Seminars in Fetal & Neonatal Medicine (2005) 10, 45e61

www.elsevierhealth.com/journals/siny

Clinical risk management in newborn

and neonatal resuscitation
John Madar*

Consultant Neonatologist & Clinical Director, SW Peninsula Neonatal Network,

Derriford Hospital, Level 5, Plymouth, Devon, England PL6 8DH, United Kingdom

KEYWORDS Summary This chapter aims to provide an overview of aspects of risk

Cord blood gases; management as they might be applied to the practice of resuscitation of the
Neonatal newborn using general principles of risk management and specific standards where
resuscitation; they apply.
Risk management Section 1 considers the matter of hazard and risk and how they may be classified.
Figures are presented to provide a clinical perspective on resuscitation with
a discussion on the hierarchy of clinical risks operating upon the baby.
Section 2 centres on a discussion of those aspects that operate to modify the
risks to the baby during a resuscitation, including environmental considerations
(location, clinical setting and equipment); staffing issues (establishment, compe-
tency, induction and training) and logistics (process, communication and
documentation).
Section 3 debates the place of cord gases in the context of the diagnosis of
perinatal hypoxaemia.
ª 2004 Elsevier Ltd. All rights reserved.

Introduction Individuals may be the cause of problems, but

The aim of this chapter is to provide a perspective
on differing aspects of newborn resuscitation
practice focussing on the potential risks and
strategies to deal with these.
‘Prevention is better than cure’
* Tel.: C44 1752 763642; fax: C44 1752 763635.
E-mail address: john.madar@phnt.swest.nhs.uk
the root often lies in failure of the systems under
which they operate. A systems analysis ideally
identifies problem areas prospectively. Strategies
can be defined to deal with these. Unidentified
problem areas are likely to cause difficulties, as
immediate strategies may be lacking.
Risk management is a logical process insepara-
ble from the best principles of clinical practice.
Success lies in the accurate modelling of potential
situations and the planning of clear strategies to
deal with these. Fortunately many situations are
dealt with by a common approach with relatively

1744-165X/$ - see front matter ª 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.siny.2004.09.014
46
few special circumstances dictating a unique re-
sponse.
Hierarchy of organisational awareness
Organisational vulnerability
Unconscious Liability
Unaware of shortfalls, problems
Conscious Liability
Aware of shortfalls, problems
Conscious Contingency
Specific plans for specific identified liabilities
Unconscious Contingency
Comprehensive systems operating cover even unexpected liabilities
Organisational integrity
The aim of any risk management strategy is to
move the organisation from the state of ignorance,
to that where systems are in place and robust
enough to cover all eventualities e including those
rare, unexpected and hitherto unplanned events.
Prerequisites to effective risk management
A sound risk management strategy
Robust methodology for any risk assessment
Appropriate resource for the initiative
Risk management strategies
It is vital to ensure all aspects are covered. The
management standards for maternity services1
developed by NHS litigation authority (NHSLA)
within the Clinical Negligence Scheme for Trusts
(CNST) identify domains to cover in dealing with
risk, be it resuscitation or any other area.
CNST Standards of clinical risk management1:
1. Organisation: Local arrangements and account-
ability for implementing clinical risk manage-
ment are clearly defined.
2. Learning from experience: The maternity ser-
vice proactively uses internal and external
information to improve clinical care.
3. Communication: Women are informed by com-
petent professionals of all aspects and options
concerning their treatment and care, and there
are clearly documented systems for manage-
ment and communication between professional
staff.
4. Clinical care: There are clear procedures for
the management of general clinical care.
5. Induction, training and competence: There are
management systems in place to ensure the
J. Madar
competence and appropriate training of all
professional staff.
6. Health records: A comprehensive system for
the completion, use, storage and retrieval of
health records is in place. Record keeping
standards are monitored through the clinical
audit process.
7. Implementation of clinical risk management: A
clinical risk management system is in place.
8. Staffing: Maternity services must provide safe
care for mothers at all times.
Steps in the process
1. Risk assessment
 Identify and stratify hazards
probability
significance
2. Risk management
 Define operational strategies to minimise
hazards
 Identify resource (finance/manpower) avail-
able to support strategies
 Execute strategies
 Evaluate results of strategies
Standards
External mandated or recommended standards
inform the process e these are the synthesis of
prior risk management processes. Many agencies
publish recommendations relevant to the care of
babies at birth.2e7
Hazards and risks
Is resuscitation hazardous? In any resuscitation,
there are a number of people involved: the baby
(or babies) being resuscitated, those undertaking
the resuscitation and those around who include
the parents and other professionals. All of these
groups may be exposed to hazards with variable
risks of these occurrings (Table 1).
Hazards to the baby
The newborn baby is the focus of efforts to restore
function. This may fail and the baby might die.
Interventions may save life but at the cost of
a damaged survivor. Physical injury may occur as
a result of resuscitation attempts e some poten-
tially avoidable. Significant organ damage may
Clinical risk management in newborn and neonatal resuscitation
Table 1 Some generic hazards in resuscitation at birth and to whom they might apply
Hazard Baby Resuscitator
Death X
Short term
Physical morbidity X X
Mental morbidity X X
Metabolic morbidity X
Long term
Physical morbidity X X
Mental morbidity X X
Neurodev morbidity X
Professional damage X X
Fiscal damage X X
result with major metabolic upset necessitating
a period of intensive care with its own problems.
Ultimately, the net effect of the resuscitation may
be permanent damage to organs including the
brain, which results in intellectual or physical
handicap and long-term problems for baby, carers
and professionals. The acceptability of these out-
comes and efforts made to reduce their occurrence
form the basis of a risk management strategy.
Hazards to the resuscitator and other
professionals
It is unlikely that the resuscitator or other involved
professionals will die e unless the stress of the
situation results in some major catastrophe such as
a myocardial infarction, or the efforts required to
attend the event place those attending at risk e as
for example where attendance involved a poten-
tially hazardous drive when distracted. The risk of
these events might be considered low. It is con-
ceivable however, that those involved might be
subject to significant mental stress e especially in
a fraught clinical situation where events have not
gone as planned, or other untoward events have
complicated matters. It is possible that personnel
could, in the course of efforts have physical injury
e such as a needle stick, or exposure to bodily
fluids. These might be short-term, or long-term
issues e such as if infection became a problem.
Depending on the course of events, there might be
potential professional or fiscal issues; either med-
ico-legal, or health related. Untoward adverse
experiences could have a significant influence on
a person’s view of their professional life and
might, for example influence a choice of career.
47
Other Prof Parents Organisation
X X
X X
X X
X
Hazards to the parents
Parents are less likely to be active participants in
resuscitation, although this may not be the case in
certain out of hospital situations. Parents are
however, very likely to be observers of any
resuscitation event and thus exposed and aware
of what is happening to their baby. These events
can be a significant emotional stress and their
interpretation of events may have a significant
part to play subsequently. Depending on the out-
come, they may be exposed to financial pressures,
and the effect of, for example, a damaged survi-
vor might have an impact on professional and
family life, altering career aims and family dy-
namics e although not always necessarily for the
poorer.
A perspective on risk
Whilst those involved in resuscitation may be
exposed to risks, the major concerns relate to
the health of the baby and the necessary inter-
ventions. Having some idea of the likelihood of
a need for intervention provides some perspective.
Attendance at resuscitations and the
resuscitation required
Help is called for when it is felt it might be needed
and part of the risk management process is de-
fining those circumstances when problems are
anticipated and putting in place systems to deal
with this. However, not all babies who require
resuscitation have a doctor (or equivalent) at
delivery, as it is not always possible to predict
the event (effectively a false negative summons).
48 J. Madar

