Stabilisation and resuscitation at birth continue to be universal medical practices and it is estimated that one quarter of neonatal deaths are caused by birth asphyxia.1

Different organisations, such as the International Liaison Committee on Resuscitation (ILCOR),2 the European Resuscitation Council,3 the American Heart Association4 and the Australian and New Zealand Resuscitation Councils5 have published recommendations for neonatal resuscitation on a regular basis. Since its inception, the Group on Neonatal Resuscitation of the SENeo (Grupo de Reanimación Neonatal de la SENeo [GRN-SENeo]) has disseminated these recommendations through a manual that is now on its third edition6 in addition to informative articles.7

While there is consensus between institutions, neonatal resuscitation practices vary across countries and even between hospitals within a single country.8–13

In 2009, the GRN-SENeo published a survey on neonatal resuscitation in delivery rooms that summarised the practices of the major Spanish hospitals in 2007.14 Following the publication of the 2010 recommendations2–4 and the third edition of the Spanish Manual de reanimación neonatal (Manual of neonatal resuscitation),7 the GRN-SENeo designed a new survey with the objective of assessing the evolution of resuscitation practices in Spain. This article presents and discusses the main results obtained from this assessment and compares them with the practices of other countries.

In the last trimester of 2012, we sent a questionnaire by electronic mail to the major hospitals that attend deliveries in Spain. The questionnaire consisted of 48 items that explored aspects related to resuscitation in the delivery room: hospital demographics, ethics, equipment and materials, staff availability and qualifications, resuscitation clinical practices and care after resuscitation (see Appendix B).

We performed a descriptive statistical analysis, expressing qualitative variables as absolute and relative frequencies. We have compared qualitative variables by means of the χ2 test. We considered P-values of 0.05 or less to be statistically significant. We show overall results for different aspects of resuscitation, comparing participating hospitals by level of care (Table 1).

This is the largest survey on neonatal resuscitation ever carried out in Spain, and the second published by the GRN-SENeo since its inception. In 2011 there were 470553 live births in Spain15; of which 347210 were attended at hospitals that participated in this survey, amounting to approximately 74% of the total births in that year. Compared to the previous survey,14 43 more hospitals participated in this one, representing 14% more of the total annual number of births. We have estimated that 4900 very low birth weight NBs receive care in the participating centres each year, a figure far exceeding the 2700 in the SEN 1500 morbidity and mortality report for year 2011.16 These figures demonstrate that the results of the survey are representative of health care practices in Spain.

The definition of the limits of viability in preterm NBs varies from country to country, and in Spain, the GRN-SENeo recommends initiating resuscitation in newborns at the threshold of 23 or 24 weeks of gestation (WG) on a case-to-case basis, taking into consideration the wishes of the parents and the morbidity and mortality rates of the particular hospital.6 According to our data, 78% of participating hospitals initiate reanimation at 23–24WG. This finding stands in contrast with data from other countries such as Japan or Germany, which have set thresholds at 22–23 WG.17,18

There is no consensus on when to discontinue resuscitation efforts when there is no detectable heart rate. Half of the participating hospitals discontinue at 10min from birth, with predominance of level III hospitals. Although the ILCOR2 considers that it is appropriate to discontinue resuscitation if there has been no detectable heart rate for 10min, and that more data are required to establish recommendations for cases of persistent bradycardia (HR<60bpm) 10–15min after birth, in actual clinical practice it may be difficult to determine when resuscitation should be discontinued. Follow-up studies in the age of therapeutic hypothermia challenge the validity of this stance, as one out of five NB with an Apgar score of 0/0/0 have no moderate or severe sequelae at ages 18–22 months19 and 6–7 years.20 One editorial has addressed this issue and concluded that we should use the data available for the age of hypothermia to reflect on the optimal moment for deciding whether to maintain or withdraw life support in NBs with very low Apgar scores. Some authors affirm that delaying this decision would allow a more accurate prognosis and enough time to explore the wishes of the parents.21

The Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics recommends that at least two members of the resuscitation team be physically present around the clock to provide care for at-risk NBs in the delivery room.22 In Spain, 94% of level III hospitals have at least two members available 24h a day, a percentage that has remained stable in the past five years7; team members are most frequently neonatologists in level III hospitals (94%) and general paediatricians in level I and II hospitals (93%). A survey conducted in the United States8 showed that 31% of resuscitation teams usually consisted of two members, so we find our data encouraging in this regard.

