CHOP Researchers Designing a ‘Delivery Room of the Future’ to Resuscitate High-Risk Newborns

The Delivery Room of the Future Frontier program will characterize the unique physiology of infants with specific anomalies at birth to inform newborn resuscitation guidelines.

researchcomm [at] chop.edu (By Lauren Ingeno)

Safe inside mom's womb, a fetus receives oxygen — not from its lungs, which are filled with fluid — but through the umbilical cord from the placenta. It isn't until birth that a baby takes its first, gasping breath.

For 90 percent of newborns, that breath will happen within the first 10 seconds of delivery, and oxygen saturation will reach healthy levels after 10 to 15 minutes. But sometimes, the baby fails to breathe on their own. Instead of pink-colored and crying, the newborn stays floppy, blue, and silent. For babies who are born extreme preterm or have congenital disorders, the number who will need resuscitation is far greater.

That's when Elizabeth E. Foglia, MD, MSCE, and her team jump quickly into action. Dr. Foglia is an attending neonatologist with the Division of Neonatology at Children's Hospital of Philadelphia.

National standards, called the Neonatal Resuscitation Program, provide more than 400,000 trained providers with one, unified approach to ensuring a newborn's survival at birth. The algorithm gives clinicians the most important steps to take to resuscitate an unresponsive baby based on physiological benchmarks such as oxygen levels, heart rate, and appearance.

However, those standards were developed based on data from healthy, full-term babies without congenital anomalies. The newborns Dr. Foglia sees in CHOP's Garbose Family Special Delivery Unit (SDU) have all been prenatally diagnosed in the Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment with birth defects.

"That presents an opportunity in the Special Delivery Unit. We have a one-size-fits-all neonatal resuscitation algorithm, and we have to adapt this in real-time to babies with inherent differences in their anatomy and physiology," Dr. Foglia said.

She and her colleagues want to more precisely know, for instance, at what point they would need to give oxygen to a baby with cyanotic heart disease, who they would expect to have low oxygen levels to begin with.

"We're making that decision based on our clinical judgment," Dr. Foglia said, "and now we will have the data to continue to improve."

As part of the 2022 CHOP Frontier Program she is leading, Dr. Foglia is seeking to inform the development of new, minute-by-minute resuscitation guidelines for newborns with congenital anomalies.

The Delivery Room of the Future will characterize the unique physiology of infants with specific anomalies at birth and compare that physiology to clinical outcomes. The Frontier Program team also will aim to optimize the medical team's performance during neonatal resuscitation, and it will develop a new digital tool to support clinicians in real-time.

Taking the Guesswork Out of Resuscitation

With the opening of the Special Delivery Unit in 2008, CHOP became uniquely positioned to not only identify this gap in neonatal resuscitation — but to solve for it. Dr. Foglia said that the field of resuscitation science is relatively new, and CHOP is one of the only hospitals in the country with such a large, unique population of newborns with anomalies to study.

"It was a volume issue. Individual hospitals never had enough babies with anomalies born in one place to study them systematically," Dr. Foglia said. "To me as a scientist, that's what makes my heart warm about the SDU. This setting provides such a rich opportunity to study these babies with more rigor, and start to contribute to the field."

In preliminary research, Dr. Foglia and colleagues have begun to study differences in vital signs between healthy, full-term babies who need resuscitation after birth with those who have congenital defects. In one study, published in the Journal of Perinatology in 2021, the research team plotted the oxygen levels of newborns with congenital heart disease after birth, comparing that physiology to nomograms that have been established for babies without anomalies.

"This gave a sense of how different oxygen levels were at every minute of life compared to newborns without heart disease, which then helps guide clinicians in making their clinical assessments and decisions during resuscitation," Dr. Foglia said.

Another study, published in 2022, was the first to characterize respiratory mechanics during lung aeration after birth among infants with congenital diaphragmatic hernia. Dr. Foglia and colleagues found that, in this population, respiratory function was heterogenous in the 15-minute period after birth.

As a next step in the project, the research team plans to compare physiology information with registry data about the newborns' clinical outcomes.

"We don't just want to know how well the baby is in the first hour after birth in the delivery room. I want to know about the relationship between the physiology immediately after birth and clinical outcomes in the NICU," she said. "Then, we can start to say, for example, 'Babies who meet these specific vital sign targets are more likely to have better clinical outcomes.'"

The researchers will plan to answer questions like, how long was their length of stay in the hospital, and what is the association between that and how high their oxygen levels were at certain time checkpoints after birth. Those answers will then become the target for therapeutic interventions and clinical trials.

"That is the overarching objective of this program," Dr. Foglia said. "How can we come up with the science that informs both our local providers — and also the global community — how best to care for babies with anomalies right after birth?"

Designing an Optimal Delivery Room

While gathering enough data to inform new resuscitation guidelines will be a long process, Dr. Foglia said that delivery room care teams can make more immediate changes to impact clinical outcomes.

To that end, Anne Ades, MD, MSEd, medical co-director of the Special Delivery Unit Neonatal Service, will lead the second aim of the Delivery Room Frontier Program: applying a Human Factors Science perspective to optimize provider performance during resuscitation.

As director of Neonatal Simulation and medical co-director of the Center for Simulation at CHOP, Dr. Ades will review cases and determine ways to standardize care during resuscitation, in order to eliminate variation and improve the delivery team's consistency and performance.

"The idea is to optimize the environment in this system to make sure that providers are performing at their peak," Dr. Foglia said. That includes thinking about factors like how many members of the medical team are in the room during resuscitation, where they should stand, and where equipment goes.

Finally, Natalie Rintoul, MD, an attending neonatologist at CHOP, will lead the third aim of the project: developing an innovative and integrated "digital coach" tool to support providers in real-time during the resuscitation of high-risk newborns.

This builds off of a prototype, called the "Critical Knowledge Platform," which Dr. Rintoul developed and employed in the Special Delivery Unit in 2018. The touch-screen platform provides a visual tool for clinicians to access key disease-specific information before the baby is born while preparing for resuscitation.

"These babies are complex, and the way the clinical team approaches their resuscitation varies from one infant to the next. So, the idea is to provide all of the information to the team, in real-time, to reduce the cognitive demand during resuscitation," Dr. Foglia said.

Still, the tool isn't perfect, Dr. Foglia says. Even though the information is available on a single platform, the touch screen is passive, meaning that providers need to know what they're looking for and flip through instructions to find it.

The digital coach, by contrast, will integrate with clinical devices, such as monitors and ventilators, to provide real-time, hands-free instructions to the clinical team, based on the new algorithms being developed for high-risk newborns.

All three arms of the project will contribute to an overarching aim: to optimize the experience for parents of high-risk newborns.

"We counsel them before the birth, but it's one thing to hear what's going to happen, and it's another thing to give birth and immediately have your baby be whisked away," Dr. Foglia said. "We're interested in determining how to both resuscitate a baby who is critically ill and needs intervention, while also supporting the parents and facilitating their opportunity to be present during for their child's first minutes after birth."