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Resuscitationandsupportoftransitionofbabiesatbirth
1.Theguidelineprocess
2.Introduction
3.Physiologyofacuteperinatalhypoxia
4.Importantguidelinechanges
5.Suggestedsequenceofactions
6.Postresuscitationcare
7.ExplanatoryNotes
8.Acknowledgements
9.References

Authors
JonathanWyllie,SeanAinsworth,RobertTinnion

1.Theguidelineprocess
TheprocessusedtoproducetheResuscitationCouncil(UK)Guidelines2015hasbeenaccreditedbytheNationalInstituteforHealthandCare
Excellence.Theguidelinesprocessincludes:
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Systematicreviewswithgradingofthequalityofevidenceandstrengthofrecommendations.Thisledtothe2015InternationalLiaison
CommitteeonResuscitation(ILCOR)ConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascularCareSciencewith
TreatmentRecommendations.
Theinvolvementofstakeholdersfromaroundtheworldincludingmembersofthepublicandcardiacarrestsurvivors.
DetailsoftheguidelinesdevelopmentprocesscanbefoundintheResuscitationCouncil(UK)GuidelinesDevelopmentProcessManual.
www.resus.org.uk/publications/guidelinesdevelopmentprocessmanual/
TheseResuscitationCouncil(UK)GuidelineshavebeenpeerreviewedbytheExecutiveCommitteeoftheResuscitationCouncil(UK),which
comprises25individualsandincludeslayrepresentationandrepresentationofthekeystakeholdergroups.

2.Introduction
Untilsuchtimethatthenewlyborninfanthassuccessfullymadethetransitiontoairbreathingitisdependentontheplacentaandumbilicalcordfor
respiration.Thenormalfunctionofbothofthesemaybeinterruptedbyanumberofpathologicaleventsbeforeorduringthebirthprocess(e.g.by
placentalabruption,cordentanglement,etc.)givingrisetoahypoxicinsultthatmaybeacute,chronicorboth(acuteonchronic).
Passagethroughthebirthcanalitselfisarelativelyhypoxicexperienceforthefetus,sincesignificantrespiratoryexchangeattheplacentais
interruptedforthe5075sdurationoftheaveragecontraction.1Althoughmostinfantstoleratethiswell,thefewthatdonotmayrequirehelpto
establishnormalbreathingatdelivery.Themajorityoftheseinfantsmerelyrequiresupportedperinataltransitionratherthanresuscitation.
Resuscitationorsupportoftransitionismorelikelytobeneededbybabieswithintrapartumevidenceofsignificantfetalcompromise,babies
deliveringbefore35weeksgestation,babiesdeliveringvaginallybythebreech,maternalinfectionandmultiplepregnancies.2Furthermore,
caesareandeliveryisassociatedwithanincreasedriskofproblemswithrespiratorytransitionatbirthrequiringmedicalinterventions36especially
fordeliveriesbefore39weeksgestation.However,electivecaesareandeliveryattermdoesnotincreasetheriskofneedingnewbornresuscitation
intheabsenceofotherriskfactors.710
Someinfantsneedsupportatbirthforreasonsotherthanhypoxia(e.g.infection),howevertheinitialapproachtotheseinfantsfollowsthesame
algorithm.
Newbornlifesupport(NLS)isintendedtoprovidethishelpandcomprisesthefollowingelements:
Enablingplacentaltransfusion(whenabletodoso)bydelayingtheclampingoftheumbilicalcord.
Dryingandcoveringthenewborninfant,andwherenecessarytakingadditionalsteps,tomaintainanormalbodytemperature(i.e.between
36.5Cand37.5C).
Assessingtheinfantsconditionandtheneedforanyintervention.
Maintaininganopenairway.
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Iftheinfantisnotbreathing,aeratingthelungswithinflationbreaths.
Continueventilatingapnoeicinfantsuntilrespirationisestablished.
Iftheheartremainslessthan60min1after5effectiveinflationbreathsand30secondsofeffectiveventilation,startchestcompressions.
Administrationofdrugs(rarely).