Table 2 The proportion of deliveries attended by Table 3 Numbers of babies requiring resuscitation
a doctor summoned at or after delivery, and including cardiac compressions or drugs in two
the numbers requiring airway intervention in a typi- different types of centres in the USA and UK
cal large UK DGH using guidelines such as those Location Texas Plymouth UK
discussed 1991e19929 1993e1999
All risks, all gestations, Low risk, Total births 30,839 30,400
n Z 17,890 R 32 weeks, Total ECC 39 (0.12%) 81 (0.27%)
n Z 11,461 C/ÿ drugsa
Doctor at Doctor after Doctor after ECC only 21 65
delivery delivery delivery ECC C drugs 14 7
Total 5133 948 477 Drugs only 4 (adrenaline) 9 (unspecified)
attended a
Not including naloxone as a drug of resuscitation.
Minimal 3867 (75%) 529 (56%) 193 (40%)
intervention
Mask inflation 852 (17%) 286 (30%) 275 (58%) to differentiate those with a very poor outlook,
Intubation 175 (3.4%) 133 (14%) 9 (2%) who tend to be acidotic and/or preterm (Figs. 1
Derriford Hospital Plymouth (UK) hospital resuscitation and 2).9
data.8 Retrospective analysis of resuscitations where
cardiac compression or drugs were required sug-
Similarly, when called, resuscitators are not gested that in a significant number of cases
always needed (effectively a false positive sum- problems related to a failure to adequately ad-
mons). The more mature the baby, the less likely dress the airway and breathing.9
they are to require resuscitation (Table 2). It is important to be aware of trends within
The specific indicators for attendance in any departments. The ability to review local data may
unit may vary. However, typical indications to identify changes in practice or outcome that
summon help before delivery might include: highlight areas of good practice, or those where
matters need reviewing (Fig. 3).
 preterm deliveries, Observational data in this series appear to
 emergency caesarian sections, demonstrate a decreasing tendency in the use of
 breech deliveries, drugs, which may reflect educational initiatives on
 thick meconium staining of the liquor, newborn life support introduced around this time.
 multiple pregnancy,
 maternal conditions potentially affecting the A hierarchy of risk
baby,
 prior identified fetal problems, There is hierarchy of risk in delivery to consider.
 other occasions if requested by obstetric staff. For example, which poses the greater risk? 1: A
delivery where there are definite problems identi-
The need for intervention at birth does not in fied in utero, but where as a result, everyone is
itself predict a poor outcome. In the above series, prepared, or 2: A delivery perceived to be un-
the overall incidence of moderate or severe early complicated but where some unexpected catas-
neonatal encephalopathy was 0.10%, and that of trophe results in a severely compromised baby in
meconium aspiration syndrome 0.15%.
The response to resuscitation e or lack of it e ECC +/- Drugs
may indicate a disease severity that heralds prob- 39

lems. The greater the level of intervention, the

>= 37weeks
more likely outcome will be compromised in the 15
short, medium or long term. The numbers re-
quiring cardiac compressions or drugs are much Acidaemia No Acidaemia
5 10
lower than those requiring airway or breathing
support. Differences in the numbers requiring Brain injury Normal Neurology
intervention occur between departments, which 5 10
may reflect variance in the size of unit, population
of babies, training of staff or the model of care Died Neurodev Delay Normal No FU
2 3 9 1
delivery (Table 3).
Outcomes tend to be poorer where cardiac Figure 1 Outcome in term babies who received
compressions are required, although it is possible external cardiac compression and drugs.9
Clinical risk management in newborn and neonatal resuscitation 49

