Journal of Perinatology (2007) 27, 8284 r 2007 Nature Publishing Group All rights reserved.

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ORIGINAL ARTICLE

Post-resuscitation complications in term neonates

MD Frazier1,2 and J Werthammer1
1

Department of Pediatrics, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA recovered at 5 min of age as normal newborns and would admit them to the wellborn nursery (NBN) unless complications were recognized in the delivery room. We undertook this study to examine whether infants delivered in our center who received substantial resuscitation beginning in the rst minute of life and seemingly recovered at 5 min of age are at increased risk of morbidity and should necessarily be cared for in an environment where ongoing evaluation and monitoring are available.

Objective: It has been recommended that all newborn babies who have received substantial resuscitation be cared for in an environment where post-resuscitation care can be provided. To test this recommendation, we examined whether infants who received delivery room resuscitation and seemingly recovered by 5 min age are at increased risk of short-term morbidity.

Study design: We undertook a retrospective analysis of the outcomes of babies who received delivery room resuscitation, and who had seemingly recovered by 5 min age, over a 1 year time period at a single academic institution. The 33 babies were compared with outcomes of 33 controls who received no resuscitation with normal 1 and 5 min Apgar scores. Complication rates and admissions to the neonatal intensive care unit (NICU) were compared between the two groups using the w2 test. Results: Fifty-two percent of the study group and three percent of the control group were admitted to the NICU (P <0.01). Short-term complications were noted in 61% of the study group and three percent of the control group (P <0.01). Conclusion: Increased short-term morbidity is demonstrated in neonates who receive delivery room resuscitation and are seemingly recovered at 5 min, when compared to a group of infants with normal Apgar scores at one and 5 min; and these infants should be cared for in an environment where ongoing evaluation can be provided. Journal of Perinatology (2007) 27, 8284. doi:10.1038/sj.jp.7211644 Keywords: post-resuscitation care; apgar score; neonate; morbidity

Introduction It has been recommended that all newborn babies who have required substantial resuscitation be cared for in an environment where post-resuscitation care can be provided.1,2 Before this study, we treated successfully resuscitated neonates who seemed fully
Correspondence: Dr J Werthammer, Department of Pediatrics, Marshall University School of Medicine, 1600 Medical Center Drive, Suite 3500, Huntington, WV 25701, USA. E-mail: Werthammer@marshall.edu Previous presentation: This study was presented in part at Pediatric Academic Societies, Annual Meeting, 5/5/2003, Seattle, Washington. 2 Current address: Division of Critical Care Medicine, Department of Pediatrics, Duke University Received 11 July 2006; revised 17 October 2006; accepted 9 November 2006

Methods In this retrospective study, we reviewed the medical records of all 2540 term infants (38 to 42 weeks gestation) delivered during a 1 year time period (7/1/2000 to 6/30/2001) at a single tertiary care perinatal center. This study was approved by the institutional review board at Marshall University. We identied 70 term infants out of 2540 delivered (2.8%), who received substantial resuscitation dened as positive pressure ventilation commencing in the rst minute of life (usually by 30s) and continuing to at least 1 min of age. All these infants had 1 min Apgar scores p4, and were receiving positive pressure ventilation at 1 min of age. Of these depressed term neonates, 33 were seemingly recovered at 5 min of age, as dened by an Apgar score X8 (study group). Following the delivery of each study group infant, the next term infant born of the same sex with 1 and 5 min Apgar scores X8 was selected for our control group. These 66 charts were analyzed to identify those infants requiring admission to the neonatal intensive care unit (NICU) as well as those who developed medical complications outside the realm of well newborn infant care. The frequency of complications between groups was compared using the w2 test. Signicance was dened as P <0.05. Three different types of deliveries are recognized in our institution, differentiated by perinatal risk factors. Type A deliveries are those of term infants without signicant risk factors. An obstetrical nurse is responsible for stabilizing these babies and assigning 1 and 5 min Apgar scores. A timer is located in each delivery area. Time of birth, 1 min and 5 min Apgar scores are recorded. An emergency buzzer is available in each delivery suite to be used if the infant shows signs of distress. An NICU team made up of a team leader (transport nurse, neonatal nurse practitioner or senior pediatric resident) and a neonatal staff nurse responds to

