Umbilical Cord Management
| Total (n=33) | Level III maternity hospitals (n=15) | Level II maternity hospitals (n=18) | P | |
|---|---|---|---|---|
| Umbilical cord management in term infants | ||||
| Vaginally delivered | ||||
| Physiologically based cord clamping (PBCC) | 7 (21.2) | 4/15 (26.7) | 3/18 (16.7) | 0.264 |
| Delayed cord clamping (DCC) | 23 (69.7) | 8/15 (53.3) | 10/18 (55.6) | |
| Immediate cord clamping (ICC) | 2 (6.1) | 3/15 (20.0) | 4/18 (22.2) | |
| Milking | 1 (3.0) | 0/15 (0) | 1/18 (5.6) | |
| Elective cesarean-delivered | ||||
| PBCC | 6 (18.2) | 4/15 (26.7) | 2/18 (11.1) | 0.598 |
| DCC | 13 (39.4) | 4/15 (26.7) | 4/18 (22.2) | |
| ICC | 12 (36.4) | 6/15 (40.0) | 11/18 (61.1) | |
| Milking | 2 (6.1) | 1/15 (6.7) | 1/18 (5.6) | |
| Emergency cesarean-delivered | ||||
| PBCC | 1 (3.0) | 0/15 (0) | 1/18 (5.6) | 0.216 |
| DCC | 2 (6.1) | 0/15 (0) | 2/18 (11.1) | |
| ICC | 26 (78.8) | 13/15 (86.7) | 13/18 (72.2) | |
| Milking | 4 (12.1) | 2/15 (13.3) | 2/18 (11.1) | |
| Umbilical cord management in preterm infants | ||||
| Late preterm | ||||
| Vaginally delivered | ||||
| PBCC | 6 (18.2) | 4/15 (26.7) | 2/18 (11.1) | 0.732 |
| DCC | 21 (63.6) | 5/15 (33.3) | 11/18 (55.6) | |
| ICC | 6 (18.2) | 6/15 (40.0) | 6/18 (33.3) | |
| Milking | 0 (0) | 0/15 (0) | 0/18 (0) | |
| Cesarean-delivered | ||||
| PBCC | 4 (12.1) | 3/15 (20.0) | 1/18 (5.5) | 0.970 |
| DCC | 11 (33.3) | 3/15 (20.0) | 5/18 (27.8) | |
| ICC | 15 (45.5) | 6/15 (40.0) | 12/18 (66.7) | |
| Milking | 3 (9.1) | 3/15 (20.0) | 0/18 (0) | |
| 29–32 weeks preterm | ||||
| Vaginally delivered | ||||
| PBCC | 11 (33.3) | 6/14 (42.8) | 5/18 (27.8) | 0.079 |
| DCC | 6 (18.2) | 5/14 (35.7) | 1/18 (5.5) | |
| ICC | 8 (24.2) | 1/14 (7.1) | 7/18 (38.9) | |
| Milking | 7 (21.2) | 2/14 (14.2) | 5/18 (27.8) | |
| Cesarean-delivered | ||||
| PBCC | 7 (21.2) | 5/15 (33.3) | 2/18 (11.1) | 0.051 |
| DCC | 8 (24.2) | 5/15 (33.3) | 3/18 (16.7) | |
| ICC | 12 (36.4) | 3/15 (20.0) | 9/18 (50.0) | |
| Milking | 6 (18.2) | 2/15 (13.3) | 4/18 (22.2) | |
| <29 weeks preterm | ||||
| Vaginally delivered | ||||
| PBCC | 8 (24.2) | 5/15 (33.3) | 3/18 (16.7) | 0.164 |
| DCC | 7 (21.2) | 4/15 (26.7) | 3/18 (16.7) | |
| ICC | 12 (36.4) | 4/15 (26.7) | 8/18 (44.4) | |
| Milking | 6 (18.2) | 2/15 (13.3) | 4/18 (22.2) | |
| Cesarean-delivered | ||||
| PBCC | 7 (21.2) | 5/15 (33.3) | 2/18 (11.1) | 0.160 |
| DCC | 7 (21.2) | 4/15 (26.7) | 3/18 (16.7) | |
| ICC | 13 (39.4) | 3/15 (20.0) | 10/18 (55.6) | |
| Milking | 6 (18.2) | 3/15 (20.0) | 3/18 (16.7) | |
Education