ECC +/- Drugs a unit’s ability to cope. Factors such as distance

39 and the presence/absence of effective transport
services modify the decision.
<37 weeks
24
Antenatal e elective delivery
Acidaemia No acidaemia It may be felt necessary to deliver the baby early
5 19
in recognition of factors that are felt to potentially
compromise mother or baby such as eclampsia or
Brain injury Normal Brain injury No IVH
4 1 6 13 severe growth restriction. Elective delivery may
also take place to ensure optimal conditions for
Died Died Died Normal No data resuscitation where the baby is well, but will need
1 1 3 8 2
complex intervention, such as with cardiac/surgi-
Figure 2 Outcome in preterm babies who received cal problems. Where there is a choice, delivery
external cardiac compression and drugs.9 after 39 weeks significantly reduces the risk of
respiratory morbidity in the baby.19
the absence of anyone other than the usual mid-
wifery support. The first example reflects a pre- Perinatal e preterm delivery
emptive approach to risk, where prior planning When a baby is being delivered early it is essential
and appropriate placement of resource minimises that the parent(s) are aware of the implications. An
the risk even where significant problems are understanding of their perspective may inform any
expected. The latter reflects an incident upon resuscitation strategy. Making them aware of the
which outcome is dependent on the ability of the potential issues relating to outcome is essential in
systems in place to respond appropriately in the immediate and subsequent management of such
a timely manner. babies. For extremely preterm babies, the presence
The first reflects a ‘preventive’ strategy, the of a senior member of the neonatal team might be
second a ‘responsive’ strategy. It is necessary for considered appropriate. For these deliveries, initial
the organisation to act in both ways. Arguably the resuscitation strategies are somewhat different and
more is the effort directed towards preventive senior experienced involvement at this stage might
measures the less is the need for responses. significantly improve the baby’s immediate and
long-term outcome. Occasionally decisions need
Preventive strategies to be made regarding the appropriateness of any
Antenatal e in utero transfer resuscitation efforts, senior input is desirable.
The appropriate elective transfer of a baby with, These situations are more manageable if there
for example a surgical problem or evidence of fetal has been opportunity to discuss matters prior to
compromise to a unit better able to deal with the delivery.
problem may reduce the likelihood of a resuscita-
tion or improve the management of a potential Responsive strategies
resuscitation. The risks of transfer have to be Perinatal e fetal compromise
balanced against the risk of staying put, as may Whilst on occasions it is possible to identify babies in
occur with a mother in threatened preterm labour, trouble before birth this is not always the case and
or where workload/staffing issues compromise babies are delivered unexpectedly in poor condi-
tion. The equipment required to resuscitate the
18 baby should be immediately available and systems
Total ECC/Drugs Drugs
16 have to be in place to communicate effectively to
14 the relevant staff. The neonatal resuscitation team
12 has to be clearly identified and available at short
10 notice and the means by which this occurs and the
8 systems used to call them have to be robust. There
6 should be clear guidelines on the circumstances
4 when such help should be summoned as well as
2 unambiguous guidance on how to call, and who
0 should attend. On occasions events happen too fast
1993 1994 1995 1996 1997 1998 1999 for the neonatal team to respond in time, so it is
Figure 3 Details of resuscitations requiring external important that the staff immediately available have
cardiac compressions (ECC) or drugs, by year (Plymouth training in the first steps in dealing with potentially
resuscitation data). compromised baby. Key staff should be identified
50
and provided with training e such as a Newborn Life
Support Course, plus ongoing support.
Summary
Attention to the ongoing process of labour and an
awareness of the possible outcomes and resources
available are essential in modifying events to
minimise the possibility of an adverse outcome.
The domains of risk
There are different areas that need to be consid-
ered when considering risk.
 Environment
B Location
B Clinical setting
B Equipment
 Staffing
B Establishment
B Induction, training, competency
 Logistic
B Process and timing
B Workload intensity
B Communication
Environment
Location
A delivery can take place in hospital, a planned
birthing centre (midwifery led unit), at home or
occasionally elsewhere. The ability to deal with
problems is significantly affected.
Deliveries are ideally planned between the pa-
rent(s) and the midwifery/obstetric care team as
part of the risk management process. Delivery is
a potential hazard and factors operating during the
pregnancy might mandate a recommendation for
delivery in a different place, or with different staff.
Mothers may choose to deliver in a hospital setting
where it is perceived that should problems occur,
the systems to deal with these are in place. Others
choose to deliver at home or in a midwifery led unit
not linked to major hospital services. In these cases,
the ability to deal with certain problems is reduced.
Any risk management process needs to consider the
potential scenarios where problems might occur
and respond. In preventative terms, perceived risks
might be managed by recommending a change of
venue from home to hospital as with antenatal
issues such as pre-eclampsia or multiple pregnancy,
or with perinatal problems such as a preterm labour
where it is inappropriate to continue with the
J. Madar
original birth plan. There need to be clear guide-
lines/protocols defining the thresholds upon which
discussions/decisions take place. If the mother is
delivering in an out of hospital setting, then there
need to be appropriate contingencies for obstetric
or neonatal emergencies.
Geography may be a confounding issue with
unplanned deliveries such as a preterm precipitate
delivery at home, or in an accident and emergency
department. Planning for these should consider
the environment and equipment available, trans-
port issues, the ability of local staff to cope, and
how specialist staff would be summoned and their
ability to deal with the problem(s).
Clinical setting
The ideal environment should facilitate, not hinder
the resuscitation of a baby in difficulties. Rooms
should be of appropriate size that crowding does
not compromise the delivery of the baby, should be
draught free and of an appropriate temperature.
There should be an accessible area where the baby
can be assessed and support required provided.
There should be unhindered access to relevant
equipment; it should be free of unwanted interfer-
ence such as excessive noise, be provided with
appropriate communications and be private.
Priorities vary. Good thermal control is essential
as this may affect outcome. However, the pres-
ence of excessive noise might not materially affect
resuscitation, unless it was sufficient to impair
rational thought or communications. Privacy is
desirable, but not essential in practical terms.
The commissioning of a delivery unit affords an
opportunity to specify room dimensions, layout and
support services such as piped air/oxygen. Other-
wise it is a matter of reviewing existing arrange-
ments. Whilst not yet mandatory, the ability to
blend gas should arguably be available10,11 and
consideration of the means by which this (and
compatible equipment) is provided. If no piped
air is available bottled air may be considered an
effective alternative, issues arise with respect to
supply and storage. Birthing pools are an example
of a potentially challenging environment, which
demand clear guidelines. Achieving adequate ther-
mal control may be difficult in the cooler and often
draughty setting of theatre where the (often
compromised) baby is exposed prior to transfer to
the resuscitation area. Home deliveries have chal-
lenges. It is possible to keep the place of birth
warm, but space, lighting and support infrastruc-
ture e among other factors e can be problems.
Those undertaking delivery and resuscitation/sta-
bilisation need to understand their environment
and have strategies to deal with restrictions.
Clinical risk management in newborn and neonatal resuscitation
Equipment
In newborn resuscitation the focus is on priorities of
temperature control, airway, breathing and circu-
latory support, however, common principles apply.
Risk management considerations are:
 can the equipment do the job required? i.e.
effective ergonomics/design (functionality)
and robust maintenance procedures.
 can staff use the equipment effectively? i.e.
appropriate environment and staff training.
 is the equipment in the right place? i.e.
effective organisation.
It is important to know who does what in order
that equipment is properly looked after.
Typical areas of responsibility/interest
 Specification Midwifery/Neonatology
 Purchase Midwifery/Obstetrics
 Use Midwifery/Neonatology
 Upkeep Midwifery
 Maintenance Unit specific maintenance serv-
ices.
All departments involved should be consulted
when commissioning equipment. Any national guid-
ance and unit strategy should be taken into
account. A pre-determined clear user specification,
accommodating specific unit based factors and
identifying the key priorities against which equip-
ment may be judged helps objectivity in assess-
ment. For example, the equipment available to
a community midwife undertaking home deliveries
will be different to that provided in a delivery suite.
It may be less sophisticated/comprehensive but
arguably more critical as there is less back up for
