Journal of Clinical Neonatology

: 2021  |  Volume : 10  |  Issue : 3  |  Page : 165--169

Reducing intraventricular hemorrhage in preterm babies less than 30 weeks of gestation in neonatal intensive care unit, level III: A bundle of care

Souher El Amouri1, Alica Bystricka2, Amrtha Paulose3, Maqbool Qadir4, Junaid Muhib Khan5,  
1 Department of Nursing Education, Al Rahba Hospital, Abu Dhabi, UAE
2 Consultant Neonatologist, Neonatal Intensive Care Unit, Mediclinic MAIR, USA
3 Neonatologist, Neonatal Intensive Care Unit, Corniche Hospital, Abu Dhabi, UAE
4 Consultant Neonatologist, Neonatal Intensive Care Unit, Madinat Zayed Hospital, Abu Dhabi, UAE
5 Director of Medical Education, Associate Director of Pediatrics Residency Program, Senior Consultant Neonatology, Neonatal Intensive Care Unit, Shakhbout Medical City/Mayo Clinics, UAE/USA

Correspondence Address:
Souher El Amouri
Department of Nursing Education, former Al Rahba Hospital, Abu Dhabi Currently, Al Jalila Children Specialty Hospital, Dubai


Intraventricular hemorrhage (IVH) is bleeding into the brain's ventricular system or around the ventricles. The etiology of IVH is multifactorial and is primarily attributed to the fragility of the germinal matrix vasculature and disturbance of cerebral blood flow. IVH is rarely present at birth. Infants born before the 30th week of gestation and weighting <1500 g at birth are at risk for this type of bleeding. The smaller and more premature, unstable infants are at the highest risk for IVH. It occurs more often in the first several days of life. This situation creates immense burden and dilemma for health-care providers mainly when challenged by family choice to withdraw support or do-not-resuscitate incompatible with country law. Purpose: To reduce the overall incidence of IVH to <10% among preterm babies born <30 weeks of gestation using a neuro bundle of care. Methodology: A quality descriptive improved project was conducted in one government sector hospital in Abu Dhabi, Level III neonatal intensive care unit. It was a retrospective study where the data were collected from 2018 to 2019. A multidisciplinary team was formed to implement the neurobundle. Descriptive statistics were used to describe the demographic and clinical finding of the project. Results: Five out of 32 infants and 1 out of 17 infants developed IVH (Grade IV), respectively, in 2018 and 2019. Conclusion: The IVH rate in premature neonates has reduced drastically from 19% (preintervention) to 6% (postintervention) due to implementation IVH bundle and staff compliance.

How to cite this article:
El Amouri S, Bystricka A, Paulose A, Qadir M, Khan JM. Reducing intraventricular hemorrhage in preterm babies less than 30 weeks of gestation in neonatal intensive care unit, level III: A bundle of care.J Clin Neonatol 2021;10:165-169

How to cite this URL:
El Amouri S, Bystricka A, Paulose A, Qadir M, Khan JM. Reducing intraventricular hemorrhage in preterm babies less than 30 weeks of gestation in neonatal intensive care unit, level III: A bundle of care. J Clin Neonatol [serial online] 2021 [cited 2021 Oct 26 ];10:165-169
Available from:

