TABLE 26.

Newborn Resuscitation

SourceLocation and Type of TrialInterventionMaternal OutcomePerinatal/Neonatal Outcome
Sibley and Sipe324 countries in 3 regions; meta-analysis of 60 studiesTBA training was associated with a significant (7%; CI: 4–9%) reduction in birth-asphyxia-specific neonatal mortality. This translated into 11% (CI: 2–21%) fewer neonatal deaths due to birth asphyxia among women cared for or living in areas served by trained TBAs.
Deorari et al447India; 14 medical college hospitals; PCSThe National Neonatal Resuscitation Program, begun in 1990, trained and certified 150 pediatricians and nurses as trainers in neonatal resuscitation, providing them with essential equipment. These core faculty trained an additional 12 000 health care providers over 2 y, and resuscitation techniques were added to medical and nursing curricula. Each hospital provided baseline data for 3 mo prior to the intervention, as well as 12 mo of intervention data.Although overall neonatal mortality was not affected, asphyxia-related deaths declined significantly (P < .01).
Bang et al439India; rural setting; RCTVHWs in 39 intervention villages were trained to provide a package of maternal and newborn care services, including health education, clean delivery, neonatal resuscitation using tube and mask ventilation, breastfeeding promotion, prevention and management of hypothermia, and detection and treatment of local infections (eg, skin, umbilical cord, as well as sepsis) with cotrimoxazole and gentamicin. Results were compared to 47 control villages without trained VHWs. Trained VHWs cared for 1676 neonates from 1995–98.There was a 48% nonsignificant decrease in the birth-asphyxia-specific NMR in the intervention area (10.5 to 5.5 per 1000 live births) from the first to the third year of the intervention period. Overall NMR dropped from 62/1000 at baseline to 25.5/1000 at intervention end. Stillbirths dropped from 32/1000 to 25.9/1000, and PMR dropped from 68.3/1000 to 47.8/1000.
Saugstad et al4456 countries; RCT609 infants were enrolled. Newborns requiring resuscitation were randomized to receive room air (n = 288) or 100% oxygen resuscitation (n = 321).No difference was seen in mortality in the first 7 d or 28 d of life between the 2 groups. There were 22% fewer infants with Apgar scores <7 after 5 min in the room-air group compared to the oxygen resuscitation group (24.8% vs 31.8%). Median time to first breath was 1.1 (CI: 1.0–1.2) min in the room air group, vs 1.5 (CI: 1.4–1.6) min in the oxygen group.
Kumar723India; rural setting; community-based surveillanceA surveillance system was created for the tracking of births and neonatal deaths in 54 villages. Over a period of 18 mo, trained field workers interviewed the family member who was present at the time of childbirth in 2041 deliveries within 2 wk after the birth. The interviews documented birth history, use of resuscitation, and the training status of the TBA, including advanced training.Birth asphyxia prevalence was 0.9% among babies delivered by TBAs with advanced training, in comparison to 2.4% in babies delivered by conventionally trained TBAs (P < .05). The mortality rate specific to birth asphyxia was 70% less among babies delivered by TBAs with advanced training, in comparison to conventionally trained TBAs (P < .05). The fatality rate of asphyxia cases was 20% lower and the PMR was 19% lower (49.4/1000 vs 61.0/1000) among newborns delivered by TBAs trained in use of resuscitation equipment compared to those delivered by TBAs trained for mouth-to-mouth breathing. However, given the small study size the difference did not reach statistical significance (P > .05).
Zhu et al448China; hospital-based setting; PCSA prospective study of 4751 newborns, 366 of whom were asphyxiated and managed by a neonatal resuscitation program (NRPG), was conducted over the period of 2 y. This group was compared to a control group comprised of 1722 live-born infants under the traditional resuscitation (TR) program.The NRPG was associated with a 65.7% reduction in early NMR. During implementation of the NRPG, only 16 infants out of 4751 births (0.34%) died within 7 d, and 2 of the deaths occurred in the delivery room. In contrast, 17 newborns out of 1722 births (0.99%) managed within the TR program, died within 7 d, with 10 of those deaths occurring in the delivery room. As a result of the implementation of the NRPG, neonatal mortality was reduced almost 3 times (χ2 = 10.54, P < .01). 20 of 21 infants with severe asphyxia were normal; 1 had cerebral palsy.
Kamenir444Kenya; rural hospital; open study: retrospective characterization of delivery practices and risk factors and prospective assessment of resuscitation practicesThe use of routine resuscitation (including nasal and oropharyngeal suctioning, drying and proper stimulation) was evaluated in newborns with birth asphyxia (n = 878). If the neonate remained apneic, bag-and-mask ventilation was started with oxygen (if available).4% of 878 newborns with asphyxia suffered unfavorable outcomes. Risk factors for unfavorable outcome included deliveries other than spontaneous normal vaginal deliveries and infants weighing <2000 g at birth.
