No recommendations regarding position of the infant during medical support of postnatal adaptation are given in international guidelines, most likely due to a lack of sufficient scientific data. The present study provides for the first time data on DR-management showing: 1. A substantial number of term infants is already cared for in side position, a habit that became more popular over the one year study period. 2. Routine interventions can be administered in side-positioned term infants. 3. Infants in side position were less agitated and seemed to have better saturation values. Whereas the present data represent– to our knowledge – the first scientific evidence that DR-management in side position is feasible and potentially beneficial, the study rises questions that can be answered only by subsequent controlled clinical trials.
In our institution the preferred position of placing infants during the postnatal adaptation period was “supine”, followed by right and left side. Although a frequent switch from one to another position was noticed, there was no detectable pattern to explain choice of position, except for caretaker’s individual preferences. Furthermore, we noticed a switch in the preferred position from “supine” to “side” during the study period. Since video recording is a standard procedure in our unit and a structured feed-back should be performed to improve quality of care, it cannot be excluded that a certain habit of individual caregivers is “contagious”. Just by watching the treatment provided by other caregivers, the individual habit can change . Since no official change of institutional guidelines occurred during the study period, this finding supports the great potential (but also possible harm) of using video monitoring in routine care.
Results of the present study suggest that routine procedures like stimulation and suctioning can be performed without any problems in either position. However, it is noteworthy that “supine” infants received stimulation for a longer time than infants in “side” position. The reason for the extended stimulation periods in supine position remains speculative. Stimulation that was performed in the first minute in the context of drying and towel change was excluded from analysis. Thereafter, infants included in the study were primarily stimulated to improve respiratory efforts. Infants in supine position (that received more stimulation) were more agitated; however, vital parameters were not better in these infants (there was even a tendency toward lower saturation values). Since stimulation did not have a beneficial effect and caused more agitation, extended stimulation of vigorous term newborns seems to be questionable [9, 10]. Although there are studies in premature infants showing that crying is an unnecessary process leading to an increased heart rate, blood pressure and desaturations [11, 12], little is known about whether increased agitation causes harm in term newborns immediately after birth. Despite the long history of using stimulation during infant’s resuscitation and its frequent use in routine DR-management , limited scientific data concerning benefit or harm of that intervention warrant further research.
Respiratory support was almost exclusively administered with the infant in supine position. In 2 infants CPAP was initially started in side position, but both infants were quickly switched to supine position. A possible explanation for these findings is that caretakers are more familiar with supine position and have a feeling of steadiness that the infant gives while lying with its back on the resuscitation table. According to the experience in other institutions, there will be no problem in administering CPAP in side position. Moreover it is argued that CPAP application with the newborn on side and caretakers hand on newborns back, could even provide more (tactile) information concerning infant’s respiratory efforts. It could be speculated that the reduced agitation in side-placed infants improves efficiency of CPAP application. However, there are no studies that associate infant positioning during CPAP application with a better outcome.
The position of the infant seemed to have no effect on heart rate. With regard to oxygen saturation, infants in side position tended to achieve values above 90% much earlier than “supine” infants. Additionally, side placed infants had higher saturation values at 5th minute than supine placed infants. However, these findings do not necessarily represent a clinical benefit since oxygen saturations were within the physiological range regardless of infant`s position. Interestingly, infants placed on the left side had a significantly higher saturation at 8 minutes when compared to those on the right side. Based on these findings it could be speculated that left side position is associated with faster postnatal lung aeration.
Whereas the results of the present study are of great interest, data do not allow any conclusions concerning a causal relationship. Since our study is not a randomized controlled trial, it cannot be excluded, that infants that “did well” were more likely to be placed on the side, whereas infants that had more difficulties to adapt (and thus required more support) were placed in supine position. However, our study provides sufficient data for a subsequent randomized controlled trial. According to the present data the trial could test the hypothesis that side-positioned infants are less agitated and do have better oxygen saturation values during postnatal adaptation.
Data of the present study are of interest to other topics as well. Whereas several studies were performed to analyse delivery room management of preterm infants, only limited data are available concerning care of term infants, despite the fact that these infants represent the majority of newborns. The present study shows the great potential of video-recording and subsequent analysis for research in DR-management .