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an alarm. The NICU is located 50 feet from the delivery area. Obstetrical nurses responsible for the neonate are required to successfully complete the Neonatal Resuscitation Program (NRP) biannually. Type B deliveries are of intermediate risk and include meconium-stained amniotic uid, infants of diabetic mothers or gestational age 30 to 37 weeks. They are attended by a neonatal team including a team leader (transport nurse, NNP or senior pediatric resident) and a neonatal staff nurse. The team leader manages the airway, assigns Apgar scores and decides on admission to the NICU. Transport nurses, NNPs and senior pediatric residents are NRP certied or hospital-based instructors. Type C deliveries are highest risk including fetal bradycardia or <30 weeks gestational age and are attended by a neonatologist with a staff nurse and pediatric resident. The neonatologist assigns Apgar scores and decides on admission to the NICU. The need for positive pressure ventilation is determined by evaluation of respirations, heart rate and color as outlined in the Neonatal Resuscitation Textbook of the NRP.1 The decision to commence positive pressure ventilation is made by the team leader in all types of deliveries. A resusitation record is completed by the team leader for every delivery that includes Apgar scores and time of commencement of assisted ventilation. This record becomes a part of the permanent hospital chart. Results A total of 66 infants participated in the study (33-study group, 33-control group). The infants in the study group were depressed during the rst minute of age, but appeared normal at 5 min of age and were breathing spontaneously. Positive pressure ventilation by bag and mask was given as an initial treatment to 29 study group infants. In addition, four newborn infants in this group with meconium-stained amniotic uid and respiratory depression were intubated for deep suctioning followed by positive pressure ventilation. One baby received drug administration to reverse narcotic depression. No infant received cardiac compressions. There were an additional 37 term neonates identied who received substantial resuscitation with 1 min Apgar scores p4 but with 5 min scores <8 who were not included in the study. Eighteen neonates were also identied who received limited PPV in the rst minute of life, but who were breathing spontaneously at 1 min of age. All these neonates had 1 min Apgar scores >4 and were not included in the study. The infants in the control group had 1 and 5 min Apgar scores X8, and none received positive pressure ventilation. Antepartum and intrapartum risk factors are outlined in Table 1. No individual factor was signicantly different between the two groups. Total perinatal risk factors were signicantly increased (P 0.03) in the study group (21/33) when compared to the control group (12/33). Prenatally, 15/33 of the study group were

Table 1 Antepartum and intrapartum risk factors

Study group (No. 33) Cesarian section Emergency C-section Shoulder dystocia Tight nuccal cord Fetal stress Fetal bradycardia Pre-eclampsia Meconium stained uid Vaginal bleeding Vaccum extraction Infant of diabetic mother Precipitus labor Magnesium therapy Maternal fever 8 2 2 4 4 2 2 4 1 2 1 1 2 1 Control group (No. 33) 4 1 0 1 2 0 2 2 0 2 1 0 0 0

recognized to be at increased risk (Type B or C delivery) compared to 7/33 in the control group. (P 0.04) The majority of the study group pregnancies (18/33), however, were considered to be low risk until the infant was born distressed, and the neonatal team was summoned. Of the 33 study group infants, 17 were transferred to the NICU (52%). Four of the 17 admitted to the NICU came directly from the delivery area, and 13 were initially admitted to NBN and transferred to the NICU when complications were recognized. Three infants remained in the NICU greater than 24 h, and 14 were transferred to NBN before 6 h age. Of the 33 infants in the control group, 1 was admitted to the NICU (3%) and was transferred to NBN after 3 h. In our study group, seven different complications were recognized in 20 infants. Four infants had two complications. Hypoglycemia (serum glucose <40 mg/dl) appeared in eight infants. Three infants had transient hypoglycemia that responded to early feeding, and ve received IV glucose therapy. In six infants, transient tachypnea of the newborn (TTN) was identied by respiratory distress receiving supplemental oxygen greater than 1 h and a diagnostic chest X-ray. They all responded to oxygen therapy for 2 to 18 h. Meconium aspiration syndrome was identied in four babies. These infants had meconium below the cords with signs of respiratory distress and one had a tension pneumothorax. Hypermagnesemia (serum magnesium >3 mg/dl) with hypotonia was identied in two infants. Pneumothorax was documented in two infants. One infant had meconium aspiration syndrome with tension pneumothorax that was corrected with needle aspiration. The other had bilateral pneumothoraces and was treated with 100% oxygen for 2 h for nitrogen washout. Signicant hyperbilrubinemia (bilirubin >20 mg/dl) was identied in one infant. One infant underwent a sepsis work-up for maternal fever during delivery thought to be secondary to chorioamnionitis. Antibiotics were
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Table 2 Comparison of control and study groups