3.Physiologyofacuteperinatalhypoxia
Ifsubjectedtosufficienthypoxiainutero,orduringpassagethroughthebirthcanal,thefetuswillattempttobreathe.Ifthehypoxicinsultis
continuedthefetuswilleventuallyloseconsciousness.Shortlyafterthistheneuralcentresinthebrainstemwhichcontrolthesebreathingefforts
willceasetofunctionbecauseoflackofoxygen.Thefetusthenentersaperiodofabsentrespiratoryeffortknownasprimaryapnoea.
Uptothispoint,theheartrateremainsunchanged,butsoondecreasestoabouthalfthenormalrateasthemyocardiumrevertstoanaerobic
metabolismalessfuelefficientprocess.Thecirculationtononvitalorgansisreducedinanattempttopreserveperfusionofvitalorgans.The
releaseoflacticacid,abyproductofanaerobicmetabolism,causesdeteriorationofthebiochemicalmilieu,addingtotherespiratoryacidosisfrom
theaccumulationofcarbondioxide.
Ifthehypoxicinsultcontinues,shudderingagonalgasps(wholebodyrespiratorygaspsatarateofabout12min1)areinitiatedbyprimitivespinal
reflexes.Ifthefetusremainsinutero,orif,forsomeotherreason,thesegaspsfailtoaeratethelungs,theyfadeawayandthefetusentersa
periodknownassecondary,orterminal,apnoeawithnofurtherspontaneousbreathing.Untilnow,thecirculationhasbeenmaintainedbut,as
terminalapnoeaprogresses,therapidlyworseningacidosis,dwindlingsubstrateforanaerobicmetabolismandongoinganoxiabeginstoimpair
cardiacfunction.Thehearteventuallyfailsand,withouteffectiveintervention,thefetusdies.Thewholeprocessprobablytakesupto20mininthe
humanfetusatterm.
Thus,inthefaceofanoxia,theinfantcanmaintainaneffectivecirculationthroughouttheperiodofprimaryapnoea,throughthegaspingphase,
andevenforawhileaftertheonsetofterminalapnoea.Thereforethemosturgentrequirementforanyseverelyhypoxicinfantatbirthisthatthe
lungsbeaeratedeffectively.Providedtheinfantscirculationisfunctioningsufficientlywell,oxygenatedbloodwillthenbeconveyedfromthe
aeratedlungstotheheart.Theheartratewillincreaseandthebrainwillbeperfusedwithoxygenatedblood.Followingthis,theneuralcentres
responsiblefornormalbreathingwillusuallyfunctiononceagainandtheinfantwillrecover.
Merelyaeratingthelungsissufficientinthevastmajorityofcases.11Lungaerationandsubsequentventilationremainscentraltoalleffortsto
resuscitateanewborninfant,butinafewcasescardiacfunctionwillhavedeterioratedtosuchanextentthatthecirculationisinadequateand
cannotconveyoxygenatedbloodfromtheaeratedlungstotheheart.Inthiscase,abriefperiodofchestcompressionmaybeneededaswellas
aerationofthelungs.Inanevensmallernumberofcases,lungaerationandchestcompressionwillnotbesufficient,anddrugsmayberequiredto
restorethecirculation.Theoutlookinthisgroupofinfantsremainspoor.

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4.Importantguidelinechanges
ThefollowingarethechangesthathavebeenmadetotheNLSguidelinesin2015,12,13somebuildonorexpandthechangesthatwere
introducedin2010.14,15
Foruncompromisedtermandpreterminfants,adelayincordclampingofatleastoneminutefromthecompletedeliveryoftheinfant,is
nowrecommended.Asyetthereisinsufficientevidencetorecommendanappropriatetimeforclampingthecordininfantswhoareseverely
compromisedatbirth.Forinfantsrequiringresuscitation,resuscitativeinterventionremainstheimmediatepriority.Stripping(ormilking)of
thecordisnotrecommendedasaroutinemeasureexceptinthecontextoffurtherrandomisedtrials.
Thetemperatureofnewlyborninfantsisactivelymaintainedbetween36.5Cand37.5Cafterbirthunlessadecisionhasbeentakento
starttherapeutichypothermia.Theimportanceofachievingthishasbeenhighlightedandreinforcedbecauseofthestrongassociationwith
mortalityandmorbidity.Eventhemildhypothermiathatwasoncefelttobeinevitableandthereforeclinicallyacceptablecarriesarisk.The
admissiontemperatureshouldberecordedasapredictorofoutcomesaswellasaqualityindicator.
Preterminfantsoflessthan32weeksgestationmaybenefitfromacombinationofinterventionstomaintaintheirbodytemperaturebetween
36.5Cand37.5Cafterdeliverythroughstabilisationandneonatalunitadmission.Thesemayinclude
Warmedhumidifiedrespiratorygases16
Thermalmattressalone17
Acombinationofincreasedroomtemperaturewithplasticwrappingofheadandbodywiththermalmattress18
Allofthesecombinationshavebeeneffectiveinreducinghypothermia.Inaddition,thedeliveryroomtemperatureshouldbeatleast26C
forthemostimmatureinfants.
AnECG,ifavailable,cangivearapidaccurateandcontinuousheartratereadingduringnewbornresuscitation.19Itdoesnot,however,
indicatethepresenceofacardiacoutputandshouldnotbethesolemeansofmonitoringtheinfant.
Resuscitationofterminfantsshouldcommenceinair.Forpreterminfants,alowconcentrationofoxygen(2130%)shouldbeusedinitially
forresuscitationatbirth.If,despiteeffectiveventilation,oxygenation(ideallyguidedbyoximetry)remainsunacceptable,useofahigher
concentrationofoxygenshouldbeconsidered.Blendedoxygenandairshouldbegivenjudiciouslyanditsuseguidedbypulseoximetry.Ifa
blendofoxygenandairisnotavailableusewhatisavailable.Ifchestcompressionsareadministered,supplementaloxygenshouldbe
increased.
Attemptstoaspiratemeconiumfromthenoseandmouthoftheunborninfant,whiletheheadisstillontheperineum,arenotrecommended.
Theemphasisshouldbeoninitiatinglunginflationwithinthefirstminuteoflifeinnonbreathingorineffectivelybreathinginfantsandthis
shouldnotbedelayed.Ifpresentedwithafloppy,apnoeicinfantbornthroughthickparticulatemeconiumitisreasonabletoinspectthe
oropharynxrapidlytoremovepotentialobstructions.Trachealintubationshouldnotberoutineinthepresenceofmeconiumandshouldonly
beperformedforsuspectedtrachealobstruction.
Nasalcontinuouspositiveairwayspressure(CPAP)ratherthanroutineintubationmaybeusedtoprovideinitialrespiratorysupportofall
spontaneouslybreathingpreterminfantswithrespiratorydistress.EarlyuseofnasalCPAPshouldalsobeconsideredinthose
spontaneouslybreathingpreterminfantswhoareatriskofdevelopingrespiratorydistresssyndrome(RDS).12,13,20
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Therecommendedcompression:ventilationratioforCPRremainsat3:1fornewbornresuscitation.Asynchronouscompressionsarenot
recommended.

