R-3Oxygen Therapy and Oximetry in the Delivery Room

7/25/2019 R-3Oxygen Therapy and Oximetry in the Delivery Room

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Review

Oxygen therapy and oximetry in the delivery room

Yacov Rabi a,b,*, Jennifer A. Dawson c,d,e

a Division of Neonatology, Department of Paediatrics, University of Calgary, Calgary, Alberta, CanadabAlberta Childrens Hospital Research Institute, Calgary, Alberta, Canadac Newborn Research Centre, The Royal Womens Hospital Melbourne, Melbourne, Australiad The Murdoch Childrens Research Institute, Melbourne, Australiae University of Melbourne, Melbourne, Australia

Keywords:

Delivery room

Heart rate

Oxygen saturation

Pulse oximetry

s u m m a r y

Pulse oximetry is increasingly being used in the delivery room. Expert recommendations state that

oxygen therapy during newborn resuscitation should be guided by pulse oximetry. Obtaining accurate

and stable oxygen saturation and heart rate information from a pulse oximeter in the delivery room can

be challenging. Understanding the properties of this device is important in overcoming these challenges.

This article describes several aspects of pulse oximetry use in the delivery room ranging from technical

issues with the device itself to clinical applications of the technology.

Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.

1. Introduction

The practice of transmitting light through tissue to measure a

patients oxygenation is nearly 80 years old. Early iterations of thistechnology could not differentiate oxygen saturations of arterial

blood from venous blood and tissue. In the early 1970s a Japanese

biomedical engineer, Takuo Aoyagi, discovered that the pulsatile

changes in light transmission through tissue could be used to

measure oxygen saturations[1] and pulse oximetry was born. In

1978, only 6 years after its discovery, the Minolta Company was the

rst to broadly market this new piece of technology. It was a major

breakthrough and quickly adopted into clinical settings.

Pulse oximetry use in the delivery room has been investigated

for more than 30 years. The earliest studies were published in 1986.

Sendak et al. [2] reported on pulse oximetry measurements in a

case series of four newborns at birth. That year, Harris et al. [3]

published a study describing continuous oxygen saturations for

the rst seven minutes after birth in 76 term newborns. A similarstudy published the following year concluded that pulse oximetry

use in the delivery room was very useful in objectively judging the

adequacy of resuscitative efforts[4].

More recently, we have seen renewed interest in this technology

for use in the delivery room. This was largely prompted by the

realization of the dangers of hyperoxia during resuscitation and the

subsequent International Liaison Committee on Resuscitations

(ILCOR) recommendation that oxygen concentration should be

titrated during resuscitation [5]. Clinicians now have to consider

what methods are best for guiding oxygen use in the delivery room.In this article, we review how pulse oximetry works as a prelude to

understanding its strengths and limitations in the delivery room

setting.

2. How does pulse oximetry work?

Oxygen saturation is the percentage of hemoglobin that is bound

with oxygen, also called oxyhemoglobin. Oxygenated and deoxy-

genated hemoglobin absorb light differently, with oxygenated he-

moglobin maximally absorbing light in the infrared spectrum at

660 nm compared to deoxyhemoglobin which maximally absorbs

light in the red spectrum at 910e940 nm. Pulse oximeters calculate

the ratio of tissue absorptions of red and infrared light to derive the

oxygen saturation of hemoglobin (SpO2). Two wavelengths of light,660 nm and 910e940 nm, are directed intoa tissuebed and a sensor

placedon theopposite side of the light source measures the amount

of light absorbed at both wavelengths. The absorption ratio is then

compared to reference values obtained from healthy volunteers

who were made hypoxic with saturations as low as 60e70% under

controlled conditions. This is why manufacturers only quote the

accuracy of their devices for oxygen saturations above 60e70%.

Pulse oximeters also display pulse rate. In a well-perfused per-

son, each heartbeat results in a pulsatile increase in the blood

volume of tissue beds. With larger tissue blood volumes, more light

from the pulse oximeter probe is absorbed causing less light to

* Corresponding author. Address: Foothills Medical Center, 1403 29 Street NW,

Room C211, Calgary, Alberta, Canada T2N 2T9. Tel.: 1 403 944 1087; fax: 1 403

944 4892.

