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Preventing ROP in the first golden hour after birth

High quality clinical care during the golden hour after brith can reduce the risk of ROP developing in preterm infants.
The concept of the golden hour comes from the field of trauma where the quality of care provided in the first 60 minutes after major injury is crucial for survival.
In neonatology, the golden hour is the first 60 minutes of a preterm baby’s life. Providing quality care for babies during this time is important for survival and reducing the risk of complications, such as ROP.
There are four stages of essential tasks and decisions that need to be undertaken for a preterm baby
in the brief period of the golden hour: Preparation before birth, Care at delivery, Managing transport of the baby, and, Care in the neonatal unit
The neonatal team needs to carefully manage and coordinate care across each stage.
Preparations for the golden hour start before birth and begin with counselling sessions with the parents to make decisions - based on local guidelines - about the resuscitation and care of the premature baby. Counselling enables clinicians to gauge parents’ expectations and provide them with information on the possible outcomes. Ideally, the obstetric and neonatal teams counsel the pregnant mother or parents together to provide consistent information on possible outcomes for the unborn baby.
“Just turn the oxygen on…” “Check our pressures….” The equipment and staff required to care for the baby should be available and ready for use in the delivery room and the neonatal intensive care unit (or NICU) before the birth takes place. Preparing equipment in the delivery room involves plugging in the resuscitator and turning on the overhead heater to full. Here we have our resuscitation trolley which we take to every resus’ on the delivery suite. And Laura is currently preparing for an intubation so preparing an ET tube. The top drawer usually has the airway equipment in, which includes endocardial tubes, an introducer. It also contains the hats that we require to secure the tube.
We use a needle to secure the tube and an ET holder so it’s really important to have laryngoscope blades of different sizes and at least two handles in case of battery failure or spare batteries in the top drawer. We also have a variety of face masks of different sizes for different sized babies, which will be available. The other drawers, we have a draw for vascular support so vascular access if you need an emergency umbilical line or cannulae. We also have a draw for chest drains and other emergencies and emergency drugs which would also be in this trolley The transport incubator should be checked, pre-warmed and have full oxygen cylinders
Care at delivery. At least two people skilled in providing care for preterm babies should be present at the birth. One pair of hands is not enough to perform all the procedures required at the beginning of the golden hour.
Immediately after delivery, the team: Makes sure the baby is kept warm. And delays clamping and cutting of the cord for 30-60 seconds if the baby is breathing. A meta-analysis of data from multiple studies has reported that delaying clamping the cord in preterm births is associated with decreased mortality and decreased need for blood transfusions.
Once the cord is cut, the team without drying the baby: takes them to the resuscitaire, places them into a plastic bag, under a radiant warmer, and covers their head with a cap. These measures have been shown to prevent loss of heat from the baby.
Preventing hypothermia in the baby is known to be important in reducing mortality especially in low birth weight babies. Evidence indicates that each decrease of 1 degree centigrade in the baby’s axillary temperature (which is recorded in the armpit) increases the odds of mortality by 28%. Guidelines recommend that the baby’s temperature is maintained at between 36.5 and 37.5 degrees centigrade.
Supporting the baby’s respiratory system is another important part of golden hour management.
The attending neonatology team: Assesses the baby’s colour, tone, heart rate and breathing. At the same time, attaches the pulse oximeter probe to the baby’s right hand. And provides respiratory support according to neonatal life support guidelines.
It is important to provide the minimal amount of respiratory support: When respiratory support is provided, a 30% oxygen mix, or air, should be used, rather than pure oxygen.
The aim is: To raise the baby’s heart above 100 beats per minute. And to slowly increase their blood oxygen saturation level to between 90% and 94%. This is because in the womb, the foetus has a low blood oxygen saturation, which, after birth, increases slowly over the first 5-10 minutes of life. The WHO guideline recommends that the blood oxygen saturation levels of preterm babies in their first minutes of life should be slowly increased from 55 to 75% saturation in the first 2 minutes and to 85 to 95% by 10 minutes.
The team: Gives surfactant a substance to improve lung function in preterm babies who can develop respiratory distress syndrome. Continuously measures and adjusts the balance of the oxygen concentration given to the baby according to need. And manages any airway obstruction. Once the baby is stabilised, the team transfers the baby into the transport incubator and shows the baby to the parents before transfer. The baby is then transferred to the hospital NICU. If the baby is to be transferred to another centre, additional precautions to keep the baby warm and prevent hypothermia must be put in place, alongside the respiratory and circulatory support. At all times, it is important to take aseptic precautions to reduce the risk of infection.
In the neonatal unit (or NICU) similar attention is paid to setting up the incubator, respiratory support and clinical monitoring equipment.
The team records the baby’s vital measurements throughout the golden hour, in the delivery room and the NICU.
The measurements recorded are: heart and respiratory rate, temperature, oxygen saturation, invasive or non-invasive blood pressure, fluid input and output and blood sugar monitoring.
It is also important that the team communicates with the parents throughout the golden hour. This may include taking photographs for the parents once the baby is stabilised.
In the NICU the team carries out a number of key care tasks.
They:Record the baby’s weight and temperature, Insert a nasogastric tube to provide nutritional support - Give vitamin K to decrease the risk of haemorrhage - Continue to monitor and manage the baby’s blood oxygen saturation level between 90% and 94%, Take a blood sample, Start intravenous fluids and give antibiotics, Insert an umbilical vessel catheter if required, - And perform a chest x-ray, and, if an umbilical vessel catheter has been inserted, an abdominal x-ray as well.
The goal is to achieve all the key care tasks within the first hour of the baby’s life. After these are completed, the team LEAVES THE BABY ALONE. One of the most important principles of neonatal care is minimal handling. The clinical care given to preterm babies during the golden hour requires adequate provision of human and technical resources. In middle- and low-income settings, these resources may not all be available. Nevertheless, many golden hour interventions can still be carried out in resource-limited settings.
For example: Delayed clamping of the umbilical cord. Use of a plastic bag and hat to keep the newborn baby warm. And monitoring vital signs.
Managing respiratory support in resource-limited settings: If piped air/oxygen and blenders are not available, use air to provide initial respiratory support. If piped air and oxygen are available but blenders are not, feed both into a Y shaped tube and adjust the flow rate to provide the desired amount of oxygen to the baby.
If modern continuous positive airway pressure (CPAP) flow drivers are unavailable, a bubble CPAP can be developed locally and used instead.
In summary: Good clinical care in the golden hour after birth improves outcomes for preterm babies, including reducing the risk of ROP. A trained team works closely together to make decisions on, and carry out, a wide range of key care tasks for the baby. They stabilise the baby in the delivery room before transfer to the NICU where further care tasks are carried out before the baby is left alone. Keeping parents involved throughout is essential – before birth, after stabilising the baby, during transfer, and, in the NICU. To maintain quality it’s important that the team follows evidence-based guidelines on golden hour interventions.