5.Suggestedsequenceofactions
Keeptheinfantwarmandassess
Infantsarebornsmallandwet.Theygetcoldveryeasily,especiallyiftheyremainwetandinadraught.Foruncompromisedinfants,adelayin
cordclampingofatleastoneminutefromthecompletedeliveryoftheinfant,isrecommended.Allowingplacentaltransfusionensuresamore
gradualtransitiontoextrauterinelifepreventingsuddenchangesinvenousreturntotheheartandthepotentialimpactoftheseonblood
pressure.
Whateverthesituationitisimportantthattheinfantdoesnotgetcold.Inallcaseswhetherinterventionisrequiredornot,drythetermornearterm
infant,removethewettowels,andcovertheinfantwithdrytowels.Significantlypreterminfantsarebestplaced,withoutdrying,intopolyethylene
wrappingunderaradiantheater.Ininfantsofallgestations,theheadshouldbecoveredwithanappropriatelysizedhat.Thetemperaturemustbe
activelymaintainedbetween36.5Cand37.5Cafterbirthunlessadecisionhasbeentakentostarttherapeutichypothermia.Theadmission
temperatureshouldalwaysberecordedasapredictorofoutcomesaswellasaqualityindicator.
Thisprocesswillprovidesignificantstimulationandwillallowtimetoassesstheinfantsbreathing,andheartrate.Anoteshouldbemadeofthe
colourandtone,althoughtheseareoflesserimportanceindeterminingtheimmediateapproachtobetakentheycanpointtowardstheseverely
acidaemicbaby(potentiallyrequiringsubstantialresuscitation)oranaemicbaby(potentiallyrequiringurgenttransfusion).
Reassessbreathingandheartrateregularlyevery30sorsothroughouttheresuscitationprocessbutitistheheartrate,whichisthekey
observation.Thefirstsignofanyimprovementintheinfantwillbeanincreaseinheartrate.Considertheneedforhelpifneeded,askforhelp
immediately.
Ahealthyinfantwillbebornbluebutwillhavegoodtone,willcrywithinafewsecondsofdeliveryandwillhaveagoodheartratewithinafew
minutesofbirth(theheartrateofahealthynewborninfantisabout120150min1).Alesshealthyinfantwillbeblueatbirth,willhavelessgood
tone,mayhaveaslowheartrate(lessthan100min1),andmaynotestablishadequatebreathingby90120s.Anunwellinfantwillbebornpale
andfloppy,notbreathingandwithaslow,verysloworundetectableheartrate.
Inthefirstfewminutes,theheartrateofaninfantisusuallyjudgedbestbylisteningwithastethoscope.Itmayalsobefeltbygentlypalpatingthe
umbilicalcordbutasloworabsentrateatthebaseoftheumbilicalcordisnotalwaysindicativeofatrulyslowheartrate.Feelingforanyofthe
peripheralpulsesisnothelpful.
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AnECGisthemostaccuratewaytoobtainarapidandcontinuousheartratereadingbutmaynotbeimmediatelyavailable,norwillitgivean
indicationofacardiacoutput.19Apulseoximetercangiveacontinuousheartrateandoximetryreadinginthedeliveryroom.Withpracticeitis
possibletoattachapulseoximeterprobeandtoobtainausefulreadingofheartrateandoxygensaturationabout90safterdelivery.21

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Figure1.Newbornlifesupportalgorithm

A4sizealgorithm:http://resus.org.uk/_resources/assets/attachment/full/0/6462.pdf

Airway
Beforetheinfantcanbreatheeffectivelytheairwaymustbeopen.Thebestwaytoachievethisistoplacetheinfantonhisbackwiththeheadin
theneutralposition(i.e.withtheneckneitherflexednorextended).Mostnewborninfantswillhavearelativelyprominentocciput,whichwilltendto
flextheneckiftheinfantisplacedonhisbackonaflatsurface.Thiscanbeavoidedbyplacingsomesupportundertheshouldersoftheinfant,but
takecarenottooverextendtheneck.Iftheinfantisveryfloppy(i.e.hasnoorverylittletone)itisusuallynecessarytosupportthejawwithajaw
thrust.Thesemanoeuvreswillbeeffectiveforthemajorityofinfantsrequiringairwaystabilisationatbirth.