E-mail address:[email protected](Y. Rabi).

Contents lists available at ScienceDirect

Seminars in Fetal & Neonatal Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . co m / l o c a t e / s i n y

1744-165X/$e see front matter Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.siny.2013.08.007

Seminars in Fetal & Neonatal Medicine 18 (2013) 330e335
mailto:[email protected]://www.sciencedirect.com/science/journal/1744165Xhttp://www.elsevier.com/locate/sinyhttp://dx.doi.org/10.1016/j.siny.2013.08.007http://dx.doi.org/10.1016/j.siny.2013.08.007http://dx.doi.org/10.1016/j.siny.2013.08.007http://dx.doi.org/10.1016/j.siny.2013.08.007http://dx.doi.org/10.1016/j.siny.2013.08.007http://dx.doi.org/10.1016/j.siny.2013.08.007http://www.elsevier.com/locate/sinyhttp://www.sciencedirect.com/science/journal/1744165Xhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.siny.2013.08.007&domain=pdfmailto:[email protected]


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reach the sensor. The pulse oximeter measures heart rate by

detecting this pulsatile change in light absorption.

The newest generation of pulse oximeters uses multiple wave-

lengths of light to measure concentrations of other types of he-

moglobin, including methemoglobin and carboxyhemoglobin.

Whereas these are of limited clinical signicance for the newborn

at birth, fetal haemoglobin may be important. Fetal hemoglobin

binds oxygen more tightly than adult hemoglobin and constitutes

close to 100% of the hemoglobin in very lowbirth weight babies [6].

Currently, pulse oximeters cannot detect fetal hemoglobin. The

practical implications are discussed later in this article.

Pulse oximeters are calibrated by their manufacturers and

cannot be adjusted by clinicians. Internal calibration occurs auto-

matically within the oximeter and, unlike other devices, does not

require an external reference standard.

3. Evidence for best practices in using pulse oximetry in the

delivery room

The transitional physiology of the newborn at birth differs

greatly from that encountered in the neonatal intensive care unit

and provides unique challenges to using pulse oximetry in the de-

livery room. Poor perfusion, motion and high ambient light can allbe present during resuscitation. Choosing the appropriate settings

can aid in rapidly obtaining accurate and stable measurements in

this environment. In addition to choosing the optimal settings on

the pulse oximeter, the user should consider how and where to

apply the sensor. Below, we provide evidence-based recommen-

dations for proper use in the delivery room.

3.1. .Pulse oximeter

In an effort to provide stable readings, pulse oximeters display a

moving average of their measurements over a user-specied time-

period. Whereas the options vary by manufacturer, the shortest

available selectable averaging time is typically 2 s. Some pulse

oximeters do not allow the user to specify the averaging time; thisis set by the device and may vary according to signal quality [7].

Leone and Finer[8] recommended that oximeters used during

neonatal resuscitation should be set to the minimal averaging time

for the SpO2 valuesto allow rapid detection of changes in oxygen

saturation. The detection of brief and severe periods of desaturation

is improved with a shorter averaging time (2 s) compared to longer

averaging times (16 s)[9]. At present, there are no outcome studies

examining the effects of averaging time. However, given the current

state of knowledge, we recommend selecting the shortest averaging

time available when the pulse oximeter is used in thedelivery room.

The sensitivity setting on a pulse oximeter controls the devices

ability to detect pulsations. A higher sensitivity will increase

detection of pulsations and therefore is more likely to provide SpO2

measurements during periods of low perfusion. Studies of pulseoximetry in the delivery room routinely used the highest sensitivity

setting available [9e13]. Again,in the absence of outcome studies, it

is reasonable to use a high sensitivity setting in situations where

the patient is poorly perfused.

3.2. Application of pulse oximeter probe

Care must be taken not to apply the probe too tightly. Bucher

et al. [14]showed that SpO2 measurements became increasingly

inaccurate with increasing pressure from the pulse oximeter probe

on the underlying tissue. The authors concluded that this was likely

due to venous congestion.

