Resuscitation 84 (2013) 1558–1561

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

Marked variation in delivery room management in very preterm

infants
Yoginder Singh a,b,∗ , Sam Oddie b
a
Department of Neonatology, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, United Kingdom
b
Bradford Neonatology, Bradford Teaching Hospitals NHS Trust, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Background: The International Liaison Committee on Resuscitation (ILCOR) and UK Resuscitation Council
Received 27 March 2013 (UKRC) updated guidance on newborn resuscitation in late 2010.
Received in revised form 4 June 2013 Objectives: To describe delivery room (DR) practice in stabilisation following very preterm birth (<32
Accepted 23 June 2013
weeks gestation) in the UK.
Methods: We emailed a national survey of current DR stabilisation practice of very preterm infants to all
Keywords:
UK delivery units and conducted telephone follow-up calls.
Stabilisation practice in preterm infants
Results: We obtained 197 responses from 199 units (99%) and complete data from 186 units. Tertiary units
Neonatal resuscitation
Survey
administered surfactant in the DR (93% vs. 78%, P = 0.01), instituted DR CPAP (77% vs. 50%, P = 0.0007),
Practice variation provided PEEP in the delivery room (91% vs. 69%, P = 0.0008), and started resuscitation in air or blended
oxygen (91% vs. 78%, P = 0.04) more often than non-tertiary units. Routine out of hours consultant atten-
dance at very preterm birth was more common in tertiary units (82% vs. 55%, P = 0.0005).
Conclusions: Marked variation in DR stabilisation practice of very preterm infants persisted one year after
the publication of revised UKRC guidance. Delivery room care provided in non-tertiary units was less
consistent with current international guidance.
© 2013 The Authors. Published by Elsevier Ireland Ltd. Open access under CC BY-NC-ND license.

1. Introduction showed marked variations in resuscitation practices of term infants

Approaches to delivery room (DR) stabilisation of preterm
infants should reflect International Consensus on Cardiopulmonary
Resuscitation (ILCOR) and UK Resuscitation Council (UKRC) guide-
lines. These were recently updated.1,2
While only around 10% of term infants need additional support
in perinatal transition2 many very preterm infants benefit from
assisted stabilisation in the delivery room. Only a few studies have
examined the consistency in clinical practice in DR resuscitation
and data from other developed countries on standard clinical prac-
tices in DR resuscitation showed inconsistency and discordance
from current clinical evidence.3–8 A recent study by Mann et al.
among UK neonatal units.3
Few data describe current clinical practices in delivery room
stabilisation of preterm infants although clinical opinion suggests
effective stabilisation is important for good outcome.6,7
The aims of our study were:
1. To describe current DR stabilisation practices for very preterm
infants (<32 weeks) of gestation at UK neonatal units.
2. To identify differences in clinical practice by unit level.
2. Methods

We sent a structured questionnaire about usual DR management

Abbreviations: NICU, neonatal intensive care unit; DR, delivery room; CPAP,
continuous positive airway pressure; PEEP, positive end expiratory pressure; NDAU,
neonatal data analysis unit; NPEU, national perinatal epidemiology unit.
∗ Corresponding author at: Department of Neonatology, Cambridge University
Hospitals NHS Foundation Trust, Box 402 NICU, Addenbrooke’s Hospital, Cambridge
CB2 0QQ United Kingdom.
E-mail address: Yogen.Singh@nhs.net (Y. Singh).
after very preterm birth in the UK.
In September 2011, we sent a previously piloted structured web
based questionnaire to neonatal contacts on the central database
of British Association of Perinatal Medicine (BAPM) and National
Perinatal Epidemiology Unit (NPEU) asking about usual delivery
room management following very preterm birth at the 199 delivery
centres. Between October and November 2011 we resent the ques-
tionnaire. Finally, we contacted non responding units by telephone
between December 2011 and January 2012, accepting a response
from a consultant, senior trainee or senior nursing sister.

0300-9572 © 2013 The Authors. Published by Elsevier Ireland Ltd. Open access under CC BY-NC-ND license.
http://dx.doi.org/10.1016/j.resuscitation.2013.06.026
 Y. Singh, S. Oddie / Resuscitation 84 (2013) 1558–1561
The data were analysed using Fisher’s exact test for categorical
variables and Mann–Whitney U test for non-parametric numerical
variables. In all the domains a P < 0.05 was considered statistically
significant. In analysing data NICUs were considered as “tertiary
units” while local neonatal units (LNUs) and special care units
(SCUs) were classified as “non-tertiary” units.
Our study was approved by local research and development
(R&D) department at Bradford Teaching Hospitals NHS Foundation
Trust but did not require ethics advisory committee approval.
3. Results
We obtained 197 responses from 199 hospitals (99%), with
186/197 (94%) questionnaires fully completed. Completion rates
were similar between tertiary (n = 55, 92%) and non-tertiary (131,
95%) units. Of the total 197 responses, 39% (n = 78) responders were
consultants, 14% (n = 28) senior trainees, and 46% (n = 91) senior
neonatal sisters.
3.1. CPAP provision
Overall 60% units (112 of 186 units) provide CPAP routinely dur-
ing stabilisation following very preterm birth. Tertiary neonatal
units provided CPAP following very preterm birth as part of the sta-
bilisation process in DR more frequently than non-tertiary neonatal
units (77% vs. 50%, P = 0.0007) (Fig. 1).
Out of those centres routinely giving CPAP, 11/44 (25%) tertiary
units only do this routinely for babies with gestation <28 weeks
compared to 4/68 (6%) of non-tertiary units (P = 0.008).
There was marked variation among both tertiary and non-
tertiary neonatal units in clinical practice under what gestation
they provide CPAP to non-ventilated infants routinely (range under
26–32 weeks of gestation).
For ventilated infants, 76% units (142 units) provide positive
end expiratory pressure (PEEP). There was a significant difference
between tertiary and non-tertiary centres (tertiary 91%, non-
tertiary 69%, P = 0.0008).
Fig. 1. Mode of CPAP or PEEP provision during DR stabilisation among tertiary and nontertiary neonatal services UK 2011–2012.
1559
3.2. Surfactant administration
Administration of surfactant in DR, regardless of infant condi-
tion, was reportedly part of their standard resuscitation practice
in 157 units (82%) while in 34 units (18%) this surfactant adminis-
tration in DR was not a routine practice. Tertiary units were more
likely to do so (93% vs. 78%, P = 0.01).
Out of those centres routinely giving surfactants, 41/52 (79%)
tertiary units only do this routinely for babies with gestation <28
weeks compared to 54/105 (51%) of non-tertiary units (P = 0.001).
There was wide variation in gestational age (range under
27–32 weeks; median for tertiary units <28 weeks while for non-
tertiary units was <29 weeks) under which different neonatal units
routinely administered surfactant in DR as part of standard resus-
citation practice.
3.3. Oxygen therapy
Of the 186 units providing data, 69 units (37%) commence sta-
bilisation in air, 83 units (45%) in blended oxygen and 34 units (18%)
in 100% oxygen. Tertiary units started stabilisation in air or blended
gas more frequently than non-tertiary units (91% vs. 78%, P = 0.04)
(Fig. 2).
3.4. Use of pulse oximeter
Pulse oximetry to monitor heart rate or titrate oxygen delivery
was used routinely in 30% units (n = 56). For 10 units (5%) this data
was not provided. There was insufficient evidence of a difference
in pulse oximetry between tertiary and non-tertiary units (79% vs.
66%, P = 0.12).
3.5. Thermoregulation
Almost all neonatal units (190 of 192; 99%) use plastic wrap-
ping to enhance thermoregulation in the DR and there was no
statistical difference between use of plastic bag in tertiary and non-
tertiary units (P = 0.477). Median gestation under what both tertiary
1560 Y. Singh, S. Oddie / Resuscitation 84 (2013) 1558–1561
Fig. 2. Proportion of neonatal services using air, oxygen or blended oxygen for DR stabilisation following very preterm birth.
and non-tertiary neonatal units used occlusive wrapping was 30
weeks).
3.6. Cord clamping
Deferred cord clamping (DCC) was reported as usual practice
at 52 units (28%). There was marked variation in duration of DCC
(30 s–3 min) with most common practice between 31 and 60 s. 4
units reported practicing cord milking. There was no significant
difference in the percentage practicing DCC between tertiary and
non-tertiary units (35% vs. 24%, P = 0.16).
3.7. Routine consultant attendance at delivery of very preterm
infants
119 units (63%) reported routine out of hours consultant atten-
dance at very preterm birth and there was wide variation between
units under what gestation consultants routinely attend very
preterm birth delivery. A higher proportion of tertiary units prac-
ticed routine consultant attendance at very preterm birth (82% vs.
55%, P = 0.0005).
4. Discussion
We found that some aspects of recommended stabilisation
practice have penetrated well into current UK practice, such as
use of occlusive plastic wrapping. The utilisation of other tech-
niques, such as delivery room CPAP, delivery room pulse oximetry
and provision of mixed ventilation gases has improved in a short
time frame, although marked variation in practice persists [3] . Our
data show that tertiary units appear to have adopted recommended
practices more quickly than other units.
Our study has significant strengths – particularly its very high
response rate, which means it is likely we are describing practices
neonatal professionals intend to deploy one year after the revised
ILCOR guidelines. However, our questionnaire approach precludes
describing actual clinical practice.
Meta-analysis of studies comparing outcome following resus-
citation in air and oxygen demonstrated increased mortality in
infants started in 100% oxygen.9 The ILCOR 2010 guidelines rec-
ommend starting resuscitation for term infants in air rather than
100% oxygen and administration of supplementary oxygen should
be regulated by blending oxygen and air and the amount delivered
to be guided by oximetry.1
Studies on preterm infants comparing initiating resuscitation in
higher oxygen (90–100%) to lower (21–30%) oxygen concentrations
showed that preterm infants starting in low oxygen concentra-
tions frequently need supplemental oxygen to achieve SpO2 targets
initially.10–12
However in the absence of evidence from large trials measuring
clinically important outcomes, it is reasonable to start resuscitation
in air or lower oxygen concentrations, which may be increased or
reduced with a blender, guided by pulse oximetry.13–15 82% of UK
units initiate stabilisation with either air or a mixture of air and
oxygen, with initial use of air being common practice and consis-
tent with teaching materials from the Resuscitation Council (UK).16
The use of oximetry has become more common, and the use of
100% oxygen less common, in association with the publication of
the recent guidance.3
Respiratory support, particularly the provision of CPAP in deliv-
ery suite is of significant and increasing interest. The SUPPORT and
COIN trials supported consideration of CPAP as an alternative to
elective DR intubation and surfactant in preterm infants.17,18 Our
data suggest that provision of CPAP in the DR has become pro-
gressively more common as compared to national survey reported
by Mann et al. survey done in 2009–2010.3 Our data suggest
that many units aim to provide this, and it may be that com-
mercially available variable PEEP valves facilitate this. We were
surprised to find this was the predominant means of delivering
CPAP in the DR, given the practical challenges of maintaining
mask seal and transferring a baby while maintaining such a
seal.19,20
Deferred cord clamping in preterm infants has been reported
to be associated with decreased incidence of intraventricular
haemorrhage (IVH), decreased need of blood transfusion, better
haemodynamic stability and lower risk of necrotising enterocol-
itis, but it is uptake in clinical practice remains quite low, perhaps
on account of the small numbers of infants studied. DCC was far
from universally practiced, with little consistency in the duration
of deferral.
Anecdotally, consultant presence at very preterm birth delivery
appears to improve DR management, increased chances of DCC and
better outcome in extremely preterm infants. More tertiary units
seem to have adopted DCC and routine out of hours consultants
presence but wide variation in practice persists among both tertiary
 Y. Singh, S. Oddie / Resuscitation 84 (2013) 1558–1561
and non-tertiary neonatal units which could reflect lack of robust
evidence in these areas.
Conflict of interest statement
The authors declare no financial or other conflicts of interest.
Financial disclosure
This paper presents independent research funded by the
National Institute for Health Research (NIHR) under its Programme
Grants for Applied Research funding scheme (RP-PG-0609-10107).
The views expressed in this paper are those of the author(s) and
not necessarily those of the NHS, the NIHR or the Department of
Health.
Acknowledgements
We would like to thank all the neonatal units and staff who
responded to our survey. We would also like to thank Mr. Richard
A. Parker from the Centre for Applied Medical Statistics, University
of Cambridge for statistical support.
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