Airwaysuctionimmediatelyfollowingbirthshouldbereservedforinfantswhohaveobviousairwayobstructionthatcannotberectifiedby
appropriatepositioningandinwhommaterialisseenintheairway.Rarely,material(e.g.mucus,blood,meconium,vernix)maybeblockingthe
oropharynxortrachea.Inthesesituations,directvisualisationandsuctionoftheoropharynxshouldbeperformed.Fortrachealobstruction,
intubationandsuctionduringwithdrawaloftheendotrachealtubemaybeeffective.Thislattermanoeuvreshouldonlybeperformedby
appropriatelytrainedstaffand,ifperformed,shouldnotundulydelaytheonsetofinflationbreathsandsubsequentventilation.

Breathing
Mostinfantshaveagoodheartrateafterbirthandestablishbreathingbyabout90s.Iftheinfantisnotbreathingadequatelyaeratethelungsby
giving5inflationbreaths,preferablyusingair.Untilnowtheinfant'slungswillhavebeenfilledwithfluid.Aerationofthelungsinthese
circumstancesislikelytorequiresustainedapplicationofpressuresofabout30cmH2Ofor23stheseare'inflationbreaths'.Beginwithlower
pressures(2025cmH2O)inpreterminfants.
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Usepositiveendexpiratorypressure(PEEP)of45cmH2Oifpossible.Itisofdemonstrablebenefitinpreterminfantsbutshouldalsobeusedin
terminfants,althoughevidenceforitsbenefitinthisgroupofinfantsislackingfromhumanstudies.Iftheheartratewasbelow100min1initially
thenitshouldrapidlyincreaseasoxygenatedbloodreachestheheart.
Iftheheartratedoesincreasethenyoucanassumethatyouhavesuccessfullyaeratedthelungs.
Iftheheartrateincreasesbuttheinfantdoesnotstartbreathingforhimself,thencontinueventilationsatarateofabout3040min1until
theinfantstartstobreatheonhisown.
Iftheheartratedoesnotincreasefollowinginflationbreaths,theneitheryouhavenotaeratedthelungsortheinfantneedsmorethanlung
aerationalone.Byfarthemostlikelyisthatyouhavefailedtoaeratethelungseffectively.Iftheheartratedoesnotincrease,andthechest
doesnotpassivelymovewitheachinflationbreath,thenyouhavenotaeratedthelungs.

Ifthelungshavenotbeenaeratedthenconsider:
Checkingagainthattheinfantsheadisintheneutralposition?
Isthereaproblemwithfacemaskleak?
Doyouneedjawthrustoratwopersonapproachtomaskinflation?
Doyouneedalongerinflationtime?weretheinspiratoryphasesofyourinflationbreathsreallyof23sduration?
Isthereanobstructionintheoropharynx(laryngoscopeandsuction)?
Willanoropharyngeal(Guedel)airwayassist?
Isthereatrachealobstruction?
Checkthattheinfant'sheadandneckareintheneutralpositionthatyourinflationbreathsareatthecorrectpressureandappliedforsufficient
time(23sinspiration)andthatthechestmoveswitheachbreath.Ifthecheststilldoesnotmove,askforhelpinmaintainingtheairwayand
consideranobstructionintheoropharynxortrachea,whichmayberemovablebysuctionunderdirectvision.Anoropharyngealairwaymaybe
helpful.
Iftheheartremainsslow(lessthan60min1)orabsentafter5effectiveinflationbreathsand30secondsofeffectiveventilation,startchest
compressions.
IfyouaredealingwithapreterminfanttheninitialCPAPofapproximately5cmH2O,eitherviaafacemaskorviaaCPAPmachine,isan
acceptableformofsupportininfantswhoarebreathingbutwhoshowsignsof,orareatriskofdeveloping,respiratorydistress.Inpreterminfants
whodonotbreatheorbreatheinadequately,youshouldusePEEPwithyourinflationbreathsandventilationsasthelungsintheseinfantsare
morelikelytocollapseagainattheendofabreathusingPEEPpreventsthis.
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Chestcompression
Almostallinfantsneedinghelpatbirthwillrespondtosuccessfullunginflationwithanincreaseinheartratewithin30secondsfollowedquicklyby
normalbreathing.11,2224However,insomecaseschestcompressionisnecessary.Chestcompressionshouldbestartedonlywhenyouaresure
thatthelungshavebeenaeratedsuccessfully.
Ininfants,themostefficientmethodofdeliveringchestcompressionistogripthechestinbothhandsinsuchawaythatthetwothumbscanpress
onthelowerthirdofthesternum,justbelowanimaginarylinejoiningthenipples,withthefingersoverthespineattheback.Compressthechest
quicklyandfirmly,reducingtheanteroposteriordiameterofthechestbyaboutonethird.25
Theratioofcompressionstoinflationsinnewbornresuscitationis3:1.
Chestcompressionsmoveoxygenatedbloodfromthelungsbacktotheheart.Allowenoughtimeduringtherelaxationphaseofeachcompression
cycleforthehearttorefillwithblood.Ensurethatthechestisinflatingwitheachbreath.Youshouldincreasetheoxygenconcentrationifyouhave
reachedthisstageofresuscitation.Youshouldalsohavecalledforhelpandapulseoximeter,ifnotalreadyinuse,willbehelpfulinmonitoring
howyouaredoing.
Donotuseasynchronouscompressions,eveniftheinfanthasatrachealtubeplaced,asmaintainingairentryintothelungremainsasimportant
nowasitwasduringtheinitialaeration.Compressingthechestduringaventilationbreathmayreduceairentry,whichmaybeharmful.
Inaveryfewinfants(lessthanoneineverythousandbirths)inflationofthelungsandeffectivechestcompressionwillnotbesufficienttoproduce
aneffectivecirculation.Inthesecircumstancesdrugsmaybehelpful.

