How Pulse Oximetry Can Help You Overcome Delivery Room Challenges

Mandi Gross

In the first moments after birth, SpO₂ and heart rate monitoring are key to assessing an infant’s health and determining next steps. At its best, pulse oximetry may help you quickly make those decisions about when and how to intervene, augmenting your clinical observations. Such observations may be inaccurate on their own, without a confirming measurement. For instance, studies have shown that visually assessing an infant’s “pinkness” as a proxy for oxygenation is unreliable—in one study the SpO₂ readings at which observers perceived infants to be pink, varied from 10 to 100 percent.¹

A robust form of monitoring, pulse oximetry can generate fast, accurate readings while minimally interfering with your tasks in the minutes following birth. Yet common delivery room conditions can make it difficult to obtain reliable heart rate and SpO₂ readings, frustrating you as you attempt to make quick decisions. Inadequate technology, a neonate’s physiological state, and the delivery room environment itself can impact how well pulse oximeters perform. Therefore, pulse oximetry is most reliable – for your patient and for you — when the technology stands up to the real-world conditions that come with both routine and emergency neonate care.

Let’s look at some of the ways consistent, accurate, noninvasive monitoring can help you overcome five common challenges in Labor and Delivery.

Challenge 1: Delayed Readings, Delayed Decisions

In neonatal resuscitation, you have less than one “golden” minute to begin assessing an infant’s heart rate.² Heart rate is one of two key vital signs pointing to whether or not to initiate ventilation, noted by the Neonatal Resuscitation Program’s 2015 Guidelines as “the most important step” for successful resuscitation. As resuscitation progresses and you use supplemental oxygen or positive pressure ventilation, peripheral oxygenation readings tell you if these interventions are working. Monitoring at one-minute intervals determines whether infants are meeting preductal SpO₂target ranges.²

The faster a pulse oximeter posts, the faster it lets you make these decisions and be certain your interventions are working. When interventions such as supplemental oxygen are not terminated quickly enough in certain cases, they may lead to long-lasting complications such as chronic lung disease and retinopathy of prematurity.³

Solutions:

Pulse oximetry monitoring may be required within the first minute of life to guide neonatal resuscitation in the delivery room according to Neonatal Resuscitation Plan Guidelines.²
A Medtronic analysis of studies by Saraswat and O’Donnell has shown that Nellcor™ pulse oximetry monitors post heart rate and SpO₂ data up to six seconds faster than comparable pulse oximeters.^4,5

Related: Nellcor™ pulse oximeters post data faster when seconds count. Read more.

Challenge 2: Inaccurate Pulse Rates, Clinical Errors

Accurate pulse oximetry may guide care, helping you minimize the invasiveness or risk of interventions. For example, a heart rate of 100 bpm along with observed respiratory effort serves as the threshold for initiating and ceasing ventilatory interventions such as supplemental oxygen, positive pressure ventilation, or CPAP. Research shows that guiding care with pulse oximetry correlated to a lower share of newborns transferred to the nursery, 32 vs. 52 percent.¹

Conversely, research also shows a pulse oximeter that gives inaccurate readings even .89 percent of the time may prompt inappropriate interventions.⁶ For example, pulse rate monitoring plays an essential role identifying delivery room patients who require resuscitation within the first minute of life.²

Solutions:

When tested against a competitor, Nellcor™ pulse oximetry exhibited a pulse rate with an accuracy range of 8.6 beats per minute, with 3.4 percent of the readings differing significantly from a reference heartbeat. Competitor accuracy range was 25.2 bpm, with 27.6 percent of reading showing significant errors.⁷
A Medtronic analysis of studies by Saraswat and O’Donnell has shown that Nellcor™ pulse oximetry technology has also demonstrated readings that track reliably with ECG, maintaining accuracy in conditions where a competitor could not.^4,5

Related: Pulse rate performance varies significantly among pulse oximeters. Learn more.

Challenge 3: Newborn Motion, “Confused” Readings

A newborn’s motion causes irregular venous blood flow, impacting the ability to properly monitor pulsatile blood flow or even resulting in failed readings.⁸ This problem shows up more often in older pulse oximeters.⁷ However, equipment of any age lacking motion-tolerant technology may mistakenly read irregular blood flows as pulsatile and give erroneous heart rate readings.

Solutions:

Motion tolerance in new generation pulse oximeters enables superior accuracy.⁸ Trials in clinical and laboratory settings have demonstrated that Nellcor™ pulse oximetry provides accurate performance – at least 95% specificity – when motion artifact is present in neonates.⁹

The Nellcor™ pulse oximetry portfolio is also compliant with ISO 80601-2-61.

Related: Motion tolerant pulse oximeters can give more reliable readings. Read the data.

Challenge 4: Poor Perfusion, Poor Accuracy

Newborns often have poorly perfused extremities immediately after birth – with readings as low as 60 percent falling within the target range at the first minute, and an approximate “normal” reading (90 percent or higher) targeted only after ten minutes, according to Neonatal Resuscitation guidelines.² Because pulse oximetry depends on pulse readings to make calculations, low blood perfusion where the sensor is attached presents a challenge to accurate readings. Studies emphasize optimizing device settings by using high sensitivity settings, as well as placing the sensor correctly, as ways to obtain readings during low perfusion periods.⁸

Solutions:

Nellcor™ pulse oximeters are made for delivery rooms. They have been validated for use in poor perfusion conditions and cleared by FDA for use in newborns.
Meeting neonate-specific challenges, Nellcor™ pulse oximetry monitors are designed to overcome patient motion and poor perfusion and have been shown to be more reliable than a competitive pulse oximeter in challenging situations.⁶

Related: Nellcor™ pulse oximetry with OxiMax™ technology in low perfusion conditions. Learn more.

Challenge 5: Sensitive Skin, Unnecessary Injuries

Sometimes, monitors meant to ensure patient safety are attached with sensors that risk damaging newborns’ fragile skin.¹⁰ In fact, adhesives have been shown to be the primary cause of skin breakdown among neonate care activities.¹¹ In one study, pulse oximetry probes caused pressure injuries six percent of the time in preterm neonates.¹¹

Solutions:

Using soft, non-adhesive sensors makes continuous monitoring less invasive. Nellcor™ SpO₂ non-adhesive sensors help avoid the skin trauma adhesives or clamps can cause to neonates’ fragile skin.¹⁰
Sensors designed for fragile skin can still be highly accurate. Nellcor™ pulse oximetry sensors with OxiMax™ technology give accurate SpO₂ and heart rate readings via calibration directly inside the sensor, as opposed to the monitor.

Related: Non-adhesive sensors for neonatal skin integrity. Learn more.

References:

1. Dawson JA, Davis PG, O’Donnell CPF, et al. Pulse oximetry for monitoring infants in the delivery room: a review. Arch Dis Child Fetal Neonatal Ed. 2007; 92(1): F4–F7.
2. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. circulation. 2015;132(suppl 2):S543–S560.
3. Sundaram V, Louis D, Saini SS, Kumar P. Pulse oximetry sensor application for neonates during resuscitation (protocol). Cochrane Database of Systematic Reviews. 2016.
4. Saraswat A, Simionato L, Dawson JA, et al. Determining the best method of Nellcor pulse oximeter sensor application in neonates. Acta Paediatrica. 2011.
5. O’Donnell CP, Kamlin CO, Davis PG, Morley CJ. Obtaining pulse oximetry data in neonates: a randomized crossover study of sensor application techniques. Arch Dis Child Fetal Neonatal Ed. 2005;90:F84-F85. doi: 10.1136/adc.2004.058925.
6. Batchelder K, Sethi R, Pinto YJ. Pulse Rate Performance of Two Pulse Oximeters in the NICU. Internal Medtronic White Paper. 06/2019-18-PM-0123.
7. Addison PS, Mannheimer PD, Ochs JP. Pulse rate performance of two pulse oximeters during challenging monitoring conditions. Internal Medtronic Study-White Paper. 09/2018–18-PM-0181.
8. Rabi Y, Dawson JA. Oxygen therapy and oximetry in the delivery room. Seminars in Fetal &Neonatal Medicine. 2013.
9. Louie A, Feiner JR, Bickler P, Rhodes L, et al., Four Types of Pulse Oximeters Accurately Detect Hypoxia During Low Perfusion and Motion. Anesthesiology. 2018; 128:520-530.
10. Widiati E, Nurhaeni N, Gayatri D. Medical-device related pressure injuries to children in the intensive care unit. Comprehensive Child And Adolescent Nursing. 2017; 40(S1):69–77.
11. Lund C, Osborne JW, Kuller J, et al. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2001;30(1):41 – 51.

TOPICS: Nellcor™ Pulse Oximetry