Newborn resuscitation and support of transition of infants at birth Guidelines

• In management of the umbilical cord, clamping after at least 60 seconds is recommended, but if this is not possible cord milking is an option in babies > 28 weeks gestation. 
• In non-vigorous infants born through meconium, immediate laryngoscopy with or without suction after delivery is not recommended.  
• Laryngeal mask may be considered in infants of ≥ 34 weeks gestation (>~2000g) if face mask ventilation or tracheal intubation is unsuccessful. 
• If there is no response to initial inflations despite an open airway, consider increasing the inflation pressure. 
• A starting pressure of 25 cm H₂O is suggested for preterm infants < 32 weeks gestation.  
• Initial delivered oxygen concentration depends upon gestation:  
  • ≥ 32 weeks gestation - 21% oxygen  
  • 28-32 weeks - 21-30% oxygen 
  • < 28 weeks - 30% oxygen.  
• In babies < 32 weeks, delivered oxygen concentration should be titrated to achieve saturations of > 80% at 5 minutes.  
• Intraosseous access is an alternative method of emergency vascular access if umbilical access is not possible. 
• Both initial and subsequent IV/IO adrenaline doses are 20  micrograms kg^-1 (0.2 mL kg^-1 of 1:10,000 adrenaline (1000 micrograms in 10 mL)), in the absence of a response to CPR give repeat doses every 3-5 minutes. 
• Stopping resuscitation should be considered and discussed if there has been no response after 20 minutes and exclusion of reversible problems.  

Resuscitation Council UK (RCUK) has produced these Newborn Life Support Guidelines, based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. [NLS CoSTR’s 2019 and 2020], and the European Resuscitation Council Guidelines for Newborn resuscitation and support of transition of infants at birth. The guidelines cover the management of the term and preterm infant.   

RCUK and the ERC have produced guidance on newborn life support in the context of COVID-19. This is based on an ILCOR CoSTR and systematic review. Our understanding of the risks to infants potentially exposed to COVID-19 and the risk of virus transmission and infection to those providing care is evolving. Please check the RCUK website for the latest guidance for treatment and resuscitator precautions.   

The process used to produce the Resuscitation Council UK Guidelines 2021 is accredited by the National Institute for Health and Care Excellence (NICE). The guidelines process includes:

• Systematic reviews with grading of the certainty of evidence and strength of recommendations. This led to the International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.   
• The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors.   
• Details of the guidelines development process can be found in the Resuscitation Council UK Guidelines Development Process Manual.  

Transition and the need for assistance after birth 

• Most infants adapt well to extra-uterine life but some require help with stabilisation, or resuscitation. Up to 85% breathe spontaneously without intervention; a further 10% respond after drying, stimulation and airway opening manoeuvres; approximately 5% receive positive pressure ventilation. Intubation rates vary between 0.4 and 2%. Fewer than 0.3% of infants receive chest compressions and only 0.05% receive adrenaline. 

Risk factors 

• A number of risk factors have been identified as increasing the likelihood of requiring help with stabilisation, or resuscitation (Figure 1).

Figure 1: Common factors associated with an increased risk of a need for stabilisation, or resuscitation at birth 

Staff attending delivery 

• Any infant may develop problems during birth. Local guidelines indicating who should attend deliveries should be developed, based on current understanding of best practice and clinical audit, and taking into account identified risk factors (Figure 1). As a guide:  
  • Personnel competent in newborn life support should be available for every delivery.  
  • If intervention is required, there should be personnel available whose sole responsibility is to care for the infant. 
  • A process should be in place for rapidly mobilising a team with sufficient resuscitation skills for any birth.  

Equipment and environment 

• All equipment must be regularly checked and ready for use. 
• Where possible, the environment and equipment should be prepared in advance of the delivery of the infant. Checklists facilitate these tasks. 
• Resuscitation should take place in a warm, well-illuminated, draught-free area with a flat resuscitation surface and a radiant heater (if available). 
• Equipment to monitor the condition of the infant and to support ventilation should be immediately available. 
• Additional equipment that might be required in case of more prolonged resuscitation should be easily accessible.  

Planned home deliveries 

• Ideally, two trained professionals should be present at all home deliveries. 
• At least one must have received quality assured training in providing mask ventilation and chest compressions to the newborn infant. 
• Recommendations as to who should attend a planned home delivery vary but the decision to undergo such a delivery should not compromise the standard of initial assessment, stabilisation or resuscitation at birth. 
• Whilst rarely required, there are limitations to the provision of advanced resuscitation at home and this should be made clear to the mother. 
• A minimum set of equipment of an appropriate size for the newborn infant should be available, a suggested equipment list is available. 
• Caregivers undertaking home deliveries should have pre-defined plans for difficult situations.  
• Unexpected deliveries outside hospital are likely to involve emergency services that should be prepared and trained for such events and carry appropriate equipment. 