Drugs
Drugsareneededrarelyandonlyifthereisnosignificantcardiacoutputdespiteeffectivelunginflationandchestcompression.Theoutlookfor
mostinfantsatthisstageispooralthoughasmallnumberhavehadgoodoutcomesafterareturnofspontaneouscirculationfollowedby
therapeutichypothermia.
Thedrugsusedincludeadrenaline(1:10,000),occasionallysodiumbicarbonate(ideally4.2%),andglucose(10%).Allresuscitationdrugsarebest
deliveredviaanumbilicalvenouscatheterorifthisisnotpossiblethroughanintraosseousneedle.26,27
Therecommendedintravenousdoseforadrenalineis10microgramkg1(0.1mLkg1of1:10,000solution).Ifthisisnoteffective,adoseofupto
30microgramkg1(0.3mLkg1of1:10,000solution)maybetried.
Adrenalineistheonlydrugthatmaybegivenbythetrachealroute,althoughofunknownefficacyatbirth.Ifthisisused,itmustnotinterferewith
ventilationordelayacquisitionofintravenousaccess.Thetrachealdoseisthoughttobebetween50100microgramkg1.
Useofsodiumbicarbonateisnotrecommendedduringbriefresuscitation.Ifitisusedduringprolongedarrestsunresponsivetoothertherapy,it
shouldbegivenonlyafteradequateventilationandcirculation(withchestcompressions)isestablished.Thedoseforsodiumbicarbonateis
between1and2mmolofbicarbonatekg1(24mLkg1of4.2%bicarbonatesolution).
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Thedoseforglucose(10%)is2.5mLkg1(250mgkg1)andshouldbeconsiderediftherehasbeennoresponsetootherdrugsdelivered
throughacentralvenouscatheter.
Veryrarely,theheartratecannotincreasebecausetheinfanthaslostsignificantbloodvolume.Ifthisisthecase,thereisoftenaclearhistoryof
bloodlossfromtheinfant,butnotalways.Useofisotoniccrystalloidratherthanalbuminispreferredforemergencyvolumereplacement.Inthe
presenceofhypovolaemia,abolusof10mLkg1of0.9%sodiumchlorideorsimilargivenover1020swilloftenproducearapidresponseand
canberepeatedsafelyifneeded.

Whentostopresuscitation
Inanewlyborninfantwithnodetectablecardiacactivity,andwithcardiacactivitythatremainsundetectablefor10min,itisappropriatetoconsider
stoppingresuscitation.Thedecisiontocontinueresuscitationeffortsbeyond10minwithnocardiacactivityisoftencomplexandmaybeinfluenced
byissuessuchastheavailabilityoftherapeutichypothermiaandintensivecarefacilities,thepresumedaetiologyofthearrest,thegestationofthe
infant,thepresenceorabsenceofcomplications,andtheparentspreviousexpressedfeelingsaboutacceptableriskofmorbidity.Thedifficultyof
thisdecisionmakingemphasisestheneedforseniorhelptobesoughtassoonaspossible.
Whereaheartratehaspersistedatlessthan60min1withoutimprovement,during1015minofcontinuousresuscitation,thedecisiontostopis
muchlessclear.Noevidenceisavailabletorecommendauniversalapproachbeyondevaluationofthesituationonacasebycasebasisbythe
resuscitatingteamandseniorclinicians.

Communicationwiththeparents
Itisimportantthattheteamcaringforthenewbornbabyinformstheparentsofthebabysprogress.Atdelivery,adheretotheroutinelocalplan
and,ifpossible,handthebabytothemotherattheearliestopportunity.Ifresuscitationisrequiredinformtheparentsoftheproceduresundertaken
andwhytheywererequired.Recordalldiscussionsanddecisionsinthebabysrecordsassoonaspossibleafterbirth.