failed/absent items. Evaluation determines the
effectiveness of the equipment but must consider
reliability, replacement, servicing and ultimately,
cost. The assessment process is equally valid for
small, disposable items such as suction catheters,
as for larger items such as resuscitaires.
Basic principles
Make it accessible. Ensure everyone knows
where equipment, drugs etc. are stored e before
they are needed and in such a way as to be easily
found.
Make it functional. Ensure the equipment can do
the job intended. For example, poor fitting face-
masks might hinder lung inflation, suction cathe-
ters of inadequate bore might render the clearance
of physically obstructed airways difficult.
51
Keep it simple. Equipment should be easy to use
and maintain. Response should be consistent (i.e.
predictable) and reliable. For example e resusci-
taires for use on delivery suites offer similar
facilities e a flat surface on which to resuscitate,
a source of heat, means of delivering positive
pressure breathing support, means of clearing
the obstructed airway (i.e. suction), somewhere
to store equipment and a means of timing the
resuscitation. However, rather like cars, whilst the
basic function is similar, layouts can be very
different and other adjuncts may be offered in-
cluding, for example, the ability to raise/lower the
platform, the presence of servo control on heat-
ing, differing means of blending the air/oxygen
supply, the incorporation of a ventilator for re-
spiratory support etc. Increasing complexity comes
with increased costs in terms of staff training and
maintenance. The potential to complicate and
possibly impede resuscitation efforts needs to be
taken into account. Matters may be compounded if
different systems are used in the same place.
Local context. Local needs are important. For
example, babies need transfer from the delivery
suite to the NNU. Whether this is on the resusci-
taire or in a transport incubator depends upon
geography and other factors. Size/manoeuvrability
of equipment, provision of continued thermal and
ventilatory support and monitoring become impor-
tant. In a resource-limited environment, it may be
felt acceptable to have a few resuscitaires moved
from room to room depending on need. Others
might specify one for each room. Some units might
choose to specify wall-mounted units, which are
less obtrusive, their lack of presence being per-
ceived as being subliminally reassuring to any
putative parents. Whichever case, contingencies
to deal with unexpected deliveries and multiple
pregnancies would be required.
Standardise within departments. Variation in
equipment may cause confusion in the potentially
fraught situation of a resuscitation and potentially
adversely affect outcome. Standardisation allows
those involved to concentrate on the clinical
issues, not on the tools. It helps those responsible
for maintenance. For example, differing T piece
circuits are used for breathing support, some with
a facility for PEEP, others without. Some circuits
are currently provided with an occlusive bung in
the manifold for mechanical ventilation, which
unless removed prevents operator cycled ventila-
tion and results in an excessive inflation times. The
devices may look superficially similar, function on
the same principles, but unless aware, any oper-
ator may not use these devices to their best effect
and potentially cause harm. Staff, especially those
52
who move between units must be made aware of
details. Where possible intra-unit variables should
be minimised/removed.
Stock-keeping is more complex with multiple
types. For example e laryngoscopes vary in size
and shape of blade. Fibre optic illumination alters
blade profile, makes it impossible to lose bulbs into
the pharynx, and allows for disposable plastic
blades. Departmental or trust wide policies on
provision may be relevant. If many different types
are in use, then the multiplicity of spares can be
a problem and users will need to be familiar with
the differing characteristics.
Ensure a fail-safe approach. Alternative means
of undertaking interventions should exist. Contin-
gencies should be made for any system failure at
any level, in any environment. Ideally, duplicate
equipment should enable resuscitation to be un-
dertaken or continue even the primary systems fail
completely.
Eg: Should wall gas supply fail, then the cylinder
supply provided on a resuscitaire should allow
continued support. However, cylinders leak if left
on circuit, and such systems are used rarely, and
thus it is important that these are checked regu-
larly and that staff are aware of how to use them.
Other examples are the provision of two sets of
laryngoscopes to allow for failure of the first set, or
the availability somewhere in the department of
a self inflating bag should T-piece or gas circuits
fail. Staff should be aware of such contingencies.
Ensure training in use. It is essential that staff
are trained. It is dangerous to make assumptions
and it is necessary to be able to demonstrate that
staff are trained. Therefore, any programme of
induction, or ongoing education must not only
provide the facility to train, but also to document
competence in the use of the equipment. This
needs to be ongoing with regular review as policies,
equipment e and staff e change with time. How
such a programme is implemented is a departmental
matter, but requires identified trainers with time
apportioned for the task. For example e those using
a resuscitaire should know how to set it up, how any
pressure regulated system works, how the suction is
provided, what is stored in the drawers, what to do
if primary systems such as gas supply fail etc.
Ensure robust and accountable schedules for
checking and servicing. The failure of equipment,
or a lack of serviceable equipment adversely
affecting a resuscitation attempt is difficult to
defend. There should be clear delineation of
duties and responsibilities with respect to mainte-
nance. There must be a clear structure for the
checking and restocking of any resuscitation equip-
ment after any use in addition to any ‘routine’
J. Madar
system of review and maintenance. Clear retriev-
able documentation of the process should be kept.
It is essential to be aware of any issues pertain-
ing to the equipment which may adversely affect
its ability to perform appropriately. Systems
should be in place to allow items of concern to
be identified to those responsible for upkeep.
Documentation must be robust. Any process needs
to include reference to relevant external agencies
such as the MHRA (Medicines and Healthcare
Regulatory Agency (UK)).
Strategies should be in place to plan for re-
placement of those items likely to wear out, or
deemed unserviceable on other grounds.
User has responsibility. Ultimately the user of
the equipment has a responsibility to ensure it
functions as expected or is identified as failing in
time to seek a replacement. In all clinical situa-
tions it is essential to check all functions before
resuscitation. Of course this is not always possible
but as a rule, assumptions should not be made
about the integrity of any equipment. Failure to
identify a lack of provision in advance may com-
promise the ability to resuscitate effectively.
Summary
The equipment used in a resuscitation, whether in
delivery suite, home delivery or elsewhere must be
subject to a rigorous policy of upkeep with those
using the equipment subject to an equally rigorous
policy of training. These processes must be regu-
larly reviewed and any information retrievable in
order to demonstrate, should it be necessary, that
appropriate systems operated to minimise the
likelihood of failure of either kit or operator.
Staffing
Establishment
Guidelines exist on the numbers and competency
of staff that should be available to deal with
delivery situations (summarised for the UK in the
CNST maternity standard No. 81) within hospital or
domestic settings. Ensuring adequate numbers are
available to work can be a challenge. Service
planners need to ensure adequate numbers of
staff are employed.
Workload varies, and the baseline establishment
of staff may be inadequate at times. Contingencies
to enable the service to cope should exist. These
might involve extra staff or, where it is felt matters
approach dangerous levels, temporary closure of
the unit. Accurate information, clear guidance and
access to relevant senior staff able to make in-
formed, balanced decisions on these matters are
Clinical risk management in newborn and neonatal resuscitation
essential. Up-to-date registers of whom to contact
in such situations should be available.
Staffing issues may compromise standards of
care. The degree to which this is tolerated is
clinically driven, taking into account relevant
standards and operational factors. In risk manage-
ment terms, whilst occasional lapses in staffing
standards might be tolerated, regular failures
suggest matters need review.
The availability of midwifery, obstetric or pae-
diatric staff is an issue, their ability to function
effectively, another.
Induction, training and competency
Issues relate to who should be trained, the delivery
of the training and means of assessment and
quality control.
Resuscitation training
Staff who might be involved in resuscitation at
birth should have the knowledge base and skills to
undertake this and be provided with the appropri-
ate tools, the use of which in they have also been
trained.
The risk management agenda includes the pro-
cesses by which
1. Levels of knowledge and skills required are
defined, set against any published standards.
2. Individual staff needs are identified.
3. Opportunities for induction and on going
training are provided.
4. Mechanisms for the assessment of competency
with remedial processes where staff fail to
achieve the defined standard are provided.