Golden hour clinical care for the preterm infant describes what should be achieved within the child’s first hour of life. Provision of good quality clinical care during the golden hour has many benefits for the newborn including a reduction in the risk of ROP.

In the video on this step, we show you how a clinical team prepares for the birth of a preterm baby and provides care in the first hour of life. The video includes footage of a team at Homerton University Hospital, United Kingdom, demonstrating good care practice at delivery.

High-quality neonatal care reduces the risk of ROP

Neonatal care during the first hours and weeks of life determines a preterm baby’s chances of avoiding retinopathy of prematurity (ROP) and its complications. Oxygen management and low-cost interventions make all the difference.

The number of new cases (the incidence) of ROP varies considerably between different neonatal intensive care units (NICU), even those with similar levels of equipment and clinical staff. Whilst there may be several reasons behind this, one reason we can be certain about is different practices in newborn care. Routinely implementing standard interventions that are known to prevent ROP will improve outcomes and reduce the incidence of ROP.

Improving outcomes of neonatal care

In high-income countries, changes to the organisation of newborn care have improved survival rates for preterm babies and reduced the risk of adverse outcomes, including severe ROP. These changes include:

  • Developing perinatal centres that provide care for high-risk pregnancies and the sickest preterm babies, and
  • Developing dedicated transport systems when babies are being transported to, or between, neonatal units.

Providing high-quality neonatal care requires teamwork between different health professionals (doctors, nurses and allied health workers) and working closely with parents and health authorities.

All neonatal units should have agreed protocols for important aspects of newborn care. These protocols should be based on the best available evidence consisting of high-quality clinical trials and systematic reviews. Good data collection methods (local, demographic and clinical) are required to monitor trends in clinical activity, document outcomes, monitor trends and compare outcomes with similar neonatal units. Sharing information and best practices is easier if several units work together and establish formal clinical networks.

Consider what you know about care practices for newborn preterm babies in your setting and the protocols that are followed. Are there gaps that can be addressed and practices that should be improved? Share your thoughts and experiences in the Comments.

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Retinopathy of Prematurity: Practical Approaches to Prevent Blindness

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