6.Postresuscitationcare
Therapeutichypothermia
Termornearterminfants,withevolvingmoderatetoseverehypoxicischaemicencephalopathy,shouldbetreatedwiththerapeutic
hypothermia.2831Wholebodycoolingandselectiveheadcoolingarebothappropriatestrategies.2833Coolingshouldbeinitiatedandconducted
underclearlydefinedprotocolswithtreatmentinneonatalintensivecarefacilitiesandthecapabilitiesformultidisciplinarycare.Treatmentshould
beconsistentwiththeprotocolsusedintherandomisedclinicaltrials(i.e.commencecoolingwithin6hofbirth,continuethecoolingfor72hbefore
rewarmingtheinfantoveraperiodofatleast4h).Alltreatedinfantsshouldbefollowedlongitudinally.Passiveoractivetherapeutichypothermia
shouldonlyinstitutedfollowingaseniorclinicaldecision.
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Glucose
Infantswhoarepretermorrequiresignificantresuscitationshouldbemonitoredandtreatedtomaintainbloodglucoseinthenormalrange.
Hypoglycaemiashouldbeavoidedinbabiesdemonstratingsignsofevolvinghypoxicischaemicencephalopathyorwhoareundergoingtherapeutic
hypothermia.Aninfusionof10%glucoseratherthanrepeatedbolusesisusuallybestattreatinglowbloodglucosevaluesandmaintainingglucose
inthenormalrange.

7.ExplanatoryNotes
Resuscitationorstabilisation
Mostinfantsbornattermneednoresuscitationandtheycanusuallystabilisethemselvesduringthetransitionfromplacentaltopulmonary
respirationveryeffectively.Providedattentionispaidtopreventingheatloss(andavoidingoverwarming)andalittlepatienceisexhibitedbefore
cuttingtheumbilicalcord,interventionisrarelynecessary.However,someinfantswillhavesufferedstressesorinsultsduringlabour.Helpmay
thenberequiredwhichischaracterisedbyinterventionsdesignedtorescueasickorverysickinfantandthisprocesscanthenreasonablybe
calledresuscitation.
Significantlypreterminfants,particularlythosebornbelow30weeksgestation,aretreateddifferently.Mostinfantsinthisgrouparehealthyatthe
timeofdeliveryandyetallcanbeexpectedtobenefitfromhelpinmakingthetransition.Maintainingthetemperaturebetween36.5Cand37.5C
isevenmoreimportantthanfortermbabies.Interventioninthissituationisusuallylimitedtokeepinganinfanthealthyduringthistransitionandis
moreappropriatelycalledstabilisation.GentleairwaysupportusingCPAPratherthanventilationmaybeadequateformanyoftheseinfants.Inthe
pastbothsituationshavebeenreferredtoasresuscitationandthisseemsinappropriateandlikelytocauseconfusion.

Umbilicalcordclamping
Forhealthyterminfantsdelayingcordclampingforatleastoneminuteoruntilthecordstopspulsatingfollowingdeliveryimprovesironstatus
throughearlyinfancy.34Forpreterminfantsingoodconditionatdelivery,delayingcordclampingforupto3minresultsinincreasedblood
pressureduringstabilisation,alowerincidenceofintraventricularhaemorrhageandfewerbloodtransfusions.35However,infantsweremorelikely
toreceivephototherapy.Therearelimiteddataonthehazardsorbenefitsofdelayedcordclampinginthenonvigorousinfant.36,37
Delayingcordclampingforatleastoneminuteisrecommendedforallnewborninfantsnotrequiringresuscitation.12,13Atpresentthereis
insufficientevidencetodefineanappropriatetimetoclampthecordininfantswhoapparentlyneedresuscitation.However,thismaybebecause
timeisthewrongdefiningparameterandperhapsthecordshouldnotbeclampeduntiltheinfanthasstartedbreathing(orthelungsareaerated).
Stripping(ormilking)oftheumbilicalcordhasbeensuggestedasanalternativetodelayedcordclampingwhentheinfantisinneedof
resuscitationhoweverthereisinsufficientevidencetorecommendthisasaroutinemeasure.Umbilicalcordmilkingdid,however,produce
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improvedshorttermhaematologicaloutcomes,admissiontemperatureandurineoutputwhencomparedtodelayedcordclampinginoncerecent
study.38

Maintainingnormaltemperature(between36.5Cand37.5C)
Naked,wet,newborninfantscannotmaintaintheirbodytemperatureinaroomthatfeelscomfortablywarmforadults.Infantswhoare
compromisedareparticularlyvulnerabletotheeffectsofcoldstress,whichmaywilllowerarterialoxygentension39andincreasemetabolic
acidosis.40Activemeasureswillneedtobetakentoavoidhypothermia,especiallyinthepreterminfantwhereateamapproachandacombination
ofstrategiesmayberequired.Theneonatalunitadmissiontemperatureofnewborninfantsisastrongpredictorofmortalityatallgestationsandin
allsettings.4144Foreach1Cdecreaseinadmissiontemperaturebelowthisrangethereisanassociatedincreaseinmortalityby28%.45
Babiesbornoutsidethenormaldeliveryenvironmentmaybenefitfromplacementinafoodgradepolyethylenebagorwrapafterdryingandthen
swaddling.46,47Alternatively,wellnewborns>30weeksgestationwhoarebreathingmaybedriedandnursedwithskintoskincontactorkangaroo
mothercaretomaintaintheirtemperaturewhilsttheyaretransferred.4654Theyshouldbeprotectedfromdraughts.