Full Text


Intraventricular hemorrhage (IVH) is one of the major complications of preterm, and it is considered a main concern for families and neonatologist. It continues to pose the challenges in neonatal intensive care units (NICUs) worldwide.[1] Regardless of ethnic group or nationality, premature babies <30 weeks of gestation are more prone to have IVH due to many factors. Ballabh[2] indicated that IVH develops in the first 3 days of life and preterm are relatively immune to hemorrhage after this period regardless of the gestational age; however, Al-Abdi and Al-Aamri[3] indicated that most of IVH occurs in 0–6 and after 24 h of life. The IVH occurs to the inherent fragility of the germinal matrix vasculature, disturbance in the cerebral blood flow, and platelet and coagulation disorders.[2],[4] In addition to that preterm infants lack the ability to regulate cerebral blood flow which could increases or decreases in response to many factors related to pain, stress, routine handling, hypoglycemia, and respiratory distress syndrome (Ballabh[2] and Inder et al.[5] as cited in Steiner[6]). The neurological complications can range from 50% to 75% of neurodevelopmental disabilities and are mainly associated with IVH.[7] The severity of IVH depends on hemorrhage occurs in the ventricles of the brain and it is classified into four levels of grading. According to McCrea and Ment,[8] Grade 1 includes germinal matrix hemorrhage; Grade 2 consists of intraventricular blood without distension of the ventricular system; Grade 3 includes blood filling and distending the ventricular system; however, Grade 4 compromises of periventricular venous infarction. This creates a huge burden psychologically and financially on the family due to hospitalization and poor outcome. A study conducted by Christian et al.[9] in the United States aimed to describe the trends in hospitalization of preterm infants with IVH and posthemorrhagic hydrocephalus (PHH) using the Nationwide Inpatient Sample and Kids Inpatient Database from 2000 to 2010. The authors found that there was a progressive increase in hospital stay for IVH and PHH. As well as the hospital cost per patient has also increased from $201,578 to $353,554 (IVH) and $260,077 to $495,697 (PHH) over 11 years. There have been numerous bundles of measures that have been introduced in NICU and aimed to prevent and reduce the severity of IVH such as delayed cord clamping, minimal handling for the first few hours, avoiding head down position, antenatal corticosteroids, and establishing standard diagnostic.[1] This was emphasized by Chiriboga et al.[10] indicating that neurobundles can decrease the incidence and severity of IVH.

Although the overall percentage of IVH in the hospital where the project was conducted was 19%, which was within the range described in the literature 15%–30%.[11],[12],[13],[7] The medical team was challenged by family choice to withdraw care of an infant which was the trigger to initiate this project. A mother at 23 weeks of gestation was admitted to the obstetric ward because of premature contractions and was informed at any time that she will deliver a premature baby. The mother asked to abort her baby because she did not want to have a mentally retarded baby. The physicians took time to convince her; however, they failed. She was informed that she will be violating the law of the country. The baby was born on 24 weeks of gestation and the mother refused to see the baby. The aim of this study is to reduce the overall incidence of IVH to <10% among preterm babies born <30 weeks of gestation using a bundle of care.


The present study was conducted from April to December 2019, used quality improvement project methodology to assess the effectiveness of implementation of a neuroprotective bundle in a Level III NICU in one of the government hospitals in UAE. The project aimed to reduce the overall incidence of IVH to <10% among preterm babies born <30 weeks of gestation using neurobundle of care. 2018 data were used as a baseline data for this study and it included infant born from March to December 2018, with gestational age <30 weeks of gestation and weighed <1500 g.

A checklist was used to assess the staff adherence to neuroprotective bundle consisting of midline head positioning during the 1st week of life, elevating the head of the incubator for 30°, maintaining normothermia 36.5°C–37°C, optimizing respiratory management, a minimal handling, and standardizing infusion rates for boluses/blood products, blood sampling technique, implementation of pain/stress reducing technique [Figure 1] were utilized in the first 72 h of life for all preterm infants. The checklist was adapted from Green[14] that used best evidence-based practice strategies identified from the literature review and mainly from Vermont Oxford Network (VON) that provides the variety of toolkits applicable to the NICU.[14] VON is a voluntary organization started in 1988 from 34 neonatal units in the United States to cover over 1500 neonatal units in 42 countries worldwide and aimed at improving the quality through a coordinated program of data-driven quality improvement, education, and research.[15]{Figure 1}

The target group of the study included <30 weeks gestation and weighing <1500 g. A convenient sample was used and composed of total 17 babies who met the inclusion criteria and was admitted to the NICU. Each neonate has bedside head ultrasound done at day 1, 3, and 7. As well as, baseline head ultrasound was obtained on the day of admission if transferred in from other facilities.

The project was presented in the Comprehensive Unit-based Safety Program (CUSP) committee meeting. The committee focuses on the culture of safety where physicians, nurses, and other clinical team members work together to improve the quality of care. CUSP aims to provide a learning environment by preventing future errors and risks of harm through identifying the errors and learning about the root causes[16] and to discuss the ways on how to improve the quality of care. The committee members meet once per month. The members discussed the case of preterm infant who the family would like to abort. The Committee introduced the neurobundle of care and discussed the ways in how to reduce IVH. There were many questions about the feasibility of implementing the project, and all the concerns were clarified. Later on a task force was formed to include nurses, physicians, and respiratory therapist. Nurses developed PowerPoint presentation and verified the content with the consultant. The PowerPoint presentation included pathophysiology of IVH, aim of the project, benefits, and how to implement the bundles. The presentation was given in half hour sessions, and the questions and queries raised at the end of the session were recorded. The education was completed within 10 days until it covered all health-care providers.

