As we know, this study was the first attempt to investigate the Resuscitation and neonatal outcomes of the neonates in Mashhad; however, the data collection was limited to one hospital.

 The findings of this study showed that the initial steps of resuscitation, including oxygen therapy, and warm keeping, were performed in 73.79% of infants.In a study conducted by Afjeh et al., it was revealed that out of the 4629 live births, 4522 newborns (97.7% of live births) recovered through early steps of resuscitation (10). In a study performed by Wyckoff et al. (11), it was indicated that 37949 infants out of 37972 neonates did not receive any resuscitation, including positive-pressure ventilation, chest compressions, and medications. Hornik et al. (12) showed that 2231 (0.25%) out of 887,910 hospitalized infants needed cardiopulmonary resuscitation.

After the initial steps of resuscitation, the positive pressure ventilation was the most frequent resuscitative activity and performed on 20.30% of neonates who needed resuscitation. Among 87464 infants born in IWK Health Centre in Nova Scotia, Canada, positive pressure ventilation was conducted for 3658 (4.2%) of neonates at birth (13). In a retrospective study conducted by Bensouda et al. (14) in Montreal, Canada, it was revealed that out of 131 neonates born in Maisonneuve Rosemont Hospital, 113 received positive pressure ventilation in the delivery room. According to Niles et al. (15), there were 6812 live deliveries in the US tertiary academic hospital within 18 months and 401 (6%) of these newborns received positive pressure ventilation.

According to the 2010 International Liaison Committee on Resuscitation guidelines, the initial steps of cardio –respiratory resuscitation are delayed cord clamping, keeping a neutral temperature, applying pulse oximetry and
if needed non-invasive ventilation. Poor respiratory drive, muscular weakness, delay in the maturation of both the Na⁺/K⁺ ATP are dependent pumps and surfactant metabolism are known as important factors for positive pressure ventilation and oxygen supplementation in neonates (10). Preterm infants after birth cannot normally achieve normal body temperature (10) since newborn babies are vulnerable to room temperature. The environmental heat that feels comfortably warm for adults is not suitable
for them (11). The association between hypothermia and mortality during hospital stay has been known for more than a century (9), especially in preterm and/or very low birth weight infants (11). Hypothermia at birth has been also associated with serious morbidities, such as intraventricular hemorrhage, need for respiratory support, hypoglycemia, and late-onset sepsis (9).

In the current study, 0.7% and 0.47% of infants required chest compressions and drug intervention, respectively (no of births: 4683, no of chest compressions: 33, and no of drug intervention: 15). According to a systematic review conducted by European resuscitation council, the application of chest compressions and/or use of adrenaline was observed just in 0.1% of babies born at term condition (9). In a 2-year study of Perlman and Risser (16), it was shown that out of 30,839 newborns, 0.12% of infants needed chest compression or drug administration. According to a study conducted by Aziz et al. for 2 years (17), 0.1% of the neonates needed chest compression and 0.08% of them needed the administration of epinephrine (no of newborns: 4565). Wall et al. (18) reported the need for chest compression and drug intervention in 0.1% and 0.05% of neonates, respectively. A study carried out by Trevisanuto et al. (19) showed that 0.25% and 0.18% of neonates were resuscitated using chest compression and drug administration, respectively, along with other therapeutic measures.

As was shown in the current study, the rate of cesarean was higher than normal vaginal delivery (52.66% versus 47.44%, respectively).On the basis of the literature, cesarean delivery can increase the issues related to respiratory transition at birth, through which medical interventions are required, especially for deliveries before the gestational age of 39 weeks (20, 21).

In the present study, 179 deaths occurred out of 4683 births. This mortality rate (3.8%) included both dead birth and death in the delivery room. In a study performed by Alexander et al. (22), the NMR values of American infants were 3.24%, 3.45%, and 8.16% for whites, Hispanics, and blacks, respectively.The rate of dead births was indicative of the poor quality of cares during pregnancy and neonatal deaths during the first hours of infant life. This indicated the low quality of care services before, during, and after delivery (23).

According to the results of this study, 18% of births occurred at gestational age lower than 36 weeks. In a study carried out by Sareshtedari et al. (3), gestational age 2), 82.7% of neonatal deaths were related to infants with birth weight of 2500 g and less.The United States reported a decrease in infant mortality rates to 89% between 1915 and 1998 (25). Despite neonatal survival strategies has progressed since 1980, no remarkable improvement was observed in reducing the low birth weight  and preterm delivery during this period (26).

Conclusion

This study was conducted to evaluate Imam Reza Hospital of Mashhad as a tertiary care center in Iran in terms of resuscitation and neonatal outcomes. The obtained results of the current study were indicative of that higher rate for cesarean surgery compared to normal vaginal delivery. The mortality rate, the number of low birth weight, and the rate of resuscitation actions were higher compared to the reported results of the studies conducted in developed countries. Accordingly, it is needed to study this issue at the national level with respect to CPR consequences in Iran.

Acknowledgements

       We thank to personals of delivery room specially midwifes at Imam Reza hospital Mashhad north east Iran.

Conflicts of interest

      The authors declare no conflicts of interest.