We have read with great interest the study by Abbey et al. recently published in Pediatric Research.1 This randomized clinical trial demonstrates that, although feasible, the use of electrocardiogram (ECG) for heart rate (HR) monitoring in the delivery room (DR) neither modifies resuscitation maneuvers nor decreases the time to stabilization in preterm infants. Therefore, the potential benefits of faster and more accurate HR readings compared to pulse oximetry (PO) do not seem to translate into a clinical benefit yet. In our opinion, the important results of this study should not be understood as a confirmation of the lack of usefulness of ECG in the DR. As the authors of this publication acknowledge, time to stabilization may not be the best outcome to assess the utility of ECG. In this regard, we present two cases of severely depressed neonates at birth in which HR monitoring with ECG was critical for the success of DR resuscitation.

The first case is a male newborn of 30 + 1 weeks gestational age born via emergency cesarean section due to persistent fetal bradycardia and hydrops fetalis. Pregnancy was uneventful with normal routine ultrasounds and laboratory tests. The mother was 34 years old and apparently healthy. Prenatal steroids were not administered. At birth, the baby was hydropic, apneic, hypotonic, and bradycardic. He required intubation, chest compressions, and several doses of intravenous (i.v.) epinephrine. Pleural and peritoneal drainage was performed and 5 ml of serous pleural fluid and 8 ml of ascitic fluid were obtained. Despite resuscitation efforts, HR remained <60 b.p.m. ECG as well as PO were used for HR monitoring from birth. After 10 min of resuscitation, the attending team noticed a dissociation of p and QRS waves on the ECG tracing. AV block was suspected and an intracavitary pacemaker was placed through the umbilical vein after which HR was stabilized at 135 b.p.m. First and fifth minute Apgar scores were 4/4. Cord pH was 7.32 and 6.89 at 30 min of life. The baby was transferred to the neonatal intensive care unit (NICU) with normal HR and SpO2 of 90% on 100% oxygen. During admission, he developed severe respiratory distress syndrome and pulmonary hypertension with profound hemodynamic instability and died 48 h after birth despite treatment. Maternal systemic lupus erythematosus with positive anti-Ro/La antibodies was diagnosed as the cause of congenital heart block.

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