcome involvement if persistent high lactate

Armstrong L, Stenson BJ. Arch Dis Child Fetal Neonatal Ed. 2007. 92(6):F430-434 INDONESIAN PICU NICU UPDATE – 2020/2021
 Neonatal Resuscitation
Flowchart

Respiratory support for EPI at first minutes of

life:
1. Adequate breathing à CPAP
2. Inadequate breathing à IPPV
3. Persistent apnoeic +/- bradycardia
à Intubation

INDONESIAN PICU NICU UPDATE – 2020/2021

 Respiratory Management:
Oxygen Management
• Balancing adequate oxygen necessity to avoid hyperoxic damage to
developing organ.
• In EPIs, resuscitation with 30% O2 is more disadvantageous than
100% O2 (but still not enough evidence)
• Current guideline recommendation: EPIs given 30% O2.

If there is no response to mask ventilation:

• Re-check ventilation adequacy
• Intubate + surfactant
• Cardiac massage or endotracheal/intravenous epinephrine if required
Perlman J. Delivery Room Resuscitation of Extremely Preterm Infants. JAMA. 2019 (321)
INDONESIAN PICU NICU UPDATE –
Mactier H, et al. Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice. Arch Dis Child Fetal Neonatal ed. 2020 (105): 232-239
2020/2021
 Respiratory Management:
Single nasal prong vs Binasal prong

RCT by Hudson et al (2001) compared

Single prong vs Binasal prong
for nasal CPAP on infants <1000 g

Results:
Binasal prong nCPAP is more effective in
preventing extubation failure (p<.001)

Davis P, et al. Arch Dis Child Fetal Neonatal Ed. 2001. INDONESIAN PICU NICU UPDATE – 2020/2021
 Respiratory Management:
Surfactant Therapy
Surfactant Indications in DR:
• Inadequate cover of antenatal steroid
• Intubated infant
• Oxygen requirement cannot be weaned
EPIs initially managed with NCPAP only à ± 50% needs intubation/MV
• Thus, early rescue surfactant is recommended for EPI
• Early rescue surfactant reduces risk of BPD and death
(RR 0.83; 95% CI 0.75-0.91)

Current surfactant administration methods:

• INSURE
• MIST/LISA

Lista G, et al. Respiratory Distress Syndrome Management in Delivery Room. InTech Open. 2018
INDONESIAN PICU NICU UPDATE – 2020/2021
 Respiratory Management:
Surfactant Therapy - INSURE
INSURE (Intubation – Surfactant – Extubation) :
• Commonly-used surfactant administration method
• Used in EPI results: Lesser MV and intubation incidence
(compared to NCPAP only)
• However, there were some disadvantages such as:
• Need for sedative medication à side effects bradycardia/hypotension
• Trauma risk during intubation and extubation

Conclusion:
Surfactant administration methods with lesser
endotracheal intubation is preferred (e.g., MIST/LISA)

Dani C, et al. The INSURE methods in preterm infants <30 GA weeks. Journal of Maternal-Fetal and Neonatal Medicine. 2010.
Gyu-Hong Sim. Update of MIST. Korean J Pediatr. 2017; 60(9): 273-281 INDONESIAN PICU NICU UPDATE – 2020/2021
 Respiratory Management:
Surfactant Therapy - MIST/LISA

• MIST (Minimally invasive surfactant therapy) /

LISA (Less Invasive Surfactant Administration)
• Avoids endotracheal intubation à support
NCPAP use at the same time
• Gentle, safe, effective and feasible non-
invasive method for EPI surfactant
administration.

Gyu-Hong Sim. Update of MIST. Korean J Pediatr. 2017; 60(9): 273-281 INDONESIAN PICU NICU UPDATE – 2020/2021
 Respiratory Management:
Surfactant Therapy - MIST/LISA
• MIST/LISA was reported to have
decreased rate of BPD and MV use in
26-28 weeks GA compared to INSURE.
• Surfactant administered within 2
hours of life to infants ≤ 28 weeks GA
reduce incidence of:
• Pulmonary interstitial emphysema
• BPD
• Pneumothorax
• Mortality

Abdel-Hady H, Nasef N. Respiratory management of preterm newborn in the delivery room. Research and Reports in Neonatology. 2012.
Gyu-Hong Sim. Update of MIST. Korean J Pediatr. 2017; 60(9): 273-281
INDONESIAN PICU NICU UPDATE – 2020/2021
 Monitoring: Respiratory Function

Aim:
To investigate use of respiratory function
monitor (RFM) to use lower tidal volume (Vt)
during PPV in DR to reduce surfactant and
MV necessity.

