KEY POINTS
- 1.
The first 60 minutes after birth constitutes a Golden Hour for a newborn infant, when appropriate clinical management can improve long-term outcomes.
- 2.
The physiologic transition from intrauterine to extrauterine life is complex, and alterations in this transition can have lasting effects, particularly in premature infants.
- 3.
After an antenatal consult, a delivery team should be assembled and briefed on maternal history, gestational age, and any prenatally known fetal diagnoses.
- 4.
There is a need for timely and appropriate resuscitation, temperature control, and minimization of transcutaneous fluid losses in all infants.
- 5.
Premature infants may need timely administration of surfactant, initiation of intravenous fluids, oxygen in appropriate concentrations, and other forms of respiratory support.
The “Golden Hour” is a well-defined term in adult trauma literature and has been adapted to the first hour of neonatal life. The Golden Hour , first published in the 1970s by R. Adams Cowley of the University of Maryland Medical Center, described use of evidence-based medicine to develop standardized protocols built around the initial hour of stabilization of the adult trauma patient ( Table 9.1 ). These protocols led to a decrease in mortality and improvement in other outcomes. In neonatology, Golden Hour terminology has been adapted to refer to the first 60 minutes of postnatal life. Evidence-based interventions and standardized protocols applied in the first hour of life ( Table 9.2 ) have been shown to improve long-term outcomes in preterm infants.
| Task | Time for Task, min | Total Time, min |
|---|---|---|
| Injury | 0 | 0 |
| On-scene response and assessment | 10 | 10 |
| On-scene emergency care | 20 | 30 |
| Extrication | 10 | 40 |
| Transportation | 10 | 50 |
| Emergency department stabilization | 10 | 60 |
| Surgical intervention by 60 min |
| Task | Time for Task, min | Total Time, min |
|---|---|---|
| Birth | 0 | 0 |
| Resuscitation | 10 | 10 |
| Transport | 5 | 15 |
| Lines | 40 | 55 |
| X-ray and intravenous fluids | 5 | 60 |
| Isolette closed by 60 min |
The physiologic transition from intrauterine to extrauterine life is complex, and alterations in this transition can have lasting effects on the newborn, particularly the extremely low birth weight (ELBW) infant. Antenatal counseling, neonatal resuscitation, transportation of the ELBW infant to the neonatal intensive care unit (NICU), respiratory and cardiovascular support, attention to thermoregulation and glucose stability, and interventions to reduce intraventricular hemorrhage (IVH) are some but not all of the considerations when addressing the needs of the ELBW infant.
The Golden Hour can be implemented for either term or preterm neonates. When referring to the Golden Hour as it pertains to term neonates, there are three main goals as set forth by the World Health Organization and the United Nations Children’s Fund (UNICEF). These goals include direct, immediate skin-to-skin contact between the mother and newborn, delayed cord clamping, and early initiation of breastfeeding where it is both medically appropriate and desired by the mother. Taken together, these interventions have decreased rates of hypothermia and hypoglycemia in the neonate and increased mother–child bonding. Mothers who have been exposed to the Golden Hour protocol have decreased rates of postpartum anxiety and are more likely to continue to exclusively breastfeed.
The Golden Hour of the Preterm or High-Risk Neonate
ELBW infants have high mortality and morbidity and are at risk for lifelong neurodevelopmental disabilities that range from subtle impairment to severe delays. In the preterm or critically ill neonate, Golden Hour protocols are more intensive and focus on many more facets of neonatal care.
A true Golden Hour protocol starts with prenatal counseling well before any planned delivery of a preterm or otherwise critically ill infant. The neonatal team should meet with the obstetric team to verify the estimated gestational age, estimated fetal weight, pregnancy complications, antenatal steroid administration, and comorbid diagnoses of any impending high-risk delivery. Based on this information, an antenatal consultation with parents should be performed to review the expected outcomes based on gestational age and comorbid diagnoses, expected length of the NICU stay, and potential interventions that may need to be performed to stabilize the infant. It is recommended that antenatal steroids be given for fetal lung maturation in infants of gestational ages 24 0/7 to 33 6/7 weeks, although institutional guidelines may vary and include lower gestational ages.
In cases of periviability or expected poor prognosis, goals of care should be discussed with parents prior to delivery based on national and institutional guidelines. These goals may include conversations around providing comfort care in place of aggressive support. This decision needs to take into account regional guidelines, perceived accuracy of gestational age dating, presence of infection in the mother (such as chorioamnionitis), level of care available at the location of delivery, and personal and spiritual beliefs of the parents. Parents should be informed about the most accurate prognostic data on morbidity and mortality currently available, based on estimated gestational age, race, and sex of their infant. It is important that parents are given time to receive counseling and make decisions regarding the management of their infant, which is why prenatal counseling is a vital component of Golden Hour management.
