1. The OB Perspective of NRP JESSICA ILLUZZI, MD, MS, FACOG

2. Objectives  Consider the historical aspects of neonatal resuscitation practices at the perineum  Review how current NRP guidelines and recommendations may affect the maneuvers of delivering the newborn, including delayed cord clamping and meconium  Discuss the importance of communication with the obstetric, midwifery, and nursing providers regarding the newborn before, during and immediately after delivery  Consider challenges in updating practices of delivering providers

3. Historical Aspects of Caring for the Neonate in the Birth Setting  Location of birth  Home to hospital setting

4. Historical Aspects of Caring for the Neonate in the Birth Setting  Providers  Traditional birth attendants; community, apprenticed midwives  Family/general practitioner  Obstetrician, family medicine, maternal-fetal medicine; and certified nurse midwives  Labor nurses and postpartum nurses; neonatal nurses  Trained neonatal practitioners and neonatologists

5. Historical Aspects of Caring for the Neonate in the Hospital Setting, mid 20 th century Obstetric Practices  Enemas, perineal shaving and iodine preps  Maternal sedation and restraints  Separate labor and delivery room  No fathers or support people  Forceps and episiotomies very common Neonatal resuscitation practices  Wide variation across hospitals  Tactile maneuvers (rubbing, slapping, pinching)  The Schultze method  Bloxsom pressure chambers  Oxygen delivery and tracheal catheterization  Self inflating bag and air way opening maneuvers  Routine separation of newborn for transition

6. Historical Aspects of Caring for the Neonate in the Birth Setting 1980’s 1987 Neonatal Resuscitation Program Increasing use of electronic fetal monitoring and fetal scalp electrodes DeLee suctioning for meconium Immediate cord clamping and cutting All infants to neonatal resuscitation bay PPV with 100% oxygen Deep suctioning for meconium 1990’s Scalp pH gases to guide labor management Widespread electronic fetal monitoring DeLee suctioning for meconium Immediate cord clamping and cutting Most infants to neonatal resuscitation bay Vaginal breeches Amnioinfusions for meconium 2000’s Scalp pH no longer performed Declining episiotomy rates End of DeLee suctioning Delayed cord clamping More infants immediate skin to skin PPV with 21% oxygen Increasing cesarean delivery rates Declining forceps and vacuum rates Singleton breeches by cesarean

7. Training of OB/GYNs in these eras 1980’s No formal training requirement in neonatal resuscitation with neonatalogy Experiential skills and practices at site of training based on current practices 1990’s Formal training requirements for graduation in all OB/GYN residencies Minimum of 10 neonatal intubations Often designated rotations with NICU and neonatal resuscitation teams (ranging from 2 weeks to 3 months) 2000’s No further requirement for neonatal intubations NICU rotations were ended in most OB/GYN residency programs NRP training often relegated to NRP textbook review and one simulation-based session/course Most academic institutions have neonatal resuscitation team, so OB/GYN resident is not engaged in actual resuscitations

8. OB/GYN Residency Training

10. Training of OB/GYNs in these eras: Potential Implications  Decrease in awareness of how to treat the depressed neonate  Decrease in understanding of the physiology of the first minute of life; primary and secondary apnea and relation to intrapartum events  Palpable decrease in collaboration between obstetrics and neonatology and the impact on continuity of care of the maternal- fetal-neonatal triad  Other effects?  The certified nurse midwifery training comparison: NRP training and minimum of 20 neonatal assessments including competency to provide primary care for well newborns from birth until 28 days of life

11. Case example  A 27 G2P1 at 38w GA presented in labor at 6cm dilation at 10am. She is GBS negative. She experiences spontaneous rupture of membranes at 12pm and is noted to have meconium stained fluid and is 8cm dilated. The fetal heart rate tracing is category II with good variability and intermittent variable decelerations.  At 2pm, she is fully dilated and begins pushing. At 2:45pm, the head emerges. The obstetrician wonders whether she should use the bulb suction to clear the airway. The neonatal PA is at the warmer preparing for assessment and resuscitation.  The body then delivers and the obstetrician cradles the infant. The infant is noted to have good tone and reflex irritability, but no immediate spontaneous cry.

12. What would your OB or CNM do?

13.  Clamp the cord immediately and pass the infant to the neonatal practitioner at the warmer?  Keep the infant cradled, and use the bulb suction like she has the habit of doing?  Place the infant on the mother’s abdomen for drying and stimulation by the RN?  Delay cord clamping?  Something else?

14. Obstetric implications of new NRP recommendations over time MECONIUM (thick or thin)  No DeLee suctioning for meconium  Bulb suction when head is on the perineum?  Suction with bulb if the infant is not depressed?  Delay cord clamping?  Skin to skin, dry and stim OR radiant warmer for neonatal practitioner assessment?  No suction or stimulation if the infant is depressed?  Current practice: Immediate cord clamping and pass off infant quickly  Implications of NRP changes?

15. Obstetric implications of new NRP recommendations DELAYED UMBILICAL CORD CLAMPING  Preterm infants (ACOG endorsed)  Vaginal deliveries  Cesareans  Full term infants (ACOG equivocal)  For vaginal deliveries, increasing prevalence, often patient driven  Cesarean deliveries still unusual  Initially depressed infants?? (Studies ongoing)  Beginning conversations about initial neonatal resuscitation with umbilical cord intact (dry, stim, position airway, assess heart rate)  Would be a ‘new’ concept for obstetrics (providers trained in NRP and who had NICU rotations may have more comfort than newer providers without strong NRP experience)

16. Assets and challenges moving forward  Strong relationships between AAP, ACOG, ACNM, AWHONN, NANN, AARC, and AABC  Liaisons on Committee on Fetus and Newborn, Obstetric Practice Committee, NRP Committee, etc.  Co-endorsement of statements based on current evidence setting standards in each organization  Planned education programs and activities to facilitate competency and change in practices when endorsed

17. Assets and challenges moving forward  Over 50,000 births per year occur out of the hospital setting  Accredited and non-accredited birth centers or home births  Typically attended by:  Certified nurse midwives  Certified professional midwives  Non-certified midwives  Accredited birth centers are required to have licensed, certified midwives and 2 NRP trained providers at each birth as well as neonatal resuscitation equipment and supplies