Studies of time to acquisition of a reliable signal with different

pulse oximeters have con

rmed manufacturer recommendations

for the optimal technique for probe application[15e17]. When an

oximeter is turned on with the probe already connected, it will

immediately begin taking measurements. If the probeis notapplied

to the baby, the oximeter measures environmental signals such as

ambient light or infrared light from a radiant warmer. This can

cause a delay in obtaining accurate measurements once the probe is

placed on the patient. To avoid this, the pulse oximeter should be

turned on rst with the oximeter cable connected. Next, the probe

is applied to the baby. Once the probe is well-positioned on the

baby, it is then connected to the oximeter cable (Fig. 1).

Is the location of probe application clinically important? The

majority of studies using pulse oximetry in the delivery room have

placed the probe on the right wrist as this preductal location re-

ects the saturation of blood that is perfusing the brain. Further-

more, nomograms of oxygen saturation at birth were created using

preductal oxygen saturations. If we are to use such nomograms to

guide the titration of oxygen, as recommended by ILCOR, it is

important that we also use a preductal probe location. There is a

large body of evidence documenting that pre- and postductal ox-

ygen saturations are signicantly different for several minutes after

birth due to right-to-left shunting of blood.

Mariani et al. [12] reported that postductal SpO2 was 5e8%

lower than preductal SpO2 but that this difference decreased after5 min. However, others have shown that this difference persists for

up to 20 min and ranges from w14% at 3 min to 5% at 17 min[18e

20]. Furthermore, pulse wave signals aredetectable sooner with the

probe applied to the hand versus the foot: 1.24 min from the hand

versus 3.06 min from the foot [18]. For these reasons, we recom-

mend placing the probe on the right wrist.

4. Interpreting the quality of signal

Delivery room resuscitation provides one of the most technically

challenging environments for obtaining an accurate and stable

signal from the pulse oximeter. Each model has its own algorithm

for identifying and displaying signal quality. The user should befamiliar with the indicators of signal quality fortheir model of pulse

oximeter to determine their condence in the displayed values.

For example, the user can be condent of a good signal when

using the Nellcor (OxiMan N600x; Tyco Healthcare, Pleasanton, CA,

USA) pulse oximeter if they observe a regular plethysmograph with

pulse search and interference indicators not lit continuously.

Similarly, a good signal on the Radical pulse oximeter (Masimo,

Figure 1. Nellcor OxiMax N-600x pulse oximeter (A) with a patient cable (B) to which

the sensor (C) is connected.

Y. Rabi, J.A. Dawson / Seminars in Fetal & Neonatal Medicine 18 (2013) 330 e335 331


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Irvine, CA, USA) is indicated by a regular plethysmograph, a high

signal IQ which represents the condence of the pulse oximeter in

the oxygen saturation and heart rate displayed with each arterial

pulse, and a good perfusion index reecting the relationship of

pulsatile to non-pulsatile blood ow at the sensor site. Other

manufacturers of pulse oximeters have different methods for

identifying a good signal.

It is common practice to manually calculate the heart rate and

compare it to the heart rate displayed on the pulse oximeter. If the

heart rate values are similar, the clinician is usually condent in the

quality of the signal. This seems to be a reasonable practice but the

reader should be aware that this approach has not been validated.

5. Challenges in using pulse oximetry in the delivery room

Pulse oximeters have been tested for validity and reliability by a

number of researchers who compared SpO2measurements against

arterial blood under a variety of conditions [21,22]. These studies

were generally conducted with rst or second generation oximeters.

In a study of preterm newborns, SpO2measurements were accurate

at arterial oxygen saturations of >93% [23]. However, at arterial

saturations of 80% fewer than half of SpO2 measurements were

within 3% of the arterial oxygen saturation. These lower oxygensaturation values are normal in therst few minutes after birth.