| Total (n=33) | Level III maternity hospitals (n=15) | Level II maternity Hospitals (n=18) | P | |
|---|---|---|---|---|
| Courses on neonatal resuscitation routinely | ||||
| 6–12 months | 20 (60.1) | 11/15 (73.3) | 9/18 (50.0) | 0.157 |
| 12–24 months | 13 (39.4) | 4/15 (26.7) | 9/18 (50.0) | |
| >24 months | 0 (0) | 0/15 (0) | 0/18 (0) | |
| Neonatal Resuscitation algorithm | ||||
| American Academy of Pediatrics (AAP) | 28 (84.8) | 11/15 (73.3) | 17/18 n (94.4) | 0.185 |
| European Resuscitation Council (ERC) | 3 (9.1) | 2/15 (13.3) | 1/18 (5.5) | |
| Romanian Resuscitation Guidelines | 3 (9.1) | 2/15 (13.3) | 1/18 (5.5) | |
Characteristics of centers and organizational aspects before birth
| Total No (%) | Level III maternity hospital (n=15) | Level II maternity hospital (n=18) | p | |
|---|---|---|---|---|
| Maternity hospital | 33 | 15 | 18 | |
| Academic hospital | 18 | 15 | 3 | |
| Number of births 2018 | 81139 | 45431 | 35708 | 0.006 |
| 3028.73±1258.38 | 1983.78±769.99 | |||
| Lowest GA of routinely assisted infants in Delivery Room (DR) | 33 (100) | 25.07±3.03 (23–32) | 30.44±3.28 (23–33) | <0.001 |
| Median 24 | Median 32 | |||
| Inborn infants with BW<1500 admitted to NICU in 2018/No of reporting centres | 23 (69.7) | 66.86±39.14 | 22.87±31.50 | 0.002 |
| 14/15 (93.33) | 15/18 (83.33) | |||
| Outborn infants with BW<1500 admitted to NICU in 2018/No of reporting centres | 20 (60.1) | 15.50±11.02 | 8.93±14.99 | 0.193 |
| 14/15 (93.33) | 15/18 (83.33) | |||
| Antenatal counseling before the delivery | 13/33 (39.4) | 9/15 (60.0) | 4/18 (22.2) | 0.027 |
| Available facilities in maternity hospitals | ||||
| Nasal CPAP/HFNC | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Mechanical ventilation (MV) | 29 (87.9) | 15/15 (100) | 14/18 (77.8) | 0.229 |
| High frequency oscillatory ventilation (HFOV) | 20 (60.6) | 12/15 (80.0) | 8/18 (44.4) | 0.041 |
| Inhaled nitric oxide (iNO) | 7 (21.2) | 7/15 (46.7) | 0/18 (0) | 0.002 |
| Therapeutic hypothermia | 10 (30.3) | 8/15 (53.3) | 2/18 (11.1) | 0.012 |
| CPAP in delivery room | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| ECMO | 0 (0) | 0/15 (0) | 0/18 (0) | NA |
| Resuscitation team present at every delivery | 27 (81.8) | 12/15 (80) | 15/18 (83.3) | 0.459 |
| Routinely resuscitation team for a low-risk delivery | ||||
| Pediatrician/neonatologist | 29 (87.9) | 13/15 (86.7) | 16/18 (88.9) | 0.626 |
| Obstetrician | 3 (9.1) | 1/15 (6.7) | 2/18 (11.1) | 0.570 |
| Anesthesiologist | 1 (3.0) | 0/15 (0) | 1/18 (5.6) | 0.545 |
| Nurse | 6 (18.2) | 2/15 (13.3) | 4/18 (22.2) | 0.423 |
