Key Components of Delivery Room Care for Optimizing Neonatal Outcomes in Term and Preterm Infants
The most critical components of delivery room care for optimizing neonatal outcomes in term and preterm infants include maintaining normothermia, implementing delayed cord clamping, providing appropriate respiratory support, and facilitating early skin-to-skin contact.
Temperature Management
Maintaining normothermia (temperature between 36.5°C and 37.5°C) after birth through admission and stabilization is critical for all newborns and should be considered a standard of care 1
Hypothermia is associated with increased neonatal mortality and morbidity across all gestational ages, including respiratory distress syndrome, metabolic derangements, intraventricular hemorrhage, and late-onset sepsis 1
For preterm infants, who are particularly vulnerable to heat loss due to high surface area-to-volume ratio and increased evaporative fluid losses, multiple interventions should be implemented 1, 2:
For term infants, drying and covering the infant's head can reduce heat losses while awaiting cord clamping 1
Admission temperature should be recorded as both a predictor of outcomes and a quality indicator 1
Umbilical Cord Management
Delayed cord clamping (DCC) is recommended for both term and preterm infants 1, 2:
Benefits of delayed cord clamping include 1, 2:
- Decreased anemia in infancy
- Improved neurodevelopmental outcomes
- Facilitated postnatal cardiovascular transition
- Increased hemoglobin and hematocrit
- Improved iron status
- Less need for transfusion in preterm infants
- Lower risk for necrotizing enterocolitis in preterm infants
During DCC, the newborn can be placed on the maternal abdomen or legs, or held by the surgeon/assistant close to the level of the placenta 1
Respiratory Support
- For preterm infants requiring ventilatory support, continuous positive airway pressure (CPAP) should be started from the first breath rather than immediate intubation 3, 4
- Noninvasive ventilation strategies in the delivery room minimize the risk of intubation in very preterm infants without adversely affecting other neonatal outcomes 3
- For term and near-term infants needing ventilatory support, start with room air (21% oxygen) 4
- For infants 29-33 weeks gestation, start with 21-30% oxygen 4
- For infants <29 weeks gestation, start with 30% oxygen and adjust according to response 4
- T-piece devices may have advantages compared to self-inflating bags for delivering consistent pressure 4
- Routine suctioning of the mouth and airways is not required 4
Skin-to-Skin Care
Skin-to-skin care (SSC) immediately after birth is recommended for all mothers and newborns, regardless of feeding or delivery method 1, 2
Benefits of SSC include 1:
- Stabilization of newborn body temperature and prevention of hypothermia
- Stabilization of blood glucose concentrations
- Decreased crying and pain in newborns
- Improved cardiorespiratory stability, especially in late preterm newborns
- Enhanced opportunity for early breastfeeding
- Decreased maternal stress
SSC should continue for at least 1 hour after birth, as defined by WHO's "Ten Steps to Successful Breastfeeding" 1
For mothers planning to breastfeed, SSC helps them recognize when their infants are ready to feed 1
Delivery Setting Considerations
- Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers with level III-IV NICUs 1
- Antenatal transfer has been associated with improved neonatal outcomes compared to postnatal transport 1
- Hospitals without optimal resources should have protocols in place for timely transport to a receiving hospital 1
- These protocols should include guidelines for initial management such as antenatal corticosteroids, magnesium sulfate for neuroprotection, and antibiotics when indicated 1
Team Preparedness and Communication
- In all settings that perform deliveries, equipment, staffing, and skills for immediate neonatal resuscitation should be available 1
- Team communication can be optimized by implementing checklists and pre/post-briefs in the delivery room 5
- Apgar scores should be assessed and documented at 1,5, and 10 minutes after delivery 1
Special Considerations for Preterm Infants
- Early administration of caffeine soon after birth may improve systemic blood flow and blood pressure in preterm infants 5
- Surfactant instillation is often not needed prophylactically provided the mother has received antenatal steroids 4
- Less invasive methods for administering surfactant may be useful when needed 4
- For late preterm infants (34-36 weeks), special attention should be paid to feeding support, glucose management, and jaundice monitoring 2
Quality Improvement in Delivery Room Care
- Implementing collaborative quality improvement projects focused on delivery room management can significantly reduce bronchopulmonary dysplasia (BPD) and the composite outcome of BPD-death in preterm infants 6
- Standardized bundles of care that include delayed cord clamping and noninvasive ventilation as first-line support have been shown to reduce intubation rates and improve outcomes 3
By implementing these evidence-based practices in the delivery room, healthcare providers can optimize outcomes for both term and preterm infants, reducing mortality and improving long-term developmental outcomes.