Most babies born at term need no resuscitation and they can usually stabilise themselves during the transition from placental to pulmonary respiration very effectively. Provided attention is paid to preventing heat loss and a little patience is exhibited before cutting the umbilical cord, intervention is rarely necessary.
Resuscitation or support of transition is more likely to be needed by babies with intrapartum evidence of significant fetal compromise, babies delivering before 35 weeks gestation, babies delivering vaginally by the breech, maternal infection and multiple pregnancies. Furthermore, caesarean delivery is associated with an increased risk of problems with respiratory transition at birth requiring medical interventions especially for deliveries before 39 weeks gestation. However, elective caesarean delivery at term does not increase the risk of needing newborn resuscitation in the absence of other risk factors.
Cord clamping
For uncompromised term and preterm infants, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended. Allowing placental transfusion ensures a more gradual transition to extrauterine life preventing sudden changes in venous return to the heart and the potential impact of these on blood pressure. As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who are severely compromised at birth. For infants requiring resuscitation, resuscitative intervention remains the immediate priority.
Preventing heat loss
The temperature of newly born infants is actively maintained between 36.5°C and 37.5°C after birth unless a decision has been taken to start therapeutic hypothermia. The admission temperature should always be recorded as a predictor of outcomes as well as a quality indicator. In all cases whether intervention is required or not, dry the term or near-term infant, remove the wet towels, and cover the infant with dry towels. Significantly preterm infants are best placed, without drying, into polyethylene wrapping under a radiant heater. In infants of all gestations, the head should be covered with an appropriately sized hat.
APGAR assessment
A healthy infant will be born blue but will have good tone, will cry within a few seconds of delivery and will have a good heart rate within a few minutes of birth (the heart rate of a healthy newborn infant is about 120–150/min). A less healthy infant will be blue at birth, will have less good tone, may have a slow heart rate (less than 100/min), and may not establish adequate breathing by 90–120 s. An unwell infant will be born pale and floppy, not breathing and with a slow, very slow or undetectable heart rate.
| Sign/Score |
0 |
1 |
2 |
| Appearance (colour) |
Pale blue |
Body pink, extremities blue |
Completely pink |
| Pulse rate |
Absent |
< 100 |
> 100 |
| Grimace (reflex irritability) |
No response to stimulation |
Grimaces when stimulated |
Cries when stimulated |
| Activity (muscle tone