Other major challenges to obtaining accurate pulse oximetry

measurements in the delivery room are motion, low perfusion and

ambient light. Pulse oximeters identify arterial blood by detecting

pulsations. Motion artefact can occur with patient movement

resulting in irregular venous blood ow that can be interpreted as

pulsatile ow. This can confuse the pulse oximeter and lead to

inaccurate measurements. Different manufacturers have developed

various strategies for dealing with this problem and have met with

some success. In a review article examining the performance of

new-generation motion-tolerant pulse oximeters, Giulinao and

Higgins[24]concluded that newer pulse oximeters have superior

performance.

Newborns often have poorly perfused extremities immediatelyafter birth. As the pulse oximeter is dependent upon identifying a

pulse to perform its calculations, this can present a challenge. If the

option is available, we recommend selecting a high sensitivity

setting for delivery room applications.

Fluorescent lights, bright lights common to surgical suites and

even light produced by radiant warmers can adversely affect

measurements [25e27]. If ambient light is excessive, the pulse

oximeter probe should be shielded with an opaque wrap [28,29].

At 26 weeks, the fetus has nearly 100% fetal hemoglobin [6].

Even at term, fetal hemoglobin represents about 70% of total he-

moglobin. At present, pulseoximeters do not measure or correct for

fetal hemoglobin which differs slightly in its light absorption

characteristics from adult hemoglobin[30,31]. Some investigators

have demonstrated that by not correcting for fetal hemoglobinconcentration, pulse oximetry overestimates the true oxygen

saturation of arterial blood by 3e6% [32e34]. There is another,

equally compelling, body of evidence from different investigators

showing that fetal hemoglobin has a trivial effect on the accuracy of

pulse oximetry SpO2 measurements [22,35e37]. Whereas studies

appear to agree that fetal hemoglobin does affect the accuracy of

pulse oximetry SpO2 measurements, there is disagreement over

whether the effect is clinically signicant.

6. Does pulse oximetry provide useful information in the

delivery room?

For pulse oximetry to be useful in the delivery room, it must

provide reliable information soon after delivery. Pulse oximeter

performance for SpO2and HR measurements in the delivery room

has been evaluated in several studies.

6.1. Oxygen saturation

Before the introduction of pulse oximeters intothe delivery room,

clinicians relied upon assessment of colour to determine the babys

oxygenation status. We now understand that clinical assessment of

colour is an inaccurate and imprecise sign of oxygenation[38].

Many studies have shown that pulse oximetry can be used to

measure oxygen saturations in the delivery room for both term and

preterm babies. The majority of these studies focused on doc-

umenting normal oxygen saturations in stable babies over the rst

minutes after birth[10,11,13,19,20,39].

How soon after birth can pulse oximetry provide reliable SpO2measurements? In experienced hands, a probe can be applied to a

baby within 15e20 s of birth[11,15,17]. Kamlin et al.[11]reported a

53% success rate in obtaining stable SpO2measurements by 1 min.

In another study, the median time to achieve stable SpO2 mea-

surements was 82 s in healthy newborns 35 weeks of gestation

[13]. In a recent study of preterm babies


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the delivery room. This allows clinicians to focus on other aspects of

resuscitation without having to stop and auscultate or palpate the

heart rate. Though evidenceof any inuence on importantoutcomes

is lacking, many experts recommend continuous oxygen saturation

monitoring [5,43,51,52] and targeting normal oxygen saturation

values[53].

8. Can we target oxygen saturation ranges in the delivery

room?

Neonatal intensive care units generally have specic SpO2target

ranges for babies receiving supplemental oxygen. However, re-

searchers have shown that it is difcult for staff to comply with

such target ranges[54e56]. In the delivery room it is likely to be

even more difcult to keep SpO2 measurement within a target

range when SpO2rises rapidly in the rst minutes.

We now understand that in the rst minutes after birth it is

normal for babies to have a low SpO2. There is the potential for

oxygen to be administered needlessly if clinicians are not aware

that babies are normally blue in the rst minutes after birth and it

may take several minutes for SpO2to reach the normalpostnatal

range [53]. When oxygen is administered, its use should betitrated to achieve normal time-based oxygen saturation values.

ILCOR recommends targeting the middle quartile of oxygen

saturation values observed in healthy babies transitioned in room

air [5]. Although there is no evidence that this approach affects

outcomes, given the current state of knowledge, it seems

reasonable.