Massawe et al443India and Tanzania; urban university hospitals; QTMouth-to-mask (MM) ventilation was compared with bag-and-mask (BM) ventilation. 174 babies were studied; 54 (30 MM and 24 BM) were born in Bombay and 120 (56MM and 64BM) in Dar-es-Salaam.The MM and the BM methods were equally effective in resuscitation of asphyxiated neonates. There were no significant differences between the 2 treatment groups by Apgar score ≥4 at 5 and 10 min, number of babies with first breath <5 min, number of babies with heart rate >130 beats/min, or number of babies with pulse oximeter values >75% at 5 min. At 5 min, 75% of all infants had Apgar scores ≥4. In Tanzania, low respiratory frequency was associated with a slow increase in heart rate above 130 beats/min.
Kumar431India; rural setting; PCSSimplified methods of resuscitation were taught to TBAs. An additional group received advanced training on use of the mucus extractor and bag-and-mask ventilation. Overall, 2041 births were reported, some delivered by conventionally trained TBAs (n = 968) and some by TBAs with advanced training (n = 911). 58 infants were asphyxiated or were fresh stillbirths, 20 of whom were delivered by TBAs with advanced training.There was a 19% decrease in the PMR among the group of women who were attended to by advanced trained TBAs.
Xiaoyu450China; rural setting; PCSAn exploratory study was created to introduce modern resuscitation to grassroots maternal and child health personnel. This study included training courses on neonatal resuscitation, on-the-spot teaching with repetition of key technical procedures, and the operational sequence of the 5 steps of the ABCDE protocol (airway, breathing, circulation, disability, and exposure). The approach highlighted the importance of endotracheal intubation and practicing neonatal resuscitation in person. In all, 223 newborns in the province were resuscitated.Asphyxia-specific NMR was reduced 86% by using the strict application of the ABCDE protocol. 223 newborns were resuscitated in the 6 mo of the project with only 1 death (a mortality rate of 0.45%). All 14 cases (100%) of severely asphyxiated babies recovered and were well upon discharge. By contrast, out of 184 babies managed prior to introduction of the program, 13 babies died of asphyxia (a mortality rate of 7.1%) (χ2 = 13.29; P < .01).
Ramji et al446India; urban hospital setting; RCTConsecutive asphyxiated newborn infants (n = 84) were allocated to either resuscitation with room air (n = 42) or 100% oxygen (n = 42).No significant differences were noted between the 2 groups for a number of outcomes including duration of assisted ventilation, time to first breath and cry and neonatal mortality. Preliminary data indicated that resuscitation with room air may be as effective as 100% oxygen in neonatal resuscitation.
Daga et al449*India; rural setting; training assessment of community-based workersIn Ganjad primary health center, training of Dais and Anganwadi workers in newborn care included provision of warmth, resuscitation of asphyxiated newborns, and identification and referral of infants with foot length <6.5 cm in a population of 20 000. Anganwadi workers supported dais in identifying and making referrals and worked as a link between dais and auxiliary nurse-midwives.There was a 70% decrease in IMR over a period of 4 y.
Daga et al441*India; rural setting; PCSDais (TBAs) (n = 67) working in a population of 22 240 were trained to provide warmth to the infant, mouth-to-mouth resuscitation of asphyxiated infants, identification of LBW and preterm infants and safe transportation of high-risk infants to primary health centers. Dais reported 30 neonatal asphyxia cases over the 3 y after the program began.Antenatal registration of pregnant women in 1990 showed a 30% increase over pre-program levels.The PMR declined by 61.5%, stillbirth rate decreased by 51.4%, and NMR decreased by 42% compared to baseline over a period of 3 y.
Pratinidhi et al438India; rural setting; PCSCHWs in a study population of 47 000 were trained in risk identification (LBW, small size, preterm birth, feeding problems) and in various techniques of newborn care, including mouth-to-mouth resuscitation. Home visits were done for screening and management of at-risk infants (n = 851) and educating mothers on newborn care. Follow-up visits were fixed for the 8th and 29th day after birth. When only 1 risk factor was present, the TBAs recommended domiciliary care by the mother and CHW using health education under the supervision of nurse or doctor. When more than 1 risk factor was present, the mother and/or infant were referred to the hospital for inpatient care. There were 3083 live births recorded during the 3 y prior to the study, and 2990 live births recorded during the 2 study years.Risk-detection rate by CHWs was 78%. The stillbirth rate decreased by 25%, from 28.4/1000 births to 21.5/1000 births. The NMR decreased by 25% from baseline over the 2-y project period, from 51.9/1000 live births to 38.8/1000 live births, but this difference was not statistically significant.
  • * Data are from the same trial.