Nancy A. Garofalo, PhD APN, NNP, Matthew Pellerite, MD, Michael Goodstein, MD, David A. Paul, MD. Joseph R. Hageman, MD

Introduction

A single potentially preventable episode of Sudden Unexpected Postnatal Collapse (SUPC) and a recently publicized lawsuit in Oregon (1) generated a lot of attention about optimal and safe early skin-to-skin contact and breastfeeding after delivery of a newborn infant in hospitals everywhere (2). SUPC has been defined as a presumably healthy infant born at greater than 35 weeks of gestation age, with a 10-minute Apgar score of greater than 7, who without warning has an event resulting in temporary or permanent cessation of breathing or cardiorespiratory failure within the first postnatal week of life (3). Garofalo and colleagues modified a definition of SUPC, by Becher et al. (4), which is sum- marized in Table 1. (1)

Approximately one-third of SUPC episodes occur in the first 2 hours after birth, one third occur between 2 and 24 hours after birth, and one third occur between 1 and 7 days after birth (3). The majority of these cases can be potentially preventable. In a recentpaper, about 53% of the SUPC cases were felt to be secondary to airway obstruction. (4)

Quality Improvement (QI) Initiatives

Here we will summarize some of the QI and educational initiatives to reduce the incidence of SUPC and near-miss SUPC. An initiative by Pearlman, Igboechi, and Paul in the Christiana Healthcare System, which was presented at the 2018 Vermont Oxford Network annual meeting, is described:

During the pre-intervention period, the clinical practice guideline for infants born vaginally recommended initiation of skin-to-skin care after an assessment by the labor and delivery nursing staff of muscle tone and breathing in infants ≥ 37 weeks. The guideline deferred initiation of skin-to-skin care for infants who were 36 weeks until a brief assessment by a pediatric provider was completed to ensure no additional supportive care was necessary. We also deferred placing the baby on the mother’s chest if mothers were receiving magnesium sulfate, felt to be overly sedated, or demonstrated or verbalized signs of fatigue. Infants placed skin-to-skin were positioned, so the infant’s face was visible, nose and mouth were not covered, the head was in the sniffing position and turned to one side, neck and shoulders were straight, and the back was covered with a blanket. An apical heart rate, respiratory rate, and temperature were obtained before starting skin-to-skin care. Infants were monitored visually by the labor and delivery nursing staff. The nursing staff was asked to remain in the room with the mother and baby during skin-to-skin care. Mothers were encouraged to provide skin-to-skin care for a minimum of one hour but could opt to continue until being transferred out of labor and delivery. Breastfeeding was recommended during the first hour and, for mothers not planning to breastfeed, formula feeding within the first two hours after birth. For infants born by Cesarean section, skin-to-skin care was initiated once the mother’s condition allowed.

In response to two cases of SUPC in May 2015 despite the use of the above guideline, a bundled intervention was developed to pre-vent SUPC. A multidisciplinary team, including neonatology staff, labor and delivery nursing, physician and nursing leadership and representatives from the hospital Quality and Safety Department, developed the intervention. The final intervention implemented was additionally informed by a systematic review of the medical literature and communication with other large delivery centers. Post-intervention, the criteria for initiating skin-to-skin care did not change. Positioning during skin-to-skin care also was done the same way as in the pre-intervention period. In addition to the previous measures, the bundled intervention included: 1) monitoring oxygen saturation by pulse oximetry starting at 10 minutes of age and 2) The “RAPP” (respiratory activity, perfusion, and position) skin-to-skin assessment tool (5,6,) (Table 2). The oxygen saturation level was monitored by placing a Masimo pulse oximeter probe (TM, Irvine, CA) on the baby’s right hand. Oxygen saturation along with other vital signs were monitored by the labor and delivery nurse and recorded every 15 minutes for the first hour after delivery and every 30 minutes subsequently for the duration of skin-to-skin care. The pulse oximeter was set to alarm for any saturation < 90%. RAPP (Respiratory effort, Activity, Perfusion, and Position) was used and scoring began immediately after an infant was placed skin-to-skin by the labor and delivery room nurse. Any score < 2 in the “position field” required RN action/ intervention. Mothers could opt out of skin-to-skin care at their discretion in both periods. Monitoring by pulse oximetry and RAPP scoring continued until the completion of skin-to-skin care during mother and infant’s stay on Labor and Delivery.

TABLE 2 ■ RAPPT Infant Scoring System

Sign	0	1	2
Respiratory	Apneic	Grunting/flaring/ retractirg/tachypneic	No distress easy regular breathing
Activity	No response	Whimpering, crying, and/or active motion of extremities	Quiet alert, sleeping, or breastfeeding. Arms and legs at rest.
Position	Nares and/or mouth are fully occluded or not visible; and/or neck fully extended ,or flexed, face into chest or breast	Nares or mouth partially occluded or partially visible; and/or neck partially extended or flexed, partial head turn	Nares and mouth uncovered and visible; neck midline, hands up by neck, head turned to side
Perfusion	Pale, dusky	Acrocyanosis	Visible parts pink
Muscle tone	Flaccid, no flextion of extremities	Extremities fully flexed or vigorous motion	Extremities fully flexed and/or slow, deliberate movement
No recoil

The intervention included more objective components to identify at-risk infants using both a visual (RAPP) and auditory alarm for the labor and delivery nursing staff (pulse oximeter). The use of the pulse oximeter allowed the baby to be continuously monitored while the nursing staff completed other critical tasks including charting and clinical care of the mother. The use of the RAPP assessment tool further mitigated the risks of under monitoring by standardizing vital sign measurements along with an evaluation of babies’ positioning and perfusion, rather than just relying on less structured visual monitoring as was done pre-intervention.