Multiple studies demonstrate the benefits of neonatal resuscitation programmes in the training of professionals that provide neonatal care at birth, in developed as well as developing and emerging countries.22–24 In addition to improving the knowledge, skills and efficiency of providers,24 such training can have a positive effect on various indicators (Apgar score, length of stay and neonatal mortality).22,23 In 2011, there were 5304 health professionals that had completed the Neonatal Reanimation courses accredited by the GRN-SENeo, and 392 active instructors.6 Data from this survey showed that the courses were offered in more than 90% of the hospitals or their service areas (97% for level III hospitals), while 84% of the participating hospitals had instructors accredited by the GRN-SENeo (94% of level III hospitals), figures that have experienced a sustained increase in recent years. These courses are based on simulation techniques and employ group dynamics, distraction, booster practice and integrated feedback, an approach proven to be highly effective.25

The equipment available in the delivery room is a good indicator of neonatal resuscitation practices. A Japanese survey26 found variability in the equipment available in different developed countries. In Spain, we found a greater availability of some equipment in level III hospitals (Table 2).

The 2010 recommendations stated that the use of CO2 detectors combined with clinical assessment is the most reliable method to confirm tracheal tube placement in neonates with cardiac output.2,4,27 One aspect deserving consideration and that could be improved in the future is the low availability of CO2 detectors in Spanish delivery rooms (7.7%), which is inferior to that of other countries, such as the United States (32%),8 Austria (36%),10 Japan (45%)26 or Canada (87%).13

Water births are an alternative to conventional delivery that is becoming increasingly popular in many countries.28 In Spain, 17.4% of hospitals have tubs available to attend labour and delivery in water, an availability that is greater in level I and II hospitals, a fact that would explain the hospitals’ choice to offer this modality. The literature has reported that at least 143 maternity units in the United States29 and 295 in the United Kingdom30 have tubs.

Therapeutic hypothermia is an accepted clinical practice in term and near-term NBs with moderate or severe HIE within 6h of birth.2–4 In Spain, passive hypothermia is initiated in the delivery room in 79.4% of hospitals (90.5% of level III hospitals), and the most frequent measure consists of switching off the radiant warmer once the NB is stable (80.6%).

Initiation of resuscitation with room air in term NBs is considered appropriate by the 2010 guidelines2–4 based on studies that demonstrated that the use of oxygen at high concentrations leads to less favourable outcomes and offers no benefits compared to the use of air.31–33 With the purpose of contributing to the rational use of oxygen, several algorithms2–6 use variations of normal pulse oximeter parameters,34 including SpO2 targets, during the first 10min of resuscitation.

Table 5 presents the clinical practices in the resuscitation of preterm NBs in different countries.10,11,13,35,36 Several measures are used to maintain body temperature in NBs less than 28 weeks of gestational age, including novel ones like the use of plastic wrap and an ambient temperature of at least 26°C in the delivery room.2,37 In Spanish hospitals, the use of radiant warmers and hats is nearly universal, while high room ambient temperatures (30%) and the use of polyethylene wrap could improve. In most countries, the use of plastic wrap ranges between 55% and 80%, although it is currently higher in the United Kingdom. The initial FiO2 for use in preterm NBs has not been established,2 and most countries, Spain included, use O2 concentrations of less than 50%. When it comes to ventilation in preterm NBs, there is variability in the devices used, with predominance of PIP and PEEP control (T-piece) and CPAP with the aim of avoiding tracheal intubation. There pressure limits used (PIP, PEEP and CPAP) are increasingly uniform. At present, sustained inflation is not a widespread practice.

When it comes to the transport of the NB from the delivery room to the NICU, the most commonly used ventilation systems were automatic resuscitators, and we have observed an increase in the use of CPAP and oxygen blenders in Spanish hospitals.

Table 6 compares the data on resuscitation equipment and practices of the latest survey on neonatal resuscitation in Spain7 and the current study. Between 2007 and 2012 there has been an increase in the availability of gas blenders and manual resuscitators (T-pieces) and in the use of pulse oximetry for the adjustment of FiO2, and a decrease in the administration of free-flow oxygen. We also found evidence of increased use of pressure-controlled devices in level III units and early CPAP to facilitate alveolar recruitment.

To conclude, we want to highlight the improvement in the neonatal resuscitation equipment and practices in Spanish delivery rooms. Some of the areas for improvement are minimising the differences between different-level hospitals, maintaining higher ambient temperatures, and increasing the use of plastic wrap, gas blenders, pulse oximetry and CO2 detectors. This survey may be useful for planning the equipment of delivery rooms and improving health care practices.

The authors have no conflicts of interest to declare.