5. A process for the recording of and review of
resuscitation situations with appropriate in-
dividual and departmental feedback is in place
to identify any learning/problem areas.
6. Information on the above are retrievable to
inform future strategy and any clinical review.
Knowledge and skills
All staff require core skills in the initial assessment
and resuscitation of any newborn baby. More
complex situations require augmented skills and
other personnel. Units should clearly specify the
levels of knowledge and skill expected of each
professional group. They may draw upon published
standards such as those of the Royal College of
Paediatrics and Child Health and Royal College of
Obstetricians and Gynaecologists3 or British Asso-
ciation of Perinatal Medicine4 when delineating
these.
53
Published standards
There is relatively little published on the spe-
cific competencies expected of staff, although
guidance exists on mechanisms of induction, train-
ing and subsequent support,(1 (standard 5), 3)
including attendance4 on courses such as the
Newborn Life Support (NLS) Course (RC(UK))12
and Neonatal Resuscitation Program (NRP) (AAP
(US))13 whose syllabuses act as templates for core
competencies, and whose testing structures serve
as a means of assessing staff. As course regulators
emphasise however, whilst the courses provide
knowledge and develop skills they are not a sub-
stitute for supervised experience in the clinical
arena and certification on such courses does not
provides a license to practice. Nevertheless, if
recommended by standard stetting organisations,
risk management strategies should accommodate
such courses.
Core knowledge and competencies
The basic skills required by a practitioner e those
comprising the ‘core competencies’ will vary, not
just by profession, but also by model of health care
(Table 4). Even when not undertaking procedures
such as intubation or obtaining venous access,
staff should understand when these might be
required, and be able to help. When considering
those less involved with birth (e.g. A&E personnel,
paramedics, GPs), the level of clinical exposure
makes maintenance of skills difficult so there is
merit in concentrating on those most likely to be
used. It is often those exposed infrequently to the
problems, that are most challenged. It is then
Table 4 Core knowledge/competencies that might
be considered when establishing a baseline for
personnel
Domain Knowledge/competency
General Physiology, equipment, thermal
care, initial assessment, team
working
Airway Position, jaw thrust, two person
support, use of Guedel airway,
inspection/suction, possibly
intubation
Breathing Use of T-piece and bagevalvee
mask systems, inflation breaths
Circulation Cardiac compressions, possibly
insertion of umbilical catheter,
possibly use of drugs
Special Meconium aspiration, preterm
considerations babies, congenital abnormalities
Based on the algorithm for newborn life support used in the
NLS (RC(UK)).12
54
important to have clear mechanisms on obtaining
appropriately skilled help.
Evolving standards of care
Staff should be up-to-date with current practice
and recommendations.14e16 Staff and departments
need to actively review local standards of care to
reflect these.17 Recent issues include the appro-
priate timing for elective caesarean section de-
liveries,18,19 the use of room air or blended oxygen
rather than 100% oxygen,10,11,20 the use of poly-
ethylene wrap/plastic bags to optimise thermal
care in the extreme preterm baby,21 optimal
neuroprotective thermal care for the hypoxic in-
fant;22 the optimal way to assess the heart rate
(using a stethoscope);23 the use of laryngeal mask
airways;24 the potential use of pulse oximetry25,26
and capnography27 in the delivery room situation.
Individual staff requirements
Individual staff needs should be identified through
a defined process of performance review or ap-
praisal. Ascertainment of the skills/knowledge of
the individual can then be translated into a strat-
egy for updating/refresher training. This review
takes place against a defined set of departmental
standards, which conform to any relevant internal
(organisational) or external standards.
Assessment needs to be pre-emptive and ongo-
ing, commencing before or soon after appointment
and subject to review. Clear documentation of the
assessment process and progress/development of
competencies at an individual level is essential.
This may inform future review, reflective learning
and may be important should any issues (internal
review, complaints, legal action, etc.) arise re-
lating to specific resuscitation events. Increasingly
such aspects are incorporated into regulatory
structures such as those of the NHS litigation
authority.1
It is essential that staffing levels and skill mix
acknowledge individual competency and do not
result in those inexperienced being expected to
carry out tasks without support.
Induction/training
It is perilous to make assumptions about the basic
level of competence of new staff, in particular
medical staff who rotate through departments
frequently. Someone who is properly trained in
a given task is more likely to perform that task
better. This premise drives many initiatives in-
cluding training in the knowledge and skills per-
taining to resuscitation e with some evidence to
support such efforts.28 The precise manner and
frequency of such training and the mechanisms by
which its effectiveness can be assessed is less clear.
J. Madar
Ensuring all new staff undergo formal NLS or
equivalent training at least gives those with no
prior background in newborn resuscitation some
training and works towards a common approach
during resuscitation situations.
Delivery of training
Institutions must resource properly structured
training; a major issue is time. Staff must be
released to attend relevant educational activities.
Members of the clinical establishment should be
credible trainers and be supported in developing
their educational and mentorship skills.
Training initiatives have evolved over years. The
involvement of interested clinicians, educational-
ists and the application of learning theory have
had a significant effect on recent efforts in the
field.29
The prerequisites of a good training programme
are:
1. provision of the relevant knowledge and skills
in appropriate form,
2. opportunity to practice until competent,
3. appropriate support in the clinical environ-
ment,
4. robust mechanisms for review.
Courses provide knowledge and develop skills,
consolidated whilst ‘learning on the job’. Practice
is informed by clinical exposure. Undertaking re-
suscitation within an appropriate supervisory
structure underpins clinical practice. Whatever
methods are used prior to working in the field,
consolidation takes place in the field.
Formal courses
A current vogue involves short, intensive training
courses e often over 1 or 2 days. Written material
and lectures provide knowledge. Skill stations and
clinically based simulated scenarios develop psy-
chomotor, evaluation and team leadership skills
such that all members collaborate effectively.
They aspire to set a baseline standard, deemed
to have been achieved by virtue of formal sum-
mative assessment.
Within the United Kingdom, the Resuscitation
Council (UK) supports the Newborn Life Support
(NLS) course,12 a course developed in the UK,
based around UK clinical practice, which operates
under their regulations and quality control sys-
tems. This course is supported/endorsed by all
the professional bodies involved with staff re-
sponsible for babies in the newborn period and, in
this country is seen as the current standard in
training in the initial assessment and support of
a newborn baby. Similar courses exist in other
Clinical risk management in newborn and neonatal resuscitation
parts of the world, such as the Newborn Re-
suscitation Program (NRP), supported in North
America.13 It might be expected that staff in-
volved with babies at birth hold a current certif-
icate in one of these.
These courses do not claim to make staff
competent in newborn resuscitation, but provide
tools to enhance the ability to deal with a re-
suscitation situation. It is acknowledged that
training is essentially experiential and based
around appropriately supervised exposure in the
clinical setting.
What is the evidence formal training is of use?
Limited evidence suggests these training interven-
tions are of benefit in influencing clinical practice
and improving outcomes.31,28 The uplift in ability
does depend on the prior knowledge and skill base
of those trained. Someone with no experience may
benefit greatly from such a course, those with
years of experience may also benefit from a review
of practice but on a differing level. However, even
when an educational programme is in place, the
defined standards of care may not be achieved.32
Departments need to ensure staff attain the set
standards. However, without reinforcement once
in the clinical arena the knowledge and skills
taught on courses will atrophy.33,34 The education-
al framework must include relevant supervised
experience and update training. Presently, UK
based midwives have a statutory requirement for
annual refresher training. Medical staff have no
such regulation. The recommended NLS course
mandates a recertification in the fourth year. This
is an arbitrary interval, chosen on a pragmatic
basis.
Individual departments must choose their in-
ternal standards based around statutory and ex-
ternally recommended requirements and set in
place an auditable structure to ensure all relevant
staff are trained e using a combination of struc-
tured courses, supervised clinical exposure and
training updates.
Competence versus confidence
It is important to be aware of the relationship
between competence and confidence. Life support
training has been shown to increase confidence e