Prospective studies of preterm resuscitation in the delivery

room that targeted an oxygen saturation value or range met with

modest success in achieving these targets. Escrig et al. [57] tar-

geted an SpO2 of 85% in conjunction with heart rate >100 bpm to

guide oxygen titration. They were able to use oxygen saturation to

guide the titration of oxygen though they did not report on the

amount of time on the SpO2target, perhaps because it was a single

value. The ROAR study (Room air vs Oxygen Administration forResuscitation of preterm infants) targeted a static SpO2 target

range of 85e92%. The primary outcome was the proportion of the

total resuscitation time the babys SpO2 remained in the target

range. They compared three groups. The high oxygen group

received a static concentration of 100% oxygen while the moderate

and low oxygen groups had the oxygen concentration titrated

starting from either 100% or 21%, respectively. The moderate ox-

ygen group spent 21% of the total resuscitation time in the target

range compared to 11% in the high oxygen group and 16% in the

low oxygen group[58].

Goos et al. [59]measured the extent to which observed SpO 2levels matched the European Resuscitation Council (ERC) oxygen

saturation targets during resuscitation of babies 30 weeks of

gestation. During the initial 10 min after birth, SpO2 values wereabove the ERC target for 44% (IQR: 12e66) of the time and below

the ERC target for 51% (IQR: 27e82) of the time. Gandhi et al.[60]

have described a system intended to facilitate maintaining SpO2values between the 10th and 50th percentiles of the normal target

range. Their Transitional Oxygen Targeting System (TOTS) plots

real-time SpO2 values in relation to the 10th and 50th percentile

SpO2 curves from a nomogram. This provides clinicians with a

visual representation of a babys SpO2 pattern in relation to the

SpO2 target range. Babies managed with this system spent a

greater proportion of total resuscitation time (52%) within the

target range compared to a control group (37%) [60]. Further

studies are needed to determine whether targeting normal oxygen

saturations during resuscitation affects clinically meaningful long-

term outcomes.

9. Does pulse oximetry use in the delivery room affect

outcomes?

The question of whether pulse oximetry affects outcomes has

long been debated in the adult, pediatric and neonatal intensive

care settings. Concerns over frequent alarms and low condence in

measurements, especially with earlier models, led some to

disparagingly refer to pulse oximeters as random number gener-

ators. Fortunately, the performance of newer generation pulse

oximeters has successfully addressed these issues to a large extent.

Research focus has shifted from validating the technology to

determining how the technology can be put to best use to improve

outcomes.

A few recent studies quantied the amount of oxygen given to

babies during resuscitation where continuous pulse oximetry was

used. Preterm babies initially resuscitated with 30% oxygen were

estimated to have received 465.6 ml/kg of pure oxygen in com-

parison to babies initially resuscitated with 90% oxygen who

received 864 ml/kg of pure oxygen [57]. Another study reported

that preterm babies resuscitated with an oxygen titration protocol

that started with room air received w37% less pure oxygen by

volume than babies resuscitated with a staticconcentration of 100%

oxygen[58]. Using pulse oximetry to guide oxygen titration mayhelp reduce the oxidative stress we impose on sick newborns at

birth, though this still awaits conrmation.

Pulse oximetry is simply a measurement tool, hence its use will

not directly inuence outcomes. Rather, its potential lies in

providing information about the safety and effectiveness of in-

terventions and guiding decision-making. As an example, three

randomized controlled studies all using pulse oximetry showed

that oropharyngeal suctioning has a negative effect on oxygenation

[61e63]. ODonnell et al. [64] measured the effects of attempted

endotracheal intubation on SpO2in the delivery room and showed

that SpO2 frequently fell during intubation attempts. During in-

terventions such as oropharyngeal suction or endotracheal intu-

bation, pulse oximetry is able to show clinicians the effect of the

intervention on a babys SpO2in real time.Kopotic and Lindner[65]studied babies at risk for respiratory

failure. Half the babies were managed without pulse oximetry

and compared with the other half managed with pulse oximetry.