Briefing 

• If there is sufficient time, brief the team (roles, tasks, responsibilities, equipment, plan). 
• Checklists are helpful.  
• Prepare the family if it is anticipated that resuscitation might be required. 

Recommendations 

• Newborn resuscitation providers must have relevant current knowledge, technical and non-technical skills.  
• Structured educational programmes, teaching the knowledge and skills required for newborn resuscitation are required. 
• The content and organisation of such training programmes may vary according to the needs of the providers and the organisation of the institutions. 
• Programmes should include: 
  • newborn life support training carried out by appropriately qualified faculty 
  • regular practice and drills 
  • simulation including team and leadership training 
  • feedback  
  • objective, performance focused debriefings and reflection. 
• Ideally, training should be repeated at least once per year. 

Recommendations 

Standards 

• The infant’s temperature should be regularly monitored after birth and the admission temperature should be recorded as a prognostic and quality indicator.  
• The temperature of newborn infants should be maintained between 36.5 °C and 37.5 °C.  
• Hypothermia (≤ 36.0 °C) and hyperthermia (> 38.0 °C) should be avoided. In appropriate circumstances, therapeutic hypothermia may be considered after resuscitation (see post-resuscitation care). 

Environment 

• Protect the infant from draughts. Ensure windows are closed and air-conditioning appropriately programmed. 
• Keep the environment in which the infant is looked after (e.g. delivery room or theatre) warm at 23–25 °C.  
• For infants ≤ 28 weeks gestation the delivery room or theatre temperature should be > 25 °C.  

Term and near-term infants > 32 weeks gestation 

• Dry the infant immediately after delivery.  
• Cover the head and body of the infant with a warm towel. 
• If no resuscitation is required place the infant skin-to-skin with mother and cover both with a towel. Monitor to ensure continued normothermia. 
• If the infant needs support with transition or when resuscitation is required, place the infant on a warm surface using a preheated radiant warmer. 

Preterm infants ≤ 32 weeks gestation 

• Completely cover with polyethylene wrapping (apart from face) without drying and use a radiant warmer. 
• If umbilical cord clamping is delayed and a radiant warmer is not accessible other measures will be needed to ensure thermal stability while still attached to the placenta. 
• Further interventions which may be required include increased room temperature, warm blankets, head cap and thermal mattress.  
• Skin-to-skin care is feasible in less mature infants however caution is required in the more preterm or growth restricted infant in order to avoid hypothermia. 
• For infants receiving respiratory support, use of warmed humidified respiratory gases should be considered. 
• A quality improvement program including the use of checklists and continuous feedback to the team has been shown to significantly reduce hypothermia at admission in very preterm infants.  

Out of hospital management 

• Infants born unexpectedly outside a normal delivery environment are at higher risk of hypothermia and subsequent poorer outcomes. 
• They may benefit from placement in a food grade plastic bag after drying, followed by swaddling.  
• Well newborns > 30 weeks gestation may be dried and nursed skin-to-skin to maintain their temperature during transfer as long as mothers are normothermic.  
• Infants should be protected from draughts and watched carefully to ensure airway and breathing are not compromised.  

• The options for managing cord clamping and the rationale should be discussed with parents before birth. 
• Where immediate resuscitation or stabilisation is not required, aim to delay clamping the cord for at least 60 seconds. A longer period may be more beneficial. 
• Clamping should ideally take place after the lungs are aerated. 
• Where adequate thermal care and initial resuscitation interventions can be safely undertaken with the cord intact it may be possible to delay clamping whilst performing these interventions. 
• Where delayed cord clamping is not possible consider cord milking in infants > 28 weeks gestation. 

• A rapid initial assessment should usually occur before the umbilical cord is clamped and cut: 
  • Observe tone (and colour). 
  • Assess adequacy of breathing.  
  • Count the heart rate.  
  • Take appropriate action to keep the baby warm during these initial steps. 
  • This rapid assessment serves to establish a baseline, identify the need for support and/or resuscitation and the appropriateness and duration of delaying umbilical cord clamping. 
  • Frequent re-assessment of heart rate and breathing will guide whether further interventions are needed. 

Tactile stimulation 

• Initial handling is an opportunity to stimulate the infant during assessment by: 
  • drying the infant 
  • gently stimulating the infant as you dry them (e.g. rub the soles of the feet or back). Avoid more aggressive methods of stimulation. 

Tone and colour

• A very floppy infant is likely to need respiratory support.  
• Colour is a poor means of judging oxygenation as cyanosis can be difficult to recognise.  
• Pallor might indicate shock or rarely hypovolaemia – consider blood loss. 

