Recent reports suggest a rising awareness of sudden unexpected postnatal collapse (SUPC).
Five SUPC events during a 17-month period.
A multidisciplinary team used a quality-improvement approach to develop the intervention. The smart aim was to develop a bundled intervention to eliminate SUPC from occurring in the delivery room during skin-to-skin care.
A bundled intervention included a standardized assessment tool and measurement of oxygen saturation levels, with prescribed responses to abnormal values, during skin-to-skin care in the delivery room.
Pre-intervention, there were five SUPC events/9143 live births (incidence 0.54/1000 live births) compared with 0 SUPC events/13,964 live births post intervention, p = 0.011. Special cause variation was achieved after implementation when the number of deliveries between SUPC events exceeded 3-sigma.
A bundled approach to monitoring during skin-to-skin care, including measurement of oxygen saturation, was associated with no additional cases of SUPC.
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Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants within 24 h of birth. Pediatrics. 2011;127:e869–73.
Lehtonen L, Gimeno A, Parra-llorca A. Early neonatal death: a challenge worldwide. Semin Fetal Neonatal Med. 2017;22:153–60.
Ludington-Hoe SM, Morgan K. Infant assessment and reduction of sudden unexpected postnatal collapse risk during skin-to-skin contact. Newborn Infant Nurs Rev. 2014;14:28–33.
Feldman-Winter L, Goldsmith JP. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics . 2016;138:e20161889.
Lutz TL, Elliott EJ, Jeffery HE. Sudden unexplained early neonatal death or collapse: a national surveillance study. Pediatr Res. 2016;80:493–8.
Pejovic NJ, Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment. Acta Paediatr Int J Paediatr. 2013;102:680–8.
Becher J-C, Bhushan SS, Lyon AJ. Unexpected collapse in apparently healthy newborns--a prospective national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Neonatal Ed. 2012;97:F30–34.
Andres V, Garcia P, Rimet Y, Nicaise C, Simeoni U. Apparent life-threatening events in presumably healthy newborns during early skin-to-skin contact. Pediatrics. 2011;127:e1073–1076.
Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47.
Thach BT. Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards. J Perinatol. 2014;34:275–9.
Neuburger J, Walker K, Sherlaw-Johnson C, Van Der Meulen J, Cromwell DA. Comparison of control charts for monitoring clinical performance using binary data. BMJ Qual Saf. 2017;26:919–28.
Feldman-Winter L. Evidence-based interventions to support breastfeeding. Pediatr Clin North Am. 2013;60:169–87.
Policy Statement. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841.
ACOG Committee Opinion. Optimizing support for breastfeeding as part of obstetric Practice. Committee opinion 756. Obstet Gynecol. 2018;132:e187–e196.
Meek JY, Noble L. Implementation of the ten steps to successful breastfeeding saves lives. JAMA Pediatr. 2016;170:925–6.
Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170:923–4.
Garofalo NA, Pellerite M, Goodstein M, Paul DA, Hageman JR. Sudden unexpected postnatal collapse (SUPC): one neonatal death is one death too many. Current concepts. Neonatol Today. 2019;14:55–58.
Garofalo NA, Pellerite M, Goodstein M, Paul DA, Hageman JR. Sudden unexpected postnatal collapse (SUPC): one neonatal death is one too many Part 2: Collaborative Quality Initiatives. 2019;14:4–6.
The project was completed with no specific financial support.
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The authors declare that they have no conflict of interest.
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Paul, D.A., Johnson, D., Goldstein, N.D. et al. Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse. J Perinatol 39, 1008–1013 (2019). https://doi.org/10.1038/s41372-019-0393-y
The Journal of Pediatrics (2020)