Babies managed with oximetry were less likely to be admitted to

the nursery (32% vs 52%). In another study by Deckardt et al.,

respiratory care was based on the baby s clinical state and SpO2measurements [66]. Oxygen was started at 100% and adjusted to

achieve an SpO2 between 80% and 92%. Using pulse oximetry

they were able to reduce the fraction of inspired oxygen (FiO 2)

from 1.0 to 0.40. The Deckardt et al.[66]and Kopotic and Lindner

[65] studies, although unmasked and non-randomized, suggest

that pulse oximetry can be effective in guiding oxygen admin-

istration to improve short-term outcomes, such as admission to

nursery and the use of oxygen or continuous positive airwaypressure. We are not aware of any studies assessing the effect of

using SpO2 measurements to guide treatment decisions imme-

diately after birth on long-term outcomes.

There may be lasting effects from short exposure to oxygen in

the delivery room. There is evidence to support concerns

regarding exposure to oxygen in the delivery room and an asso-

ciation with an increased risk for the development of childhood

cancers. Spector et al. reviewed data from a large prospective

cohort of>50 000 children enrolled in the National Collaborative

Perinatal Project (NCPP) and described a higher risk of cancer in

children exposed to more than 3 min of oxygen in the delivery

room than in children without oxygen exposure (hazard ratio:

2.87) [67]. The authors speculate that reactive oxygen species

could damage DNA and increase susceptibility to developing



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cancer. In a similar study, the odds ratio for developing childhood

cancer following exposure to oxygen at delivery was 2.57 and

increased to 3.54 if manual ventilation lasted more than 3 min

[68]. Both studies point to a potential dose response with higher

risks of cancer associated with longer exposure to oxygen [67,68].

Whereas there is a clear biologic relationship between oxygen

exposure and the formation of cancerous cells in vitro, it remains

unclear whether it was the oxygen exposure and/or the babiesunderlying conditions that contributed to the increased risk in

these studies.

10. Conclusions

Pulse oximetry is a useful adjunct to clinical assessment in the

delivery room but clinicians attending newly born infants should

have a good understanding of normal fetal-to-neonatal transition.

Different models of pulse oximeter have differences in calibration

and algorithms for detecting and managing artefact, and demon-

strating signal quality. Therefore, it is important for clinicians

managing babies in the delivery room to understand the charac-

teristics of the pulse oximeter that they use and to be aware of

indicators that measurements might be unreliable. Titrating oxygen

administration to SpO2measurements is reasonable at the currenttime. However, there are no randomized trials measuring the

impact of using different SpO2 targets in the delivery room on long-

term outcomes.

Funding sources

J.A. Dawson is a recipient of a National Health and Medical

Research Council (NHMRC) Post Doctoral Fellowship and is sup-

ported by the Victorian Governments Operational Infrastructure

Support Program.

Conict of interest statement

Y. Rabi has a patent in Japan and patent pending applications in

the USA and European Union, for technology to help guide oxygen

titration in the delivery room. He has a revenue sharing agreement

with Masimo Corp. for distribution of this technology.

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Pediatrics 2011;128:740e

52.

Practice points

Pulse oximetry can accurately measure oxygen satura-tions and heart rate during delivery room resuscitation.

Pulse oximeters have user-modifiable settings thataffect the ability to obtain stable measurements in thedelivery room.

Acquiring stable readings of oxygen saturation andheart rate within 2 min of birth is feasible in clinicalpractice.

Pulse oximetry provides real-time information impor-tant for decision-making (e.g. oxygen titration) duringresuscitation.

Research directions

Creation of new oxygen saturation nomograms forbabies who have had delayed cord clampingperformed.

Determine whether targeting normal oxygen satura-tions during resuscitation affects clinically importantoutcomes.

Determine the optimal approach to titrating oxygenduring resuscitation (i.e. starting FiO2, frequency of FiO2adjustments, magnitude of FiO2 adjustments).

Y. Rabi, J.A. Dawson / Seminars in Fetal & Neonatal Medicine 18 (2013) 330e335334
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R-3Oxygen Therapy and Oximetry in the Delivery Room

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