Conclusion:
Using RFM in DR prevents use of large Vt and
PIP (peak inflation pressure) during
respiratory support inflation.

Limitation:
RFM studies for extremely premature infants
are still ongoing

Sarrato et al. American Journal of Perinatology. 2018. INDONESIAN PICU NICU UPDATE – 2020/2021
 Monitoring:
Pulse Oximetry
Target: Pre ductal saturation (right hand)
Conventional pulse oximetry (venous):
Reading accuracy could be affected by several factors such as motion
artifact and monitoring site interferences (low perfusion, oedema,
clammy skin, etc)
è False low or high SpO2 results à risk of over / under oxygenation

Arterial pulse oximetry has developed additional signal processing algorithm that is able to
distinguish SpO2 of both arterial AND venous thus:
o Ability to identify separately between arterial and venous signal
o Isolate venous signal that frequently shows unreliable reading
o Focus on arterial signal è Consistent SpO2 result

Dawson JA. Managing Oxygen Therapy during Delivery Room Stabilization of Preterm Infants. JPED vol 160. 2012.
Hay W, et al. Reliability of conventional and new oximetry in neonatal patients. Journal of Perinatology. 2002; 22:360-266 INDONESIAN PICU NICU UPDATE – 2020/2021
 Monitoring:
Electrocardiogram
• ECG monitoring in DR displays heart rate earlier and more accurately than
pulse oximetry
• Shah et al (2019): Introduction of ECG monitoring in delivery room resulted
in decreased intubation rate, and increased chest compression with no
difference in mortality.
Non-ECG ECG

Shah et al. Impact of ECG monitoring in delivery room resuscitation and neonatal outcomes. Resuscitation. 2019 (143): 10-16 INDONESIAN PICU NICU UPDATE – 2020/2021
 Monitoring: NIRS

Result:
SpO2 < 80% at 5 minute
after birth = significantly
Conclusion: diminished rcStO2 values
NIRS could be used to monitor
during respiratory support for infants in DR
Binder-Heschl et al. Oxygen saturation targeting during delivery room stabilization: what does this mean for regional cerebral oxygenation. Frontiers in INDONESIAN PICU NICU UPDATE – 2020/2021
Pediatrics. 2019 (274)
 Neonatal Transport from DR to NICU
• Maintaining temperature of extremely
premature infants (EPI) is very important.
• However, there are risk of temperature
change during transporting the infant
from infant warmer to incubator (even
preheated).
• Therefore, a device that combines
incubator and infant warmer is the ideal
way to maintain thermoregulation Example:
Neonatal Incubator & Infant Radiant Warmer in one device

Bell EF. Iowa Neonatology Handbook. 2020. INDONESIAN PICU NICU UPDATE – 2020/2021
 Transport Ventilator
Transport ventilator is
recommended for EPI to:
• Show real-time lung dynamic
• Prevent volutrauma
• Prevent hypocapnia

Courtesy of dr. R Adhi Teguh Perma Iskandar, Sp.A(K) in “Ventilation Strategies to Prevent Chronic Lung
Disease”. Indonesian PICU NICU Update .2020 INDONESIAN PICU NICU UPDATE – 2020/2021
 Developmental Care in DR

Developmental care in delivery room is

important because:
• Fetal neurologic system is in highly active
stage during 3rd trimester gestation
àincluding sensory experiences that EPI
faced in DR
• EPI neurodevelopment duration occurs
with greater risk (normal infant has
protective environment of the womb) à
risk of poor neurobehavioral outcome
(e.g., Autism; etc)

Altimier L, Phillips R. The Neonatal Developmental Care Model: Advanced Clinical Applications of the Seven Core Measures for
Neuroprotective Family-centered Developmental Care. Newborn & Infant Nursing Review. 2016 (16):230-244 INDONESIAN PICU NICU UPDATE – 2020/2021
Summary
• Management of extremely premature infants in delivery room
requires complex preparation and active management plans, due to
their nature of higher risk of death / neurodevelopmental impairment
than other infants.

• Even until now, more optimal methods to handle extremely

premature infants in delivery room is still being studied.

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021