ECG monitoring in the delivery room is not reliable for all patients

Pulseless electrical activity: a misdiagnosed entity during asphyxia in newborn infants?

“…Accuracy of ECG is of clinical importance as underestimation of HR can result in unnecessary interventions, whereas overestimation may result in a failure to recognise the need for resuscitation. No clinical study has systematically examined the limitations of ECG measurement of HR, but reports are starting to emerge regarding the potential limitations of ECG technology in subsets of infants 3. In our controlled laboratory experiment, auscultation was 100% accurate in determining the presence of effective cardiac activity; in a delivery room situation with a newborn infant undergoing resuscitation procedures this may not be the case.…”

“…This is of clinical importance as underestimation of HR can result in unnecessary interventions, whereas overestimation may result in a failure to recognise the need for resuscitation. A recent case report raised concerns about the reliability of ECG in a newborn infant with hydrops fetalis requiring extensive resuscitation, potentially due to thoracic subcutaneous oedema 3. Pulseless electrical activity (PEA) is a preterminal rhythm characterised by cardiac electrical activity but the absence of a palpable pulse is commonly seen following cardiac arrest in adults.…”

Heart Rate Assessment during Neonatal Resuscitation

“…Despite this efficacy, the use of ECG also has several limitations including (i) time needed to clean newborns' skin (e.g., from blood, vernix, mucus or amniotic fluid), (ii) potential signal interference from suboptimal placed ECG-lead (due to aforementioned fluids), (iii) potential damage and risk of infection caused by the leads on the delicate skin of premature infants, and (iv) or special clinical cases involving hydrops fetalis [17] or pulseless electric activity (PEA) which could result in misinterpretation of displayed ECG HR [24,42,47].…”

“…Current NRP guidelines recommend the use of umbilical cord palpation, auscultation, pulse oximetry (PO), and electrocardiography (ECG) for HR assessment during neonatal resuscitation at birth [1,2,4,15]. However, there have been some concerns about their accuracy, latency or feasibility for clinical assessment [16][17][18][19][20]. Below, we discuss recommended HR assessment approaches, their outcomes, and ongoing challenges ( Table 1).…”

Pulseless Electrical Activity Complicating Neonatal Resuscitation

“…Despite clear advantages of ECG, limitations and challenges associated with this technology are now emerging during the resuscitation of critically ill neonates. A recent case report described a hydropic infant whose extensive chest wall edema prevented detection of a heart rate by ECG [4]. …”