| Midwife | 32 (97) | 15/15 (100) | 17/18 (94.4) | 0.545 |
| Routinely resuscitation team for a high-risk delivery | ||||
| Pediatrician/neonatologist | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Obstetrician | 4 (12.1) | 2/15 (13.3) | 2/18 (11.1) | 0.626 |
| Anesthesiologist | 3 (9.1) | 1/15 (6.7) | 2/18 (11.1) | 0.570 |
| Nurse | 6 (18.2) | 3/15 (20.0) | 3/18 (16.7) | 0.577 |
| Midwife | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Resuscitation team members qualified with full resuscitation skills | ||||
| Pediatrician/neonatologist | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Obstetrician | 0 (0) | 0/15 (0) | 0/18 (0) | NA |
| Anesthesiologist | 8 (24.2) | 3/15 (20.0) | 5/18 (27.38) | 0.459 |
| Nurse | 0 (0) | 0/15 (0) | 0/18 (0) | NA |
| Gestational age limit for initiating full resuscitation at birth | ||||
| Yes | 19 (57.6) | 15/15 (100.0) | 18/18 (100) | NA |
| Range | 20 (60.6) | 22–32 | 22–32 | - |
| Median gestational age | 20 (60.6) | 24 | 24 | NA |
| Gestational age limit /No of reporting centres | 20 (60.6) | 23.53±0.74 | 24.44±2.04 | 0.111 |
| Time limit to stop full resuscitation in severely asphyxiated infant | ||||
| Yes | 24 (72.7) | 11/15 (73.3) | 13/18 (72.2) | 0.627 |
| Time limit (minutes±SD) /No of reporting centers | 23 (69.7) | 22.73±13.85 / 11/15 (73.3) | 20.83±6.33 / 12/18 (66.7) | 0.673 |
Temperature and Thermal Management in the Delivery Room
| Total (n=33) | Level III maternity hospitals (n=15) | Level II maternity Hospitals (n=18) | p | |
|---|---|---|---|---|
| Temperature (T°) of DR °C | 33 (100) | 24.40±1.05 | 24.39±1.24 | 0.978 |
| T° of operating room °C | 33 (100) | 23.33±2.02 | 23.83±1.82 | 0.461 |
| Thermal management for preterm infants (<32 weeks) | ||||
| Increasing DR T° | 13 (39.4) | 5/15 (33.3) | 8/18 (44.4) | 0.386 |
| Preheating the radiant warmer | 29 (87.9) | 15/15 (100.0) | 17/18 (94.4) | 0.370 |
| Servo-controlled T° | 23 (69.7) | 11/15 (73.3) | 12/18 (66.7) | 0.488 |
| Pre-warmed towels | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Polyethylene plastic bag or wrap | 24 (72.7) | 11/15 (73.3) | 13/18 (72.2) | 0.627 |
| Hat | 20 (60.6) | 10/15 (66.7) | 10/18 (55.6) | 0.386 |
| Thermal mattress | 7 (21.2) | 3/15 (20.0) | 4/18 (22.2) | 0.609 |
| Heated/humidified gases | 18 (54.5) | 13/15 (86.7) | 14/18 (77.8) | 0.525 |
| Thermal management for infants considered at risk of HIE - Passive cooling started: | ||||
| Within 1 hour | ||||
| 1–2 hours | 19 (57.5) | 9/15 (60.0) | 10/18 (55.6) | - |
| 2–4 hours | 2 (6.1) | 1/15 (6.7) | 1/18 (5.5) | |
| 4–6 hours | 12 (36.4) | 5/15 (33.3) | 7/18 (38.9) | |