something evident from questions to the candi-
dates.35 True competence can be hard to quantify.
The assessment of competence is often subjective
and based around structured observational assess-
ment of practice either within the construct of
a course (in which case it is more controlled, but
effectively out of context), or in clinical practice.
Different staff requires differing support
mechanisms depending on their competence
55
and confidence. The confident but incompetent
staff member is a liability who needs to be
identified.
Asset
Competent, Confident
Able to perform, happy to do so – relatively low risk
Competent, Unconfident
Able to perform, less happy to do so – safe, but needs support
Incompetent, Unconfident
Not able to perform, but reluctant to try –potential liability, in need of
training & support
Incompetent, Confident
Unable to perform, thinks can do so – high risk of problems, needs
intervention
Liability
Team working
Poor team work compromises outcome, those
supervising resuscitations (not specifically neona-
tal) not only need good core clinical competencies
but also skills in leadership and an awareness of
the performance not just of themselves but other
members of the team.30
Monitoring performance and education
in the future
Video recording has been shown to be useful in
ascertaining whether resuscitation followed rec-
ognised guidelines. Usual practice after resuscita-
tion is to record in the patient record the sequence
of events and outcome. By their very nature, such
records are retrospective and somewhat subjec-
tive, based around the recollection of the individ-
ual, aided by any contemporaneous notes made
during the process. An investigation into the
accuracy of documentation compared to voice
activated contemporaneous commentary sug-
gested the written record underreported interven-
tions during resuscitation attempts.36
In addition to an accurate record of events such
records may play a vital part in any future analysis;
as part of a quality assurance programme to assess
compliance with guidelines and on an individual
basis to assess competence and aid learning.37 The
effectiveness of any training intervention can be
reviewed.38 Videos have been valuable in review-
ing the operational effectiveness of a resuscitation
team, and in developing an approach to the
leadership skills essential when undertaking re-
suscitation.29,30,33
Within the medico-legal sphere, the contempo-
raneous nature of an audio or video recording has
strength. Such initiatives are generally within the
research domain rather than accepted practice
despite their evident strengths. There is limited
work investigating why such initiatives are not more
56
in the mainstream. The concept of such retrievable
records might be intimidating to those involved.
Documentation
It is essential that clear records of any training are
kept and are retrievable. This is important at the
individual level and forms part of any portfolio. For
the institution a record of staff competencies is
essential when considering the clinical standards
around which a unit operates as well as for any
specific clinical situation where it is necessary to
review the skill base of the staff involved.
Summary
The provision and monitoring of appropriate train-
ing within a department is essential to place staff
in the best position to be able to provide appro-
priate care and reduce the potential for adverse
events. Adequate resources need to be in place to
achieve this.
Logistics
Process
The resuscitation of a baby is part of a process
which begins in utero and ends after birth. In-
tervention at various points may significantly
affect outcome. A situation where a resuscitation
in less than optimal circumstances was required
might have been avoided had other decisions been
made earlier. Therefore it is essential that the
whole process is critically reviewed.
Data on cases dealt with by the NHSLA suggest
a significant number of adverse events relate to
failures in process, where earlier definitive action
before delivery might have resulted in an altered
outcome (personal communication).
Communication
Good communication at all levels is a vital part of
the risk management process whatever the subject
matter. This is acknowledged through the CNST
standards1 of which 2 out of 8 deal with matters of
communication and documentation. Systems or
root cause analysis39 often reveal that problems
arise because of breakdowns in communication at
various levels.
In any given clinical situation, the matters
discussed between staff and between staff and
parents need to be unambiguous, clearly docu-
mented and accessible to others where appropri-
ate. Any discussions should be clearly recorded in
a manner that facilitates later review. Clear
guidance should be provided to staff to ensure
they are able to record all relevant facts and to
J. Madar
refrain from documenting opinions unless fully
supported by sound evidence.
There are critical time frames with respect to
resuscitation at birth.
Antenatal
Neonatal staff needs to be aware of any prior
obstetric discussions and vice versa. Appropriate
staff should be involved. Senior staff aware of all
the potential issues and able to inform parents of
true expectation and likely outcome should coun-
sel those expecting a baby in circumstances which
may be complicated e e.g. extreme prematurity,
congenital abnormality, from which an agreed
strategy for the birth should evolve.
Any discussion with parents including those re-
quiring consent or assent need to be underwritten
by robust evidence based clinical guidelines and
information where possible. This should include not
just national data,40e42 but local outcome data.43
Information should be available for parents in
various formats to acknowledge differences in their
ability to absorb information. Language and cultural
differences can be a major pitfall unless contingen-
cies are made, including multilingual leaflets, and
accessible interpreters. Where critical life deter-
mining decisions are to be made qualitative studies
suggest parents may not wish to be the final arbiter
of outcome, but they need to be well informed and
their views acknowledged during the process.44
Perinatal
For any maternity department the guidelines on
who to call for resuscitation and when need should
be clear. The mechanisms by which the teams are
called (typically via switchboard/bleep systems)
need to be clearly specified and staff need to
understand what to do if initial attempts to call for
help are unsuccessful.
During a resuscitation communication is equally
vital, not just between those involved with the
resuscitation efforts, the delegation of someone to
record accurately the key events and if necessary,
drugs given, may be useful when retrospectively
reconstructing the sequence of events.
The parent(s) are likely to be witnesses to the
event. In childbirth it is impossible/unreasonable
to exclude them. Their subsequent recollection
and interpretation of events are likely to be very
subjective, but may be critical in any ensuing
review. The ability to identify a member of staff
to deal with the parents and to acknowledge their
presence may be vital, if sometime difficult in
fraught circumstances.
Clinical risk management in newborn and neonatal resuscitation
Post-natal
The documentation of the events surrounding
any resuscitation forms a vital part of the risk
management process. Records need to be as
objective as possible. Staff need to be trained in
how to comprehensively and accurately record the
proceedings of any resuscitation. They must un-
derstand the important components of any such
record and also the significance of comments and
judgements made. It is important to recognise the
potential significance of comments, which may not
have any factual basis, and to refrain from re-
cording these. Opinion may be interpreted as fact.
The development of a clear structure for any
subsequent record with supporting documentation
might help in retaining objectivity. Such a structure
was developed to aid in the recording of adult
resuscitation events.45 No such formally structured
equivalent currently exists for newborn resuscita-
tion although guidelines are provided through the
training and documentation supporting the struc-
tured courses.
Staff need to be mindful of the fact that the
hospital record may be made accessible to others
when reviewing any resuscitation events and that
they may be called upon to justify any comments
in a medico-legal setting. The potential usefulness
of audio/video recording as an objective record of
events at this stage has been previously discussed.
It is vital that parents are allowed the opportu-
nity to meet with those responsible for any re-
suscitation e whether successful or not e as soon
as practically possible after the event, in order
that they can be provided with a clear account of
event and potential outcome and have any ques-
tions dealt with. Clear records of these discussions
should be maintained.
An important part of the risk management
process is that of review. Any significant resusci-
tation events should be reviewed, those involved
allowed a timely debrief in order that points of
good practice and potential problem areas can be
identified. Critical incidents should be reported
through whatever mechanisms exist. Multidisci-
plinary meeting of all interested parties, with
documented review processes and effective
executive action are the hallmark of a conscien-
tious responsive organisation.
There should be appropriate evaluation of out-
come to inform future efforts. The outcome of
survivors of critical resuscitation efforts should be
followed up. Unless an expected and predicted
outcome, postmortem examinations should be
carried out on those where efforts have failed as
there may be factors which were not immediately
evident prior to the event. Parents should be given