Breathing 

• Is the infant breathing? - Note the rate, depth and symmetry, work/effort of breathing as: 
  • adequate 
  • inadequate/abnormal pattern - such as gasping or grunting 
  • absent. 

Heart rate 

• Determine the heart rate with a stethoscope and a saturation monitor +/- ECG (electrocardiogram) for later continuous assessment.  
  • Fast (≥ 100 min^-1) – satisfactory 
  • Slow (60-100 min^-1) – intermediate, possible hypoxia 
  • Very slow/absent(< 60 min^-1) – critical, hypoxia likely 
• If the infant fails to establish spontaneous and effective breathing following assessment and stimulation, and/or the heart rate does not increase, or decreases if initially fast, respiratory support should be started. 

Classification according to initial assessment 

• On the basis of the initial assessment, the infant can usually be placed into one of three groups as the following examples illustrate. 

 Preterm infants  

• Preterm babies should be managed in the same way as term babies with these considerations: 
  • Consider alternative/additional methods for thermal care e.g. polyethylene wrap. 
  • Apply a saturation probe +/- ECG. 
  • Gently support, initially with CPAP, if breathing.  

• Following initial assessment and intervention continue respiratory support if:  
  • The infant has not established adequate, regular breathing, or  
  • The heart rate is < 100 min^-1.  
• Ensuring an open airway, aerating and ventilating the lungs is usually all that is necessary. Without these, other interventions will be unsuccessful.  

During active resuscitation 

If the HR remains below 60 min^-1 despite adequate control of the airway, effective ventilation and chest compressions for 30 seconds, then consider: 

• Adrenaline:  
  • Intravenous is the preferred route, intra-osseus is an alternative:  
    • 20 micrograms kg^-1 (0.2 mL kg^-1 of 1:10,000 adrenaline [1000 micrograms in 10 mL]). 
  • intra-tracheal route if intubated and no other access available. 
    • 100 micrograms kg^-1 (1.0 mL kg^-1 of 1:10,000 adrenaline [1000 micrograms in 10 mL]) 
  • If tracheal adrenaline is given IV or IO access should still be sought. 
  • Subsequent doses every 3-5 minutes if heart rate remains < 60 min^-1. 
• Glucose: 
  • In a prolonged resuscitation to reduce likelihood of hypoglycaemia. 
  • Intravenous or intraosseous:  
    • 250 mg kg^-1 bolus (2.5 mL kg^-1 of 10% glucose solution). 
• Volume replacement 
  • With suspected blood loss or shock unresponsive to other resuscitative measures. 
  • Intravenous or intraosseous:  
    • 10 mL kg^-1 of group O Rh-negative blood or isotonic crystalloid. 
• Sodium bicarbonate: 
  • May be considered in a prolonged unresponsive resuscitation to reverse intracardiac acidosis.  
  • Intravenous or intraosseous:  
    • 1–2 mmol kg⁻¹ sodium bicarbonate (2–4 mL kg^-1 of 4.2% solution) by slow intravenous injection. 

• Consider other reversible factors (e.g. tension pneumothorax, hypovolaemia, equipment failure) or congenital abnormalities.

• Infants who have required resuscitation may later deteriorate. Post resuscitation care should be in an environment in which close monitoring can be provided. 
• Care provided during the resuscitation should be accurately documented. 

Glucose 

• Monitor glucose levels carefully after resuscitation. 
• Have protocols/guidance on the management of unstable glucose levels. 
• Avoid hyper- and hypoglycaemia. 
• Avoid large swings in glucose concentration. 
• Consider the use of a glucose infusion to avoid hypoglycaemia. 

Thermal Care 

• Aim to keep the temperature between 36.5 °C and 37.5 °C.  
• Rewarm if the temperature falls below this level and there are no indications to consider therapeutic hypothermia (see below). 

Therapeutic Hypothermia 

• Once resuscitated, consider inducing hypothermia to 33-34 °C in situations where there is clinical and/or biochemical evidence of significant risk of moderate or severe HIE (hypoxic-ischaemic encephalopathy). 
• Clearly document the evidence to justify treatment including cord blood gases and neurological examination. 
• Arrange safe transfer to a facility where monitoring and treatment can be continued. 
• Therapeutic hypothermia, without HIE, is likely to be harmful (see temperature maintenance). 

Documentation and Prognosis 

• Ensure clinical records allow:  
  • accurate retrospective evaluation of the clinical state of the infant at birth 
  • documentation of interventions and response during the resuscitation 

Where intervention is anticipated 

• Whenever possible, decisions to resuscitate an extremely preterm or clinically complex infant should include close consultation with the parents and senior clinicians. 
• Discuss options, including the potential need and magnitude of resuscitation and the prognosis before delivery to develop an agreed plan. 
• Carefully record all discussions and decisions in the mother’s notes prior to delivery and in the infant’s records after birth.  