| Mean±SD | 33 (100) | 2.53±1.96 | 2.72±1.93 | 0.783 |
| Range | 33 (100) | 1–5 | 1–5 | - |
| Median | 33 (100) | 1.0 | 1.5 | - |
Circulation, and Medications in the delivery room
| Total (n=33) | Level III maternity (n=15) | Level II maternity (n=18) | P | |
|---|---|---|---|---|
| Heart rate assessment | ||||
| Palpation of the umbilical cord | 21 (63.6) | 8/15 (53.3) | 13/18 (72.2) | 0.224 |
| Palpation of peripheral pulses | 1 (3.0) | 0/15 (0) | 1/18 (5.5) | 0.545 |
| Stethoscope | 33 (100) | 15/15 (100) | 18/18 (100) | NA |
| Three-lead ECG monitor | 2 (6.1) | 0/15 (0) | 2/18 (11.1) | 0.290 |
| Pulse oximeter | 22 (66.7) | 11/15 (73.3) | 11/18 (61.1) | 0.357 |
| Surfactant use in delivery room | ||||
| Yes | 12 (36.4) | 7/15 (46.7) | 5/18 (27.8) | 0.224 |
| LISA | 2 (6.1) | 1/14 (7.1) | 1/18 (5.5) | 0.692 |
| INSURE | 9 (27.3) | 6/15 (40.0) | 3/18 (16.7) | 0.135 |
| Caffeine use in delivery room | ||||
| Yes | 4 (12.1) | 2/15 (13.3) | 2/18 (11.1) | 0.626 |
| Sodium bicarbonate use in delivery room | ||||
| Yes | 3 (9.1) | 0/15 (0) | 3/18 (16.7) | 0.150 |
| Asphyxia | 1 (3.0) | 0/15 (0) | 1/18 (5.5) | 0.253 |
| Severe metabolic acidosis | 2 (6.1) | 0/15 (0) | 2/18 (11.1) | |
Airway and ventilation in the delivery room
| Total | Level III maternity hospitals (n=15) | Level II maternity Hospital (n=18) | P | |
|---|---|---|---|---|
| Available facilities in hospitals | ||||
| Air/oxygen blender | 29 (87.9) | 15/15 (100) | 14/18 (77.8) | 0.075 |
| Pulse oximeter | 29 (87.9) | 15/15 (100) | 14/18 (77.8) | 0.075 |
| Heated/humidified gases availability | 17 (51.5) | 8/15 (53.3) | 9/18 (50.0) | 0.483 |
| Initial FiO2 | ||||
| ≥35-week | ||||
| 21% | 27 (81.8) | 12/15 (80.0) | 15/18 (83.3) | - |
| 30% | 5 (15.2) | 3/15 (20.0) | 2/18(11.1) | - |
| 50% | 1 (3.0) | 0/15 (0) | 1 (5.5) | - |
| Mean±SD | 33 (100) | 22.80±3.72 | 23.61±7.19 | 0.696 |
| Range | 33 (100) | 21–30 | 21–100 | - |
| Median | 33 (100) | 21 | 21 | - |
| <35-week infant | ||||
| 21% | 5 (15.2) | 1/15 (6.7) | 4/18 (22.2) | - |
| 25–30% | 24 (70.7) | 14/15 (93.3) | 10/18 (55.5) | - |
| 40% | 2 (6.1) | 0/15 (0) | 2/18 (11.1) | - |
| 60% | 1 (3.0) | 0/15 (0) | 1/18 (5.5) | - |
| 100% | 1 (3.0) | 0/15 (0) | 1/18 (5.5) | - |
| Mean±SD | 33 (100) | 29.40±2.32 | 34.31±18.79 | 0.316 |
| Range | 33 (100) | 21–30 | 21–100 | - |
| Median | 33 (100) | 30 | 30 | - |
| PPV | ||||
| Self-inflating bag | 12 (36.4) | 7/15 (46.7) | 5/18 (27.8) | 0.514 |
| T-piece device (Neopuff) | 21 (63.6) | 10/15 (66.7) | 11/18 (61.1) | |
| Mechanical ventilator | 0 (0) | |||