Study group Control group P-value Gestational age Birth weight Complications NICU admission Type A delivery (lowest prenatal risk) Type B delivery (intermediate prenatal risk) Type C delivery (highest prenatal risk) 39.361.92 39.151.13 P 0.53 3510516 3389428 P 0.30 20/33 (61%) 1/33 (3%) P <0.01 17/33 (52%) 1/33 (3%) P <0.01 18/33 26/33 P 0.04 13/33 7/33 P 0.11 2/33 0/33 P 0.15

Abbreviation: NICU, neonatal intensive care unit.

started until cultures were negative at 48 h. Of the 33 infants in the control group, one had TTN treated with oxygen for 3 h. The study and control groups are compared in Table 2. Complication rates and NICU admissions were signicantly higher in the study group (P <0.01). Discussion To our knowledge this is the rst study demonstrating a postresuscitation morbidity in term neonates. Low Apgar scores, however, at 1 and 5 min have been shown to be predictive of neonatal morbidity and mortality. In a report from the Collaborative Perinatal Project involving analysis of 49 000 infants, low Apgar scores were risk factors for death in the rst year of life and cerebral palsy (CP). In infants of birth weight >2500 g, those with 1 min Apgar scores 0 to 3, regardless of subsequent scores, when compared to those with 1 min scores 7 to 10 had a higher death rate (5.6 vs 0.9%) and higher incidence of CP (1.5 vs 0.2%). When these data were further analyzed, those infants with 1 min scores 0 to 3 and subsequent scores 4 to 10 still had a higher death rate (3.1 vs 0.9%) and increased incidence of CP (0.7 vs 0.29%). Infants with very low 1 min scores and seemingly recovered at 5 min with scores >7 were not compared.3 In one large retrospective study, children who recovered from a low 1 min score to a normal 5 min score have been shown to have a 5.8-fold increased risk of neonatal death and 17-fold increased

risk for cerebral palsy when compared with infants with two normal scores.4 However, another study did not indicate a correlation with a low 1 min score and asphyxia, as dened by an abnormal umbilical artery pH.5 Our study is limited in that we have analyzed data from only 1 year at a single institution. Our comparisons, however, show statistical differences between our study and control groups for both morbidity and NICU admissions. In summary, we have demonstrated an increased morbidity in neonates who have received substantial resuscitation in the rst minute of age and seemingly recovered at 5 min when compared to a group of infants who have received no resuscitation with normal Apgar scores at one and 5 min, and we would support the recommendation that these babies be cared for in an environment where post-resuscitation care can be provided. As a result of this study we have established a modied hospital charge for a 6 h close observation period in the NICU for all babies who receive substantial resuscitation in the delivery room.

Acknowledgments
We thank Ada Edwards, NNP, for her extensive help in data retrieval for this project.

References
1 Kattwinkle J (ed). Textbook of Neonatal Resuscitation of the NRP, 5th edn 2006, p 118, 712. 2 American Academy of Pediatrics American College of Obstetricians and Gynecologists, . In: Gilstrap LC, Oh W (eds). Guidelines for Perinatal Care 5th edn. American Academy of Pediatrics: Elk Grove Village, Illinois, 2002, p 195. 3 Nelson KB, Ellenberg JH. Neonatal signs as predictors of cerebral palsy. Pediatrics 1979; 64: 225232. 4 Moster D, Lie RT, Irgens LM, Bjerkedal T, Markestad T. The association of Apgar score with subsequent death and cerebral palsy: a population-based study in term infants. J Pediatr 2001; 138: 798803. 5 Boehm FH, Fields LM, Entam SS, Vaughn WK. Correlation of the one-minute Apgar score and umbilical cord and acid-base status. South Med J 1986; 79: 429431.

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