Recommendation
Unlessyouhavedecidedtoimplementtherapeutichypothermia,takeactivestepstomaintainthetemperatureofthenewlyborninfantbetween
36.5Cand37.5Cfrombirthtoadmissionandthroughoutstabilisation.Iftheresuscitationisprolonged,considermeasuringtemperatureduring
theresuscitation.

Oximetryandtheuseofsupplementaloxygen
Ifresourcesareavailable,usepulseoximetryforalldeliverieswhereitisanticipatedthattheinfantmayhaveproblemswithtransitionorneed
resuscitation.Oxygensaturationandheartratecanbemeasuredreliablyduringthefirstminutesoflifewithamodernpulseoximeter.Datafrom
healthyspontaneouslybreathinginfantshasbeenusedtoinformwhenoxygenshouldbegiven(seealgorithm).55
Thesensormustbeplacedontherighthandorwristtoobtainanaccuratereadingofthepreductalsaturation.56,57Placementofthesensoron
theinfantbeforeconnectingtotheinstrumentmayresultinfasteracquisitionofsignal.Inmostcasesareliablereadingcanbeobtainedwithin90s
ofbirth.58Pulseoximetrycanalsoprovideanaccuratedisplayofheartrateduringperiodsofgoodperfusion.
Inhealthyterminfants,oxygensaturationincreasesgraduallyfromapproximately60%soonafterbirthtoover90%at10min.Inpreterminfants
hyperoxaemiaisparticularlydamagingandifoxygenisbeingusedandthesaturationisabove95%theriskofhyperoxaemiaishigh.Thereforethe
rateofriseinoxygensaturationafterbirthinpreterminfantsshouldnotexceedthatseeninterminfants,althoughsomesupplementaloxygenmay
berequiredtoachievethis.57,59

Colour
Usingcolourasaproxyforoxygensaturationisusuallyinaccurate.60However,notingwhetheraninfantisinitiallyverypaleand,therefore,either
acidoticoranaemicatdeliverymaybeusefulasanindicatorforlatertherapeuticintervention.
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ECGmonitoringofheartrate
Clinicalassessmentofheartrate,whetherbypalpationofthecordorapexoftheheartorbylisteningwithastethoscopetendstobe
inaccurate.61,62ThereisincreasingevidencesupportingtheuseofECGmonitoringasameansofrapidlydeterminingtheheartrateduring
resuscitationitisquickertoprovideanaccuratereadingthanpulseoximetrybutdoesrequirethattheECGleadsmakegoodcontactwiththe
skin.19,63

Airwaysuctioningwithorwithoutmeconium
Routineelectiveintubationandsuctioningofvigorousinfantsatbirth,doesnotreducemeconiumaspirationsyndrome(MAS).64Nordoes
suctioningthenoseandmouthofsuchinfantsontheperineumandbeforedeliveryoftheshoulders(intrapartumsuctioning).65Eveninnon
vigorousinfantsbornthroughmeconiumstainedamnioticfluidwhoareatincreasedriskofMAS,intubationandtrachealsuctioninghasnotbeen
showntoimprovetheoutcome.6668Thereisnoevidencetosupportsuctioningofthemouthandnoseofinfantsbornthroughclearamnioticfluid.

Recommendation
Routineintrapartumoropharyngealandnasopharyngealsuctioningforinfantsbornwithclearand/ormeconiumstainedamnioticfluidisnot
recommended.
Thepracticeofroutinelyperformingdirectoropharyngealandtrachealsuctioningofnonvigorousinfantsafterbirthwithmeconiumstained
amnioticfluidwasbaseduponpoorevidence.Thepresenceofthick,viscousmeconiuminanonvigorousinfantistheonlyindicationforinitially
consideringvisualisingtheoropharynxandsuctioningmaterial,whichmightobstructtheairway.Ifaninfantbornthroughmeconiumstained
amnioticfluidisalsofloppyandmakesnoimmediaterespiratoryeffort,thenitisreasonabletorapidlyinspecttheoropharynxwithaviewto
removinganyparticulatematterthatmightobstructtheairway.Trachealintubationshouldnotberoutineinthepresenceofmeconiumandis
performedonlyforsuspectedtrachealobstruction.6872Theemphasisisoninitiatingventilationwithinthefirstminuteoflifeinnonbreathingor
ineffectivelybreathinginfantsandthisshouldnotbedelayed,especiallyinthebradycardicinfant.