Other healthcare facilities have also developed specific approaches to more intense monitoring of infants in the first two hours following delivery. For example, Goodstein and colleagues devised a selective approach to close monitoring and wellness checks forinfants during the first 2 hours following delivery based on their York Hospital Skin to Skin Risk Assessment (Goodstein, personal communication 2019).

Garofalo and coauthors have created a SUPC educational module that is now a part of the orientation of all clinical providers who work in labor and delivery as well as in postpartum. They have used the term “pink and positioned” to summarize these concepts for the parents of the newborn when they have their baby skin-to-skin: Airway- the mother can see that the baby’s nose and mouth are unobstructed. Breathing- a parent can see the rise of baby’s chest. Color- a parent can see that the lips and tongue are pink and the baby does not look blue/dusky. This module is outlined in a recent paper in Neonatology Today (7).

Davanzo and colleagues have also outlined a detailed initiative to prevent SUPC, while making skin-to-skin contact and breastfeeding safer, especially during the first 2 hours of postnatal life in the care of maternal-infant dyads in Italy (8). Their initiative includes (1) a checklist for newborn infants during the first 2 hours of postnatal life, and (2) advice to mothers and healthcare professionals aimed at the prevention of SUPC during and after the first 2 hours of postnatal life. (8).

Prevention and Outcomes

Based on the international and limited U.S. literature, it is clear that not all SUPC episodes are potentially preventable (2). It is also true that the range of incidence figures for SUPC that have been reported in the literature supports the point made by many clinicians that SUPC is a “rare” event (2-11). However, I think all of us would agree that a single SUPC event, if felt to be potentiallypreventable, is, as we state in the title of this article, one newborn infant death too many. As we more closely examine SUPC, we also find that there are events or episodes that are referred to as “near misses” (2-11). However, up to 50% of SUPC survivors have residual neurodevelopmental impairment (4).

We have designed several initiatives based on this hypothesis: A percentage of SUPC events may be preventable by implement- ing a safety monitoring bundle for all newborn infants. The efficacy and generalizability of each approach need to be determined through further implementation and evaluation. Some portion of SUPC may be effectively prevented by frequent assessment post-delivery of the mother/infant dyad, and educating staff and parents to ensure that the infant is “pink and positioned” during “distraction-free” breastfeeding and skin-to-skin contact, as recommended by the AAP (12). We will present and discuss these initiatives in detail in Part 2 of our paper.

References:

1. Abrams A. This Mother Is Suing a Hospital for Millions After SheAccidentally Killed Her Son. Published at Time.com. Aug 10, 2017. Available from http://time.com/4896278/oregon-mother-sues-hospital-suffocated-son/
2. Rodriguez N, Pellerite M, Hughes P, Wild B, Joseph M, Hageman JR. An acute event in a newborn. Video Corner. NeoReviews 2018;18(12):e717-e720.
3. Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: A review of cases, definitions, risks, and pre- ventive measures. Transl Stroke Res. 2013 April; 4(2): 236–247. Epub 2013 Feb 23.
4. Becher JC, Bhushan, SS, Lyon AJ. Unexpected collapse inapparently healthy newborns-a prospective national study of a missing cohort of neonatal deaths and near-death events, Arch Dis Child Fetal Neonatal Ed. 2012; 97: F30-4.
5. Pearlman SA, Igboechi E, Paul DA. A bundled intervention including pulse oximetry prevents sudden unexpected postnatal collapse (SUPC). Vermont Oxford Network, 2017.
6. Ludington-Hoe SM, Morrison-Wilford BL, DiMarco MD, Lotas M. Promoting newborn safety using the RAPPT assessment and considering Apgar criteria: A Quality Improvement project. Neonatal Network 2018; 37(2):85-95.
7. Garofalo N, Pellerite M, Newkirk A, Noto J, Filler LE, Smith MM, Hageman JR. An Innovative Educational Program for the Prevention of Sudden Unexpected Postnatal Collapse (SUPC) of Newborns. Neonatology Today 2018;13 (11):1.
8. Davanzo R, De Cunto, A, Paviotti, G et al., Making the First Days of Life Safer: Preventing Sudden Unexpected Postnatal Collapse while Promoting Breastfeeding. Journal of Human Lactation 2015, Vol. 31(1) 47–52
9. Lutz TL, Elliot EJ, Jeffrey HE. Sudden unexplained early neonatal death or collapse: A national surveillance study. Pediatr Res 2016;80:493-498.
10. Thach BF. Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards. J Perinatol 2013; 34:275- 79.
11. Bass JT, Gartley T, Lyczkowski DA, Kleinman R. Trends in the incidence of sudden unexpected infant death of the newborn. J Pediatr 2018;196:104-8.
12. Feldman-Winter L, Goldsmith JP, Committee On F, Newborn, Task Force On Sudden Infant Death S. Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Pediatrics 2016;138.

Disclosure: The authors have no disclosures.