Checklist [Figure 1] was distributed to all nurses and physician through E-mails, everyday during rounds the consultants and education team follows up the nurses' adherence to the bundle of care.

Nurses, respiratory therapist, and physicians were educated and instructed in how to follow the checklist. Some of the interventions that included team collaboration in checklist included under the title of minimal stimulation. The interventions included cluster cares by coordinating with physicians nurses and respiratory therapist and keep cell phones on the silent mode and visitors were educated as well to do the same.

Descriptive statistical analysis was conducted on the retrospective data that were collected on 2018 and 2019.

An ethical approval was obtained from hospital institutional review board, and all patients' information were coded and stored in the shared folder protected by a password.


Data were collected in NICU included 32 infants from March to December 2018 and 17 infants from April to December 2019, all were <30 weeks of gestation. Five out of 32 infants and one out of 17 infants developed IVH (Grade IV), respectively, in 2018 and 2019.

[Table 1] represents the demographic data of infant born 2018 and 2019. The data present predominantly 47% of 24–27 weeks of gestation in 2019 which indicating the higher risk for IVH and 81% for newborn were between 1000 and 1500 g from 2018.{Table 1}

The overall incidence of IVH fell from 19% (6 infant) in 2018 to 6% (one infant) in 2019 and in particular by reduction of 9.6% in Grade IV, as shown in [Table 1] and [Figure 2].{Figure 2}


Although the incidence of premature was predominant in 2019 (47%) compared (31%) in 2018 in regard to gestational age 24–27 weeks, the study showed the success of implementation neuro-bundle with a positive outcome, the overall IVH rate dropped from 19% to 6% in preterm <30 weeks of gestation. The result of this study was consistent as reported in other studies.[10],[6],[17],[18] Standardizing the care and educating the health-care providers in NICU were the main contributor for making this project successful. This project helped staff to learn more about the pathophysiology of brain damage, importance of minimal handling, and to provide care when needed. Only one infant developed severe IVH due to extreme prematurity and with an early_ onset Escherichia coli infection. Maternal chorioamnionitis and early-onset sepsis are among the predisposing factors of germinal matrix hemorrhage.[19] Early-onset E. coli sepsis in preterm infants could be related with increased risk of severe IVH.[20]

Although the results of this project support the utilization of a neuroprotective bundle, the results could not be generalized due to small sample size. Moreover, due to sample size and study used retrospective data which already collected, that prohibited from conduction other statistical analysis such as using comparative assessment; however, the data presented provided some solid information. It is recommended to replicate the study in other hospital settings, including larger sample and to conduct over a longer period of time. This project provided additional evidence to the literature mainly from the gulf area about the impact of use of neuro-bundle in standard of care in NICU to reduce the incidence of IVH. The most rewarding aspect of this project was that the case presented earlier yielded in a positive healthy child with no IVH after using neurobundle during infant' hospitalization.


Neuroprotective bundle interventions are a promising modality that helps in reducing IVH and its success rely mainly on staffs compliance in implementing IVH bundle. It is important to focus on sustaining the implementation of neurobundle to have a consistent improved quality of care.


We would like to extend our gratitude to Nursing Team at Neonatal Intensive Care Department, and in particular Anitha Seethapathy, Myla Amat, and Nurhaida Hassan for their valuable contribution to the study by educating staff and collecting the data.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1El-Atawi K, Elhalik M, Kulkarni T, Abdelsamed A, Alexander L, Satyan A. Risk factors, diagnosis, and current practices in the management of intraventricular hemorrhage in preterm infants: A review. Acad J Ped Neonatol 2016;1:555-61.
2Ballabh P. Pathogenesis and prevention of intraventricular hemorrhage. Clin Perinatol 2014;41:47-67.
3Al-Abdi SY, Al-Aamri M. A systematic review and meta-analysis of the timing of early intraventricular hemorrhage in preterm neonates: Clinical and research implications. J Clin Neonatol 2014;3:76-88.
4Turova V, Sidorenko I, Eckardt L, Rieger-Fackeldey E, Felderhoff-Müser U, Alves-Pinto A, et al. Machine learning models for identifying preterm infants at risk of cerebral hemorrhage. PloS One 2020;15:e0227419.
5Inder TE, Perlman JM, Volpe JJ. Preterm intraventricular hemorrhage/post hemorrhagic hydrocephalus. In: Volpe JJ, Inder TE, Darras BT, deVries LS, du Plessis AJ, Neil JJ, et al., editors. Volpe's Neurology of the Newborn. Philadelphia: Elsevier; 2018. p. 637-98.
6Steiner I. Implementing a neuro-bundle in a level III neonatal intensive care unit. In: Doctor of Nursing Practice Degree Thesis. Maryland, USA: UMB Digital Archive; 2019.
7Gilard V, Tebani A, Bekri S, Marret S. Intraventricular hemorrhage in very preterm infants: A comprehensive review. J Clin Med 2020;9:1-11.
8McCrea HJ, Ment LR. The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clin Perinatol 2008;35:777.
9Christian EA, Jin DL, Attenello F, Wen T, Cen S, Mack WJ, et al. Trends in hospitalization of preterm infants with intraventricular hemorrhage and hydrocephalus in the United States, 2000-2010. J Neurosurg Pediatr 2016;17:260-9. doi: 10.3171/2015.7.PEDS15140. Epub 2015 Nov 6. PMID: 26544084.
10Chiriboga N, Cortez J, Pena-Ariet A, Makker K, Smotherman C, Gautam S, et al. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing sever ICH: A quality improvement project. J Perinatol 2019;39:143-51.
11Schmid MB, Reister F, Mayer B, Hopfner RJ, Fuchs H, Hummler HD. Prospective risk factor monitoring reduces intracranial hemorrhage rates in preterm infants. Dtsch Arztebl Int 2013;110:489-96.
12El-Atawi K, Elhalik M, Kulkarni T, Zakaria A, Abdelsamed A, Alexander L, et al. The first sixty minutes in preterm neonates' life: Predicted morbidities and interventions. J Pediatr Neonatal Care 2018;8:1-8.
13Al-Mouqdad MM, Abdelrahim A, Abdalgader AT, Alyaseen N, Khalil TM, Taha MY, et al. Risk factors for intraventricular hemorrhage in premature infants in the central region of Saudi Arabia. Int J Pediatr Adolesc Med. 2021 Jun;8(2):76-81. doi:10.1016/j.ijpam.2019.11.005. Epub 2019 Nov 25. PMID: 34084876; PMCID: PMC8144857.
14Green N. Reducing Intraventricular Haemorrhage. (Master's Projects and Capstones, University of San Francisco, San Francisco, USA); 2017. Available from: [Last accessed on 2020 Oct 22].
15Edwards EM, Ehret DE, Soll RF, Horbar JD. Vermont Oxford Network: A worldwide learning community. Transl Pediatr 2019;8:182-92.
16Rockville. The Comprehensive Unit-based Safety Program (CUSP). Agency for Healthcare Research and Quality; 2017. Available from: -surgery/sections/implementation/implementation-guide/guide- cusp.html. [Last accessed on 2020 Oct 22].
17Christ L, Barber J, Murray A, Dunleavy M, Stoller J, Taha D, et al. Reducing intraventricular hemorrhage in a level III Neonatal interventricular intraventricular hemorrhage. BMJ Qual Saf 2015;15:731-2.
18de Bijl-Marcus K., Brouwe AJ, De Vries LS, Groenendaal F, Wezel-Meijler GV. Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: A multicentre cohort study. Arch Dis Child Fetal Neonatal Ed 2020;105:419-24.
19Villamor-Martinez E, Fumagalli M, Mohammed Rahim O, Passera S, Cavallaro G, Degraeuwe P, et al. Corrigendum: Chorioamnionitis is a risk factor for intraventricular hemorrhage in preterm infants: A systematic review and meta-analysis. Front Physiol 2019;10:102.
20Ipsita G, Abhay L, Stacey D, Khorshid M. Early onset Escherichia coli sepsis and severe intraventricular hemorrhage in extremely premature infants: Cases series and literature review. Acad J Pediatr Neonatol 2017;3:555612.