| Ventilatory interface routinely used | ||||
| Facial mask | 24 (72.7) | 14/15 (93.3) | 10/18 (55.5) | 0.018 |
| Short binasal prongs | 9 (27.3) | 1/15 (6.7) | 8/18 (44.4) | |
| Laryngeal mask | 4 (12.1) | 2/15 (13.3) | 2/18 (11.1) | 0.626 |
| The skill of the team on intubation | ||||
| Excellent | 16 (48.5) | 10/15 (66.7) | 6/18 (33.3) | 0.141 |
| Good | 13 (39.4) | 5/15 (33.3) | 8/18 (44.4) | |
| Sufficient | 3 (9.11) | 0/15 (0) | 3/18 (16.7) | |
| Insufficient | 3 (3.0) | 0/15 (0) | 1/18 (5.5) | |
| Sustained lung inflation | ||||
| Yes, routinely | 7 (24.2) | 2/15 (13.3) | 5/18 (27.8) | 0.140 |
| Yes, occasionally | 8 (21.2) | 6/15 (40.0) | 2/18 (11.1) | |
| Never | 18 (54.5) | 7/15 (46.7) | 11/18 (61.1) | |
| PIP levels routinely administered to start PPV (cmH2O) | ||||
| Late preterm and term infants | ||||
| <18 cm H2O | 7 (21.2) | 2/15 (13.3) | 5/18 (27.8) | 0.225 |
| 20 cm H2O | 9 (27.3) | 4/15 (26.7) | 5/18 (27.8) | |
| 25 cm H2O | 17 (51.5) | 9/15 (60.0) | 8/18 (44.4) | |
| Mean±SD | 33 (100) | 22.0±3.23 | 20.72±2.69 | |
| Range | 33 (100) | 15–25 | 16–25 | |
| Median | 33 (100) | 21 | 20 | |
| Preterm infants | ||||
| <18 cm H2O | 14 (42.4) | 4/12 (33.3) | 10/17 (58.8) | - |
| 20 cm H2O | 11 (33.3) | 3/12 (25.0) | 1/17 (5.9) | - |
| 25 cm H2O | 4 (12.1) | 5/12 (41.7) | 6/17 (35.3) | - |
| Mean±SD | 33 (100) | 20.42±3.39 | 18.76±3.68 | 0.230 |
| Range | 33 (100) | 15–25 | 8–25 | - |
| Median | 33 (100) | 20 | 18 | - |
| PEEP levels (cmH2O) | ||||
| Late preterm and term infants | ||||
| 4 | 1 (3.0) | 0/15 (0) | 1/18 (5.5) | - |
| 5 | 16 (48.5) | 9/15 (60.0) | 7/18 (38.9) | - |
| 6 | 14 (42.4) | 5/15 (33.3) | 9/18 (50.0) | - |
| 7 | 1 (3.0) | 1/15 (6.7) | 1/18 (5.5) | - |
| 8 | 1 (3.0) | 0/15 (0) | 0/18 (0) | - |
| Mean±SD | 33 (100) | 5.47±0.64 | 5.61±0.85 | 0.592 |
| Range | 33 (100) | 5–7 | 4–8 | - |
| Median | 33 (100) | 5 | 6 | - |
| Preterm infants | ||||
| 5 | 18 (54.5) | 8/12 (66.7) | 10/17 (58.8) | - |
| 6 | 10 (30.3) | 3/12 (25.0) | 7/17 (41.2) | - |
| 7 | 1 (3.0) | 1/12 (8.3) | 0/17 (0) | - |
| 8 | 0 (0) | 0/12 | 0/17 | - |
| Mean±SD | 33 (100) | 5.42±0.67 | 5.41±0.50 | 0.982 |
| Range | 33 (100) | 5–7 | 5–6 | - |
| Median | 33 (100) | 5 | 5 | - |
| Meconium-stained amniotic fluid management in a non-vigorous infant | ||||
| Suctioning of the oro- and nasopharynx before delivery of the shoulders | 5 (15.2) | 2/14 (14.3) | 3/18 (16.7) | 0.467 |
| Intubation and subglottic aspiration | 5 (15.2) | 1/14 (7.1) | 4/18 (22.2) | |
| Starting PPV after removing secretions | 22 (66.7) | 11/14 (78.6) | 11/18 (61.1) | |