Neonatal Resuscitation Practices in Romania: A Survey of the Romanian Association of Neonatology (ANR) and the Union of European Neonatal and Perinatal Societies (UENPS)

Political changes and socio-economic development in Romania since 1990 together with the implementation of public health measures were associated with important decreasing trends in neonatal mortality from 8.9 deaths per thousand live births in 1990 to 3.1 deaths per thousand live births in 2021 [1,2]. A significant reduction in neonatal mortality can be achieved by immediate assessment and prompt and correct resuscitation of the newborn at birth, especially the high-risk ones. The first minutes after birth (“golden minute”) is crucial for establishment of breathing and oxygenation, with major impact on survival and long-term outcome of the newborn [3]. Thus, the implementation of new evidence-based interventions in neonatal resuscitation, such including support of physiologic transition from intrauterine to extrauterine life, umbilical cord management at birth, achievement of neutral thermal environment, titration of the inspiratory fraction of oxygen, the use of non-invasive techniques of respiratory support should be o priority all over the world [4]. The Romanian Association of Neonatology developed and continuously reviewed national guidelines in accordance with the updated American Academy of Pediatrics (AAP)/American Heart Association (AHA) guidelines and International Liaison Committee on Resuscitation (ILCOR) recommendations.

According to the Romanian Standards of Perinatal Care (2002) there are three levels of maternity hospitals classified depending on the level of competence: level I (healthy term infants), level II (healthy and sick full-term and preterm infants over 32 weeks of gestational age who do not require invasive ventilation) and level III (regional centers) where critical infants requiring intensive care and treatment and invasive respiratory support are cared for, especially preterm infants under 32 weeks of gestational age.

The aim of our study was to evaluate the current neonatal resuscitation practices in Romanian maternity hospitals with more than one thousand of births per year and to compare the results between level III and level II centers.

This study is part of a European survey on delivery room practices endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Romanian Association of Neonatology (ANR). The survey was approved by Padua Provincial Institutional Review Board (protocol # 0035420) and declared as not meeting the criteria for human subject research. The cross-sectional electronic survey was based on a 91-item structured questionnaire elaborated by a committee of experts on neonatal resuscitation and members of the task force of the Neonatal Resuscitation of the Italian Society of Neonatology, having 2018 as the reference year for data collection [5]. The questionnaire was anonymous and contained questions about epidemiological data, perinatal organizational aspects, medical equipment, initial steps interventions, ventilation and oxygen therapy, ethics, and education [5,6,7]. The questionnaire was distributed through ANR by email link (www.surveymonkey.com) to heads of neonatal departments of 53 Romanian maternity hospitals with more than one thousand of births per year between October 2019 and September 2020. The answer to the questionnaire was considered as informed consent of the participants. A reminder was sent to nonresponders for 3 times [5].

The overall response rate to the questionnaire was 62.26% (33/53), 83.33% (15/18) for level-III centers and 51.43% (18/35) for level-II centers. Of the responding centers, 18 (54,54%) were academic hospitals, 15 (83,33%) were level III and 3 (16,67%) level II hospitals. In 2018, responding centers reported 81.139 births representing 42.66% of all Romanian births (190.170) (8). The results of the survey are reported in Tables 1–6.

There were significant differences between level-III and level-II maternity hospitals regarding the number of births in 2018 (3028.73±1258.38 vs 1983.78±769.99; P=0.006), lowest GA of routinely assisted infants in delivery room (25.07±3.03 weeks vs 30.44±3.28, P<0.001), inborn infants with BW<1500 admitted to neonatal intensive care unit (NICU) in 2018 (66.86±39.14 g vs 22.87±31.50 g; P=0.002), and antenatal counseling of parents before the delivery of a very preterm infant or an infant with expected problems (60% vs 22.2%; P=0.027).

The availability of nasal continuous positive airway pressure (CPAP)/high flow nasal canula (HFNC), mechanical ventilation, CPAP in delivery room, the presence of resuscitation team at every delivery, the routinely presence of pediatrician/neonatologist for a low-risk/high risk delivery, and time limit to stop full resuscitation in severely asphyxiated infant were similar between centers. Level-III maternity hospitals were significantly more able to provide high frequency oscillatory ventilation (HFOV) (80% vs. 44.4%; P=0.041), inhaled nitric oxide (iNO) (46.7% vs. 0%; P=0.002), and therapeutic hypothermia (53.3% vs. 11.1%; P=0.012) as compared to level-II maternity hospitals. (Table 1)

Thermal management for preterm infants (<32 weeks) was similar among centers as regards temperature of delivery/operating room and ensuring thermal comfort to avoid heat loss. Regarding thermal management for infants considered at risk of hypoxic-ischemic encephalopathy (HIE), passive cooling was started between 1–2 hours of life both in level-III and level-II maternity hospitals. (Table 2).

There were no significant differences of umbilical cord management regardless of GA between responding centers. (Tabel 3)

No significant differences were identified between responding level II and III centers regarding available equipment designed for effective ventilation during resuscitation. Air/oxygen blenders, pulse oximeters were available in 87.9% of centers, T-piece devices (Neopuff) in 63.6% and heated/humidified gases in the delivery room in only 51.5% of maternity hospitals (level-III 53.3% vs level-II 50%). For positive pressure delivery, both level III and level II centers preferred T-piece device (Neopuff) followed by self-inflating bag. The PIP levels (cmH₂O) used in term, late preterm, and preterm infants were higher in level-III centers compared with level-II centers, whereas PEEP levels (cmH₂O) used in term and late preterm infants were higher in level-II centers compared with level-III centers, but the difference was not statistically significant. A PEEP level of 5 cmH₂O was preferred for preterm infants both in level-III and level-II centers. Initial FiO₂ was 21% in infants with GA higher than 35 weeks and 30% in preterm infants in all centers. For meconium-stained amniotic fluid management in a non-vigorous infant, starting PPV after removing secretions was the most frequent procedure (66.7%), followed by intubation and subglottic aspiration (15.2%), and suctioning of the oro and nasopharynx before delivery of the shoulders (15.2%), without significant differences between centers. Among technical aspects, fewer level-II resuscitation teams self-evaluated as having excellent skill on performing endotracheal intubation than level-III (Table 4).

All neonatologists are using stethoscopes for heart rate assessment during neonatal resuscitation, 63.6% of them are also using palpation of the umbilical cord, but only 6.1% are using a three-lead ECG monitor, without differences between centers. Surfactant and caffeine administration in delivery room was similar among centers. Sodium bicarbonate was still used in delivery room only in level-II maternities although in a small proportion (16.7%) (Table 5).

Courses and training on neonatal resuscitation are routinely held in all Romanian maternity hospitals, in 60.1% of units at 6–12 months, and in 39.45% at 12–24 months. Most of these courses follow neonatal resuscitation algorithm of American Academy of Pediatrics (AAP) (84.8%) (Table 6).

The Romanian survey evaluated the neonatal resuscitation practices in maternity hospitals with more than 1000 of births per year. Overall, all regions of the country were represented in the study and the results are reflecting an important part of the neonatal level II and III centers in Romania (42.66% of the number of births in 2018). The results demonstrated no major variations in the delivery room management of term and preterm infants between the centers, highlighting a good compliance with international/national guidelines.

The results of the Romanian survey are reflecting the implementation stage of international and national guidelines of neonatal resuscitation in maternity hospitals with more than 1000 births per year. The adherence to new guidelines was high among responding centers regarding thermal and umbilical cord management, initial FiO₂, but aspects like antenatal counseling, EKG monitoring, laryngeal mask, and heated/humidified gases availability and administration, and simulation-based training require further implementation.