After the antenatal consultation is performed, a delivery team should be assembled. All team members should be briefed on maternal history, gestational age, and any prenatally known fetal diagnoses. The charge nurse and admitting nurse in the NICU should be included in this discussion and should inform the delivery team members of the bed spot to which the neonate will be admitted. The admitting team should have a prewarmed isolette, common medications and fluids available at bedside, and anticipated ventilatory support in the patient’s room before arrival of the patient. Assignment of neonatal delivery team roles is especially important in a high-risk delivery. The team leader should be designated early and should assign specific roles to every team member attending the delivery. Before the delivery of the infant, all delivery room equipment should be checked and verified to be in appropriate working order, per Neonatal Resuscitation Program (NRP) guidelines. Adequate personnel and equipment should be on hand for deliveries with multiple gestations or known congenital anomalies.
Although the Golden Hour is, in name, focused only on the first hour of postnatal life, such protocols have lifelong benefits for at-risk infants. Implementation of Golden Hour practices has improved time to surfactant administration, early administration of dextrose and amino acids, rates of normothermia on admission to the NICU, odds of developing chronic lung disease, and odds of developing retinopathy of prematurity by providing a multifaceted protocol for care of the preterm neonate ( Fig. 9.1 ).
Delayed Cord Clamping
Preterm or high-risk newborns are at particularly high risk for anemia, both from prematurity and from iatrogenic losses. Delayed umbilical cord clamping (clamping of the cord 30 seconds to 3 minutes after birth) has been associated with a decreased need for postnatal blood transfusions, decreased IVH, and decreased rates of necrotizing enterocolitis. The most current NRP 2015 guidelines acknowledge the benefit of delayed cord clamping but also acknowledge that there are inadequate studies on the safety of performing delayed cord clamping in a patient who requires resuscitation. For this reason, NRP recommends delaying cord clamping for 30 seconds after birth in only those term and preterm infants not requiring resuscitation at birth.
Hypothermia
One of the main foci in the Golden Hour protocols is the prevention of hypothermia, defined as a temperature <36.5°C. Hypothermia is a dangerous condition in the newly born ELBW with a reported prevalence on admission estimated to be between 45% and 93%, depending on gestational age and birth weight of the infant. , Each degree of temperature drop is associated with a 28% increase in neonatal mortality, and temperature on admission to the NICU is a strong predictor for neonatal mortality.
Temperature regulation is most difficult in the initial first few minutes to hours after birth as a newly born infant transitions between in-utero and ex-utero environments where conduction, convection, and evaporative and radiative heat loss are much greater. Due to infants’ relatively large body-to-surface area, heat losses due to these four mechanisms are increased, which makes infants uniquely susceptible to heat loss. Per NRP guidelines, the goal body temperature of the preterm neonate should be maintained between 36.5°C and 37.5°C.
Hypothermia is associated with substantially increased morbidity and mortality, including:
- •
Delayed adjustment to newborn circulation
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Hypoglycemia
- •
Metabolic acidosis
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Coagulopathy
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Oxygen dependency
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Intraventricular hemorrhage
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Late-onset sepsis
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Poor neurodevelopmental outcomes
- •
Death
Despite what is known about the risks of hypothermia, and strategies to combat it, hypothermia remains a common problem.
Strategies to prevent hypothermia include , :
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Prewarming the resuscitation table
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Prewarming and humidifying the isolette
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Maintaining the delivery room temperature between 25°C and 28°C
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Use of heated, humidified respiratory gases for resuscitation
- •
Use of a polyethylene wrap or food-grade plastic bag
- •
Use of an insulated head cap
- •
Exothermic heated mattresses (monitor closely for associated hyperthermia)
- •
Avoidance of drafts around the resuscitation area (no opening or closing of doors, no air vents, etc.)
In the delivery room, the radiant warmer, or isolette, that will be used for resuscitation should be prewarmed and positioned in an area that is as free from air drafts as possible. This means positioning the resuscitation area in the farthest point away from doors and air vents. Cardiorespiratory monitoring leads should be placed on the infant’s skin upon arrival to the resuscitation area so that an insulated hat and polyethylene wrap can be immediately applied to the infant before any intentional drying has occurred. The wrap traps evaporative moisture losses between the infant’s skin and the wrap, which creates humidity and further decreases evaporative water and heat losses. Once the wrap and hat are in place, they should not be removed. All resuscitative efforts can be performed through the thin film of the bag. Umbilical lines can also be placed with the polyethylene wrap in place, either by folding the edges of the wrap inward to surround the umbilical stump or by cutting a hole just large enough for the umbilical stump if the polyethylene covering is a continuous bag.
One member of the resuscitation team should be responsible for checking the body temperature of the newborn throughout the resuscitation. A transcutaneous temperature probe in servo control mode can be placed on the infant’s abdomen per unit protocol, but this temperature should be periodically confirmed with axillary temperature readings. There are varying guidelines on when to remove the polyethylene wrap, but most sources agree that the infant should achieve and maintain normothermia for at least 1 hour prior to removal of the wrap or bag.
Respiratory Support in the Golden Hour
Initial respiratory support in the Golden Hour should focus on lung-protective ventilation strategies. The latest guidelines from the NRP should be followed, and pulse oximetry should be used as soon as possible in the delivery room. For infants less than 35 weeks’ gestation, a 21% to 30% fraction of inspired oxygen (Fi o 2 ) should be used during resuscitation. In infants >35 weeks’ gestation, a 21% Fi o 2 should be used. The Fi o 2 should be titrated to achieve optimum preductal saturations ( Table 9.3 ).