57
an opportunity to meet with senior professionals at
a later date as it is often the case that questions
arise, or information is forthcoming (such as that
of a postmortem) which can inform a later consul-
tation.
Summary
Failures in communication are often found to be at
the root of many problems experienced not just in
resuscitation. Attention to establishing good com-
munications at all levels is essential in minimising
the likelihood of future problems.
Cord blood gases
The pros and the cons
Introduction
The value of cord blood analysis is based on the
premise that it is a proxy for the status of the baby,
and that significant derangement of the acide
base status of the cord blood represents a similar
state in the baby. Thus a baby, who by virtue of
a significant hypoxaemic stress has generated,
by anaerobic metabolism, a lactic acidosis, poten-
tially compounded by CO2 retention and a respira-
tory component will have acidotic cord blood
gases. Acidotic cord blood gases therefore may
imply intrapartum fetal hypoxia.
The cons.
It could be argued that taking blood from the cord
after delivery is an information gathering exercise
and does not change management of the infant,
which is mandated by the clinical condition at
birth. As such it is of no direct relevance to the
resuscitation.
The motive for their collection is explained by
an increasing need to provide evidence within
a medico-legal framework of the presence or
absence of a pre-existing problem before birth in
the context of attributing cause to any hypoxice
ischaemic problems faced by a baby.
Some units collect cord blood gas data of all
deliveries46e51 others are more selective.52 Varia-
tion in practice between obstetric units in the
UK presumably reflects a lack of consensus on
whether analysis is useful and what should be
measured.53 The 26th RCOG study group on intra-
partum surveillance54 recommended universal
sampling of both artery and vein as an assessment
of the fetus after labour although NICE recom-
mends at least selective sampling in a more recent
review of practice.55 Data from all deliveries
demonstrate that a significant number of abnormal
58
gases would be missed by this practice e 31/42
values in O4000 spontaneous cephalic deliveries
(Derriford Hospital Perinatal Research Group e
personal communication). A few feel that the
process of obtaining cord gases may be potentially
harmful by preventing physiological placental
transfusion of blood after delivery.56
The relationship between cord blood acidosis
and outcome is not a secure one. Even when the
cord gases have been significantly acidotic
(pH % 7.00), babies have subsequently had no
detectable problems in the short or the long
term.46,51 Conversely, significantly unwell babies
may have cord gases above pH 7.00 in the normal
range (Fig. 4) and may well have a poorer
outlook.57 Acidaemia may not reflect cellular
acidosis in some situations.
There is variance in the parameters measured
and the interpretation placed upon these. The pH
in isolation has been used as the measured vari-
able.46,50 Measurement of the base deficit in
conjunction with this is advocated48,58,59 because
it reflects the metabolic component of the pH.
Interpretation of the pCO2 may have value52 in
determining any respiratory component to the
acidosis. There is some interest in lactate as a more
direct measure of hypoxaemic stress.60
Cord artery pH in babies with 1 minute Apgar < 4 at
birth
25
Number of babies
20
15
10
5
0 the metabolic state of the baby. The presence
< 7.00 7.00-7.20 > 7.20 No value
Arterial pH
1 Minute Apgar score for babies with arterial cord
pH <= 7.00
25
Number of babies
20
15
10
5 acidosis and using pH values at or below 7.00 with
0 identification of the metabolic component appears
0-3 4-6 >7 No data
1 min Apgar score
Figure 4 Graphs illustrating relationship between pH
and Apgar score for babies with Apgar ! 4 and arterial
cord pH % 7.00. Derriford Hospital, Plymouth (UK) data
2003 e total births 4268.
J. Madar
There is some debate as to where to measure
the values from. Conventionally cord arterial blood
analysis is quoted as it is felt to better reflect the
baby. Paired samples are often recommended as
they allow discrimination of the artery with a com-
parison of paired values from both artery and
vein;52,61,62 others find no difference between
arterial and venous values48 although this might
reflect inadvertent sampling from the same vessel
(commonly the vein). The site of sampling along
the cord may have a significant effect on values.63
Cord gas values are used with other markers of
fetal stress to improve sensitivity and specificity.
However, opinion differs as to the best markers.
The Apgar score is advocated as a structured
indicator of fetal well-being. Some use the 5-min
score (48.49) with a value !7 taken as the
threshold indicator of compromise. However, de-
spite the preference for the 5-min score by many,
others argue that the 1-min score is a better
discriminator.6 Or that there is but a weak corre-
lation with the measured blood variables.51,52
Some present no data on Apgar but use alternative
markers of neonatal ill health and encephalopa-
thy.58
Overall there would appear to be considerable
variance on the best way of using cord blood gas
analysis, which has limitations as an independent
marker of severe perinatal hypoxia. It is thus
perilous to extrapolate values into a diagnosis of
perinatal hypoxaemia or make any judgement on
long-term outcome without other supportive evi-
dence.
The pros.
Despite the restrictions on the method, cord blood
gas analysis does have merits. Measuring cord
gases soon after birth provides some indication of
of significant acidosis may support a diagnosis
of severe intrapartum hypoxia and may aid in
ascribing a cause to any subsequent neurological
sequelae. A normal gas may facilitate a defence of
obstetric practice.
The method appears to have validity in both
preterm and term infants.49 It is vital however,
that any measurement is taken in context. It is
important to use an appropriate definition of
to have some correlation with outcome.
Where the measured blood variables have been
shown to have some predictive value is when they
are correlated with other observed clinical
markers of fetal stress, such as the condition at
birth (typically recorded as the Apgar score),
Clinical risk management in newborn and neonatal resuscitation
degree of resuscitation required49 and markers of
neonatal encephalopathy.58
There is evidence that the clinical progress of
the infant following resuscitation better informs
predictions of outcome.51 The cord pH neverthe-
less sets a baseline against which subsequent
measurements of blood gas parameters can be
compared. When these correct rapidly, the impli-
cation might be of a relatively minor stress and
a good outcome, as opposed to those where there
is considerable delay in correction of any acidosis
e implying a more sustained insult.50
Conclusion
On their own, cord gases cannot be used reliably to
predict any subsequent adverse event, particularly
in an infant who appears otherwise well where the
available evidence suggests poor values do not
necessarily correlate with any compromised long-
term outcome.
To be of value, whatever cord variables are
collected must be recorded along with all relevant
antenatal information pertaining to the labour and
also the relevant clinical markers of health in the
baby. These should include the components that
make up the Apgar score, the degree of resuscita-
tion required, any sequential blood gas analysis,
and any subsequent markers of illness including
those pertinent to a diagnosis of neonatal enceph-
alopathy, such as seizures.
It is for this reason and to help place any
electronic fetal monitoring in context that cord
blood gases are advocated by the RCOG and Royal
College of Midwives in at least deliveries with fetal
compromise and arguably all deliveries55,64 as to do
so reflects the difficulties in predicting poor out-
comes. It is made clear that collection forms only
part of the assessment of the fetus and that
appropriate clinically relevant information such
as that discussed above should also be collected.
There are standards laid down for the collection of
this information, and departments need to be
mindful of the potential consequences of failing
to have this available.
Cord blood analysis needs to be placed in
perspective. Only when used in an appropriately
directed manner, with a clear understanding of the
clinical context in which the sample was taken,
can the values obtained be useful in ascribing
significance to peripartum events. It is important
to recognise that cord values in the ‘pathological
range’ can be associated with well (non-acidotic)
babies e and may thus reflect local conditions
operating on the cord blood, and that conversely,
babies at birth who demonstrate all the hallmarks
59
of severe hypoxia may have cord blood values in
the non-pathological range e which might indicate
a genesis for the problem not related to intra-
partum events.
Used appropriately the technique has a place in
the risk management of resuscitation and may be
useful in any analysis of events for audit, or other
more adversarial purposes.
Overall summary
The processes involved in managing the risks in
respect to resuscitation are no different to those
of any other domain. However, they highlight the
multifaceted nature of the activity, which requires
a structured approach encompassing many differ-
ent areas, and input from professionals in many
fields. The cost in human and fiscal terms of
a poorly carried out resuscitation is potentially
very high and thus it is an area that deserves close
attention.
References
1. Clinical negligence scheme for trusts. Clinical risk man-
agement standards for maternity services. NHS Litigation
Authority; April 2004.
