Prone or Supine Effect After Caesarean Delivery on Respiratory Outcomes in Full Term Infants
Prone or Supine Effect After Caesarean Delivery on Respiratory Outcomes in Full Term Infants
Investigators will compare 500 full term babies delivered by SCD randomized into two groups,
 prone or supine position. Investigators will use a Panda warmer with built in Nellcor pulse
 oximeter. Each infant will have heart rate (HR), oxygen saturation via pulse oximetry,
 respiratory rate and respiratory effort documented every 1 minute for the first 5 minutes of
 life; beyond the initial 5minutes of life, monitoring as well as infant's management will be
 done as per current Weiler hospital protocols. The intervention group will be placed in prone
 position for first five minutes immediately after birth, and then changed to supine position.
 The control group will be placed supine from birth. Investigators will check for the
 incidence and severity of RD, supplemental oxygen need and duration, positive pressure
 ventilation (PPV) need and duration or other use of respiratory support (intubation).
 Additionally, investigators will record the number of infants requiring admission to the NICU
 in each group, days of ventilatory support as well as the length of hospitalization.
1. Consent obtained prior to actual operative delivery and anesthesia

 2. Prior to start of surgery an opaque envelope with random selection of post delivery
 position, supine or prone, is opened

 3. Pediatric team confirms with Obstetrician and delivery team the position in which the
 infant will be given to pediatrics

 4. Pediatric team member accepting the infant stays by the operating room table to observe
 the delivery At actual delivery, the Panda radiant warmer Apgar clock will be started by
 a Pediatric team member positioned at the warmer when the baby is delivered. Vitals
 signs of HR, color and oxygen saturations will be recorded each minute for first five
 minutes. Respiratory effort will be noted. The Apgar clock is available to document the
 timing of the minute intervals heart rate and oxygen saturations on the preprinted grid
 of the survey data sheet.

 6. When a Group A (supine) infant's transfer is made to Pediatrics, the infant will be kept
 in the supine position in transit to warmer and on warmer until first towel drying completed,
 30 - 60 seconds, consistent with NRP protocol. Pulse oximetry and temperature probe will be
 placed. Vitals signs of HR, color and oxygen saturations will be recorded each minute for
 first five minutes. Respiratory effort will be noted.

 When a Group B (start in prone position) the obstetrician places the baby in prone position,
 clamps and cuts cord. The baby is given to Pediatrics in the prone position. The infant will
 be kept in the prone position in transit to warmer and on warmer for first towel drying
 completed. Pulse oximetry and temperature probe will be placed. Vitals signs of HR, RR and
 oxygen saturations will be recorded each minute for first five minutes. Respiratory effort
 will be documented.

 7. As toweling is changed the baby in prone position continues as such until five minutes
 pass. After five minutes the baby is turned to supine position as per standard NRP protocol.

 8. Decision to initiate positive pressure ventilation and /or oxygen supplementation will be
 guided by published NRP 2010 lower saturation targets (1 min <60%, 2 min <65%, 3 min <70%, 4
 min <75%, 5 min <80%) and/or by grunting, retractions ; discontinuation by high saturation
 targets (1min >65%, 2 min >70%, 3min >>75%, 4 min >80%, 5 min >85%) and resolution of
 respiratory distress. Positive pressure ventilation will be delivered via Neopuff device in
 supine position (both groups); CPAP 5cm 21% initially, then the amount of oxygen will be
 titrated to meet oxygen saturation target for given minute of life.

 9. After no more than 30 minutes, Primary Assignment for admission to the NBN vs. NICU is
 made by a trained member of the study who was not in the operating room at the beginning of
 the delivery when the initial positioning of the infant was revealed. This is possible with
 24 hour coverage from attendings, fellows, and mid-level practioners. Determination is based
 on Weiler NICU admission protocols.

 10. If infant is to go to NBN then STS and breastfeeding protocols will be followed.

 11. Infants developing respiratory distress in the NBN will be transferred to the NICU for
 further evaluation and care 12. Infants admitted to NICU directly or via NBN would have vital
 signs monitored as per NICU nursing protocol until discharge 13. Documentation of Length of
 Stay in NBN or NICU will collected 14. Documentation of intensity of care, type of support,
 maximum FiO2 required and duration of respiratory support in NICU will be collected.
Inclusion Criteria:

 -  Obstetrical patients delivering at Weiler Hospital.

 -  Any woman not in labor, who is undergoing scheduled caesarean deliveries at term (37 -
 42 completed weeks of gestation),

 Exclusion Criteria:

 -  Women with prior rupture of membranes

 -  Women receiving magnesium sulfate

 -  Women with known illegal drug history

 -  fetus with known congenital anomalies or if meconium stained fluid is present.

 -  mother with maternal fever, chorioamnionitis

 -  babies experiencing fetal distress e.g. abnormal fetal heart tracing,

 -  non vigorous newborn at birth (defined as per NRP guidelines as infant with
 apnea/gasping, heart rate <100/min, poor tone).