Laryngealmask
Severalstudieshaveshownthatlaryngealmaskairways(LMAs)canbeusedeffectivelyatbirthtoventilatethelungsofinfantsweighingover
2000g,greaterthan33weeksgestationandapparentlyneedingresuscitation.7377CasereportssuggestthatLMAshavebeenusedsuccessfully
whenintubationhasbeentriedandfailedandoccasionallyviceversa.OnesmallrandomisedstudyhassuggestedthatLMAsmayreducethe
needforintubationcomparedtofacemaskventilation,78howeverLMAscostaboutthreetimesasmuchanditisnotclearhowmanyoftheinfants
resuscitatedusinganLMAwouldhaverespondedtogoodqualityfacemaskventilation.DataonLMAuseinsmallerorlessmatureinfantsare
scarce.

Recommendation
ConsiderusinganLMAduringresuscitationofthenewborninfantiffacemaskventilationisunsuccessfulandtrachealintubationisunsuccessfulor
notfeasible.TheLMAmaybeconsideredasanalternativetoafacemaskforpositivepressureventilationamongnewborninfantsweighingmore
78

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than2000gordelivered34weeksgestation.78TheLMAmaybeconsideredasanalternativetotrachealintubationasasecondaryairwayfor
resuscitationamongnewborninfantsweighingmorethan2000gordelivered34weeksgestation.78Thereislimitedevidenceevaluatingitsuse
fornewborninfantsweighing<2000gordelivered<34weeksgestationandnoneforthoseinfantsreceivingcompressions.

UseoftheLMA,nonetheless,shouldbelimitedtothoseindividualswhohavebeentrainedtouseit.Itsusehasnotbeenevaluatedinthesetting
ofmeconiumstainedfluid,duringchestcompressions,orfortheadministrationofemergencyintratrachealmedications.

Exhaledcarbondioxide
Detectionofexhaledcarbondioxideconfirmstrachealintubationinneonateswithacardiacoutputmorerapidlyandmoreaccuratelythanclinical
assessmentalone.Itwillnot,however,distinguishbetweencorrectplacementwiththetipofthetrachealtubeinthetracheaandincorrectinsertion
withthetipintherightmainbronchus(i.e.toolong).Falsenegativereadingsmayoccurinverylowbirthweightneonatesandininfantsduring
cardiacarrest(inthesecasesabriefperiodofchestcompressionsmaybringaboutacolourchangeasmorecarbondioxideisdeliveredtothe
lungs).Falsepositivesmayoccurwithcolorimetricdevicescontaminatedwithadrenaline,surfactantandatropine.

Drugsinresuscitationatbirth
Ventilationandchestcompressionmayfailtoresuscitatefewerthan1in1000infants.23Inthisgroup,resuscitationdrugsmaybejustified.Whilst
thereisevidencefromanimalstudiesforbothadrenalineandsodiumbicarbonateinbringingaboutreturnofspontaneouscirculation,thereisno
placebocontrolledevidenceinhumaninfantsfortheeffectivenessofanydruginterventioninthissituation.Evenforadultsandchildrenincardiac
arrest,thereisinsufficientevidencetosuggestthatvasopressorsimprovelongtermsurvival.
Forthisreasonuseofdrugsbeforeachievinglungaerationfollowedbychestcompressions(knowntobeeffectiveresuscitativeinterventions)can
neverbejustified.12,13

Glucose
Hypoglycaemiaisassociatedwithadverseneurologicaloutcomeinaneonatalanimalmodelofhypoxiaandresuscitation.79Newbornanimalsthat
werehypoglycaemicatthetimeofahypoxicischemicinsulthadlargerareasofcerebralinfarctionand/ordecreasedsurvivalcomparedto
controls.80,81However,onlyasingleclinicalstudyhasshownanassociationbetweenhypoglycaemiaandpoorneurologicaloutcomefollowing
perinatalhypoxia.82Inadults,childrenandextremelylowbirthweightinfantsreceivingintensivecare,hyperglycaemiaisassociatedwithaworse
outcome.8084However,inchildren,hyperglycaemiaafterhypoxiaischaemiadoesnotappeartobeharmful,85whichconfirmsdatafromanimal
studies86someofwhichsuggestitmayevenbeprotective.87Thesituationremainsunclearandunfortunately,therangeofbloodglucose
concentrationthatisassociatedwiththeleastbraininjuryfollowingasphyxiaandresuscitationcannotbedefinedbasedonavailableevidence.

8.Acknowledgements
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TheseguidelineshavebeenadaptedfromtheEuropeanResuscitationCouncil2015Guidelines.Weacknowledgeandthanktheauthorsofthe
ERCGuidelinesforResuscitationandsupportoftransitionofbabiesatbirth:
JonathanWyllie,JosBruinenberg,CharlesChristophRoehr,MarioRdiger,DanieleTrevisanuto,BerndtUrlesberger.

NICEhasaccreditedtheprocessusedbyResuscitationCouncil(UK)toproduceitsGuidelinesdevelopmentProcessManual.
Accreditationisvalidfor5yearsfromMarch2015.Moreinformationonaccreditationcanbeviewedatwww.nice.org.uk/accreditation

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