Beyond basic resuscitation: What are the next steps to improve the outcomes of resuscitation at birth when resources are limited?

Abstract

Implementation of basic neonatal resuscitation in low- and middle-income settings consistently saves lives on the day of birth. What can be done to extend these gains and further improve the outcomes of infants who require resuscitation at birth when resources are limited? This review considers how resuscitation and post-resuscitation care can advance to help meet the survival goals of the Every Newborn Action Plan for 2030. A brief summary of the evidence for benefit from basic neonatal resuscitation training in low- and middle-income countries highlights key aspects of training, low-dose high-frequency practice, and implementation with single providers or teams. Reorganization of processes of care, as well as new equipment for training and selected clinical interventions can support further quality improvement in resuscitation. Consideration of the resuscitation algorithm itself focuses on important actions for all babies and special considerations for small babies and those not crying after thorough drying. Finally, an examination of the vital elements of assessment and continued stabilization/care in the health facility draws attention to the opportunities for prevention of intrapartum-related events and the gaps that still exist in postnatal care. Extending and improving implementation of basic resuscitation to make it available to all newborns will assure continued benefit to the largest numbers; once high coverage and quality of basic resuscitation are achieved, health systems with maturing capacity can extend survival gains with improved prevention, more advanced resuscitative interventions, and strengthened postnatal care.

Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) – a randomized clinical trial

“…The HBB algorithm is routine at the hospital and emphasizes that within the first minute after birth, “The Golden Minute”, a baby should breathe or receive positive-pressure ventilation. All babies who do not cry after drying should have their airways cleared and receive stimulation to breathe, followed by positive-pressure ventilation if necessary [4]. Before the study all staff underwent a recapitulation of the HBB algorithm including training sessions with the modified algorithm performing intact cord resuscitation.…”

“…In the Global Burden of Disease 2010 study, intrapartum-related conditions comprised 50.2 million disability adjusted life years [3]. A high priority goal in the global community as recognized by the World Health Organization is prevention of stillborn and newborn mortality; this has resulted in initiatives such as Every Newborn Action Plan [4, 5].…”

Effect of skill drills on neonatal ventilation performance in a simulated setting- observation study in Nepal

“…Despite the description of the QI interventions in HBB program, there are evidence gap on QI interventions that improve and maintain neonatal resuscitation performance in simulated settings [19–21]. One of the most recommended QI interventions in resuscitation is daily skill drills [22]. Barriers exist in implementation of daily skill drills in clinics for the health workers [23].…”

Helping Babies Breathe: When Less Is More

“…Hypothermia is one of the most powerful predictors of mortality and delayed umbilical cord clamping is associated with decreased in-hospital mortality [8, 9]. Attention to these initial steps in the HBB Action Plan results in more than 90% of babies beginning spontaneous breathing without the need for positive-pressure ventilation [10]. Maintaining skin-to-skin contact avoids later hypothermia and the separation of mother and baby.…”

“…A rise in heart rate is the most important indicator of effective ventilation; however, the algorithm relies on the more subjective assessment of chest rise. HBB deliberately focuses on the initial steps of stabilization and positive-pressure ventilation and omits chest compressions, intubation, and medications to help providers to attain mastery of the basic skills that effectively resuscitate 97% of newborns [10]. …”