For every birth 

• It is reasonable for mothers/fathers/partners to be present during the resuscitation where circumstances, facilities and parental inclination allow. 
• The views of both the team leading the resuscitation and the parents must be taken into account in decisions on parental attendance.  
• Parents should be kept informed of the resuscitation or stabilisation care provided to their infant. 
• Witnessing the resuscitation of their infant may be distressing for parents. If possible, identify a member of healthcare staff to support them and to keep them informed during resuscitation.  
• Allow parents to hold or even better to have skin-to-skin contact with their infant as soon as possible after delivery or resuscitation, even if unsuccessful. 
• Provide an explanation of any procedures and why they were required as soon as possible after the delivery. 
• Ensure a record is kept of events and any subsequent conversations with parents. 
• Allow for further discussions at a later time to allow parents to reflect and to aid parental understanding of events. 
• Consider what additional support is required for parents following delivery and any resuscitation. 

• Recommendations must be interpreted in the light of current national/regional outcomes.  
• When discontinuing, withdrawing or withholding resuscitation, care should be focused on the comfort and dignity of the infant and family. 
• Such decisions should ideally involve senior paediatric/neonatal staff.  
• Where life-sustaining treatment is withheld or withdrawn, infants should be provided with appropriate palliative (comfort-focused) care. 

Discontinuing resuscitation 

• When the heart rate has been undetectable for >10 minutes after delivery, review: 
  • clinical factors (e.g. gestation, dysmorphic features) 
  • effectiveness of resuscitation 
  • clinical team views about continuing resuscitation.  
• Stopping resuscitation should be discussed and occur if there has been no response after 20 minutes and reversible problems have been excluded.   
• Partial or incomplete heart rate improvement with resuscitative efforts makes treatment decisions more complex. It may be appropriate to take the infant to the intensive care unit and consider withdrawing life sustaining treatment if they do not improve. 

Withholding resuscitation 

• Decisions about withholding life sustaining treatment should usually be made after discussion with parents in the light of regional or national evidence on outcomes.  
• Attempted resuscitation is usually not appropriate where there is extremely high (> 90%) predicted neonatal mortality and unacceptably high morbidity in surviving infants.  
• Resuscitation is nearly always indicated if there is a high (> 50%) survival rate and what is deemed to be acceptable morbidity.  
• Resuscitation should also usually be commenced in situations where there is uncertainty about outcome and there has been no chance to have prior discussions with parents. 
• In conditions where there is low survival (< 50%), high morbidity and the anticipated burden of medical treatment for the child is high, parental wishes regarding resuscitation should be sought and usually supported.

Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres JW, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Szyld E, Trevisanuto D, Velaphi S, Weiner GM; Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.  https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 33098917.  

Madar J, Roehr CR, Ainsworth S, Ersdal H, Morley C, Rüdiger M, Szczapa S, tePas A, Trevisanuto D, Urlesberger B, Wilkinson D, Wyllie JP. European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014 

Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar J, Berg K, Olasveengen T, Wychoff M, Greif, R, Singletary N, Castren M, de Caen A, Wang T, Escalante R, Merchant R, Hazinski M, Kloeck D, Heriot G, Neumar R, Perkins GD on behalf of the International Liaison Committee on Resuscitation.  COVID-19 infection risk to rescuers from patients in cardiac arrest. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 2020 March 30. Available from: http://ilcor.org

Systematic Review COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley PT, Nolan JP, Soar J, Perkins GD.Resuscitation. 2020 Jun;151:59-66. https://pubmed.ncbi.nlm.nih.gov/32325096/. Epub 2020 Apr 20 Search updated: 5th August 2020. No change to Treatment Recommendation. 

Dawson JA, Kamlin CO, Vento M, Wong C, Cole TJ, Donath SM, Davis PG, Morley CJ. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010 Jun;125(6):e1340-7. https://pubmed.ncbi.nlm.nih.gov/20439604/ Epub 2010 May 3. PMID: 20439604. 

Wyllie JP, Wyckoff MH, de Almeida MF, Aziz K, El-Naggar W, Fabres JG, Fawke J, Foglia EE, Guinsburg R, Hosono S, Isayama T, Kawakami B, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Sugiura T, Trevisanuto D, Weiner GM and Dainty KN. Family Presence During Neonatal Resuscitation. International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, Nov 2020. Available from: http://ilcor.org 

British Association of perinatal Medicine. Perinatal Management of Extreme Preterm Birth before 27 weeks of gestation A Framework for Practice October 2019