2. Clinical standards. Advice on planning the service in
obstetrics & gynaecology. RCOG; July 2002.
3. The training needs of professionals responsible for re-
suscitation of babies at birth. Joint committee RCPCH &
RCOG; October 1998
4. Standards for hospitals providing neonatal intensive and
high dependency care. 2nd ed. BAPM; December 2001.
5. Getting the right start@ the national service framework for
children, young people and maternity services e standard
for hospital services. Department of Health; April 2003.
6. Commission for Healthcare Audit and Inspection, !www.
chai.org.ukO.
7. National Institute for Clinical Excellence, !www.nice.org.
ukO.
8. Allwood ACL, Madar RJ, Baumer JH, Readdy L, et al.
Changes in resuscitation practice at birth. Arch Dis Child
Fetal Neonatal Ed 2003;88:F375e9.
9. Perlman JM, Risser R. Cardiopulmonary resuscitation in the
delivery room. Arch Pediatr Adolesc Med 1995;149:20e5.
10. Saugstad OD. Resuscitation of newborn infants with room-
air or oxygen. Semin Neonatol 2001 Jun;6(3):233e9.
11. Vento M, Asesnsi M, Sastre J, et al. Oxidative stress in
asphyxiated term infants resuscitated with 100% oxygen.
J Pediatr 2003;142:240e6.
12. Resuscitation at birth. The newborn life support provider
course manual. RC(UK); 2001.
13. Neonatal resuscitation program e textbook of neonatal
resuscitation. 4th ed. American Academy of Pediatrics;
2000.
14. International guidelines for neonatal resuscitation: an
excerpt from the guidelines 2000 for cardiopulmonary
resuscitation and emergency cardiovascular care: interna-
tional consensus on science. Pediatrics 2000 Sept;106:
pe29.
60
15. Phillips B, Zideman D, Wyllie J, Richmond S, et al. European
resuscitation council guidelines 2000 for newly born life
support. A statement from the Paediatric Life Support
Working Group and approved by the Executive Committee
of the European Resuscitation Council. Resuscitation 2001
Mar;48:235e9.
16. Guidelines relating to the birth of extremely immature
babies (22e26 weeks gestation). Thames Regional Perinatal
Group; March 2000.
17. Finer NN, Rich WD. Neonatal resuscitation: raising the bar.
Curr Opin Pediatr 2004 Apr;16(2):157e62.
18. National Collaborating Centre for Women’s and Children’s
Health. Clinical guideline e caesarian section p51. National
Institute for Clinical Excellence; April 2004.
19. Madar J, Richmond S, Hey E. Surfactant-deficient respira-
tory distress after elective delivery at ‘term’. Acta Paediatr
1999 Nov;88(11):1244e8.
20. Saugstad OD, Ramji S, Irani SF, et al. Resuscitation of
newborn infants with 21% or 100% oxygen. Follow-up at
18e24 months. Pediatrics 2003 Aug;112(2):296e300.
21. Vohra S, Frent G, Campbell V, Abbott M, Whyte R. Effect of
polyethylene occlusive skin wrapping on heat loss in very
low birth weight infants at delivery. A randomised trial.
J Pediatr 1999;134:547e51.
22. Thoresen M. Cooling the newborn after asphyxia e
physiological and experimental background and its clinical
use. Semin Neonatol 2000 Feb;5(1):61e73.
23. Owen CJ, Wyllie JP. Determination of heart rate in the baby
at birth. Resuscitation 2004 Feb;60(2):213e7.
24. Gandini D, Brimacombe JR. Neonatal resuscitation with the
laryngeal mask airway in normal and low birth weight
infants. Anaesth Analg 1999;89:642e3.
25. Kopotic RJ, Lindner W. Assessing high risk infants in the
delivery room with pulse oximetry. Anesth Analg 2002 Jan;
94(1 Suppl.):S31e6.
26. Sahni R, Gupta A, Ohira-Kist K, Rosen TS. Motion resistant
pulse oximetry in neonates. Arch Dis Child Fetal Neonatal
Ed 2003 Nov;88(6):F505e8.
27. Repetto JE, Donohue PA-CPK, Baker SF, Kelly L, Nogee LM.
Use of capnography in the delivery room for assessment of
endotracheal tube placement. J Perinatol 2001 JuleAug;
21(5):284e7.
28. Ryan CA, Clark LM, Malone A, Ahmed S. The effect of
a structured neonatal resuscitation program on delivery
room practice. Neonatal Netw 1999 Feb;18(1):25e30.
29. Finer NN, Rich W. Neonatal resuscitation: toward improved
performance. Resuscitation 2002 Apr;53(1):47e51.
30. Cooper S, Wakeham A. Leadership of resuscitation teams:
‘‘lighthouse leadership’’. Resuscitation 1999 Sep;42(1):
27e45.
31. Deorari AK, Paul VK, Singh M, et al. Impact of education &
training on neonatal resuscitation in 14 teaching hospitals in
India. Ann Trop Paediatr 2001 Mar;21(1):29e33.
32. Mitchell A, Niday P, Boulton J, Chance G, Dulberg C.
A prospective clinical audit of neonatal resuscitation
practice in Canada. Adv Neonatal Care 2002 Dec;2(6):
316e26.
33. Carapiet D, Fraser J, Wade A, Buss PW, Bingham R. Changes
in paediatric resuscitation knowledge among doctors. Arch
Dis Child 2001;84:412e4.
34. Jabbour M, Osmond MH, Klassen TP. Life support courses:
are they effective? Ann Emerg Med 1996;28(6):690e8.
35. Wyllie JP. Personal communication.
36. Singhal N, McMillan DD, Yee WH, Akierman AR, Yee YJ.
Evaluation of the effectiveness of the standardised neo-
natal resuscitation program. J Perinatol 2001 Sep;21(6):
388e92.
J. Madar
37. Scherer LA, Chang MC, Meredith JW, Battistella FD.
Videotape review leads to rapid and sustained learning.
Am J Surg 2003 Jun;185(6):516e20.
38. Carbine DN, Finer NN, Knodel E, Rich W. Video recording as
a means of evaluating neonatal resuscitation. Pediatrics
2000 Oct;106(4):654e8.
39. Sentinel events: approaches to error reduction and pre-
vention. Jt Comm Qual Improv 1998 Apr;24(4):175e86.
40. Costeloe K, Hennessy E, Gibson A, Marlow N, Wilkinson AR.
The EPICure study: outcomes to discharge from hospital for
infants born at the threshold of viability. Pediatrics 2000;
106e671.
41. Breart G, Kaminski M, Dehan M, et al. Survival of very
preterm infants: EPIpage, a population based cohort study.
Arch Dis Child Fetal Neonatal Ed 2004;89:F139e44.
42. Cust AE, Darlow BA, Donoghue DA. Australian and New
Zealand neonatal network. outcomes for high risk New
Zealand newborn infants 1998e1999: a population based,
national study. Arch Dis Chid Fetal Neonatal Ed 2003 Jan;
88(1):F15e22.
43. Learning from Bristol: the report of the public inquiry into
children’s heart surgery at the Bristol Royal Infirmary
1984e1995. Bristol Royal Infirmary Enquiry 2001, !www.
bristol-inquiry.org.ukO.
44. Brinchmann BS, Forde R, Nortvedt P. What matters to the
parents? A qualitative study of parents’ experiences with
life and death decisions concerning their premature infants.
Nurs Ethics 2002 Jul;9(4):388e404.
45. Cummins RO, Cochair DC, Cochair MFH, Nadkarni V, et al.
Recommended guidelines for reviewing. reporting and
conduncting research on in-hospital resuscitation; the in
hospital ‘Utstein style’. A statement for healthcare pro-
fessionals from the AHA, ERC, HSFC, ARC, RCSA. Circulation
1997;95:2213e39.
46. King TA, Jackson GL, Josey AS, et al. The effect of profound
umbilical artery academia in term neonates admitted to
a newborn nursery. J Pediatr 1998;132:624e9.
47. Van de Berg PP, Nelen WLDM, Jongsma HW, Nijland R, et al.
Neonatal complications in newborns with an umbilical
artery pH ! 7.00. Am J Obstet Gynecol 1996;175:1152e7.
48. Victory R, Penava D, da Silva O, et al. Umbilical cord pH and
base excess values in relation to neonatal morbidity for
infants delivered preterm. Am J Obstet Gynecol 2003;189:
803e7.
49. Sedhev HM, Stamilio DM, Macones GA, Graham E, et al.
Predictive factors for neonatal morbidity in neonates with
an umbilical arterial cord pH less than 7.00. Am J Obstet
Gynecol 1997;177(5):1030e4.
50. Casey BM, Goldaber KG, McIntire DD, Leveno KJ. Outcomes
among term infants when two-hour postnatal pH is
compared with pH at delivery. Am J Obstet Gynecol 2001;
184:447e50.
51. Nagel HTC, Vandenbussche FPHA, Oepkes D, et al. Follow-
up of children born with an umbilical arterial blood pH ! 7.
Am J Obstet Gynecol 1995;173(6):1758e64.
52. Belai Y, Goodwin TM, Durand M, et al. Umbilical arteriove-
nous pO2 and pCO2 differences and neonatal morbidity in
term infants with severe acidosis. Am J Obstet Gynecol
1998;178:13e9.
53. Waugh J, Johnson A, Farkas A. Analysis of cord blood gas at
delivery: questionnaire study of practice in the United
Kingdom. BMJ 2001;323:727.
54. Recommendations arising from the 26th RCOG study group.
In: Spencer JAD, Ward RHT, editors. Intrapartum fetal
surveillance. London: RCOG press; 1993.
55. The use of Electronic Fetal monitoring. Evidence based
clinical guideline number 8. RCOG; May 2001.
Clinical risk management in newborn and neonatal resuscitation
56. Morley GM. Cerebral palsy and cord blood gases. eBMJ May
2002 letters e response to Waugh J et al. (53).
57. Hermansen MC. The acidosis paradox: asphyxial brain injury
without coincident academia. Dev Med Child Neurol 2003;
45:353e6.
58. Andres RL, Saade G, Gilstrap LC, Wilkins I, et al. Association
between umbilical blood gas parameters and neonatal
morbidity and death in neonates with pathological fetal
academia. Am J Obstet Gynecol 1999;181:867e71.
59. Ross MG, Gala RG. Use of umbilical artery base excess:
algorithm for the timing of hypoxic injury. Am J Obstet
Gynecol 2002;187:1e9.
60. Westgren M, Divon M, Horal M, et al. Routine measurement of
umbilical artery lactate levels in the prediction of perinatal
outcome. Am J Obstet Gynecol 1995;173(5):122e46.
61
61. Westgate J, Garibaldi J, Greene K. Umbilical cord blood
analysis at delivery: a time for quality data. Br J Obstet
Gynecol 1994;101:1054.
62. Low JA, Panagiuotopoulos C, Derrick EJ. Newborn compli-
cations after intrapartum asphyxia with metabolic acidosis
in the preterm fetus. Am J Obstet Gynecol 1995;172:
805e10.
63. Perlman S, Goldman RD, Maatuk H, Ron E, Shinwell E,
Blickstein I. Is the sampling site along the umbilical
artery significant? Gynecol Obstet Invest 2002;54:
172e5.
64. Royal College of Obstetricians and Gynaecologists, Royal
College of Midwives. Towards safer childbirth. Minimum
standards for the organisation of labour wards. Report of
a joint working party. London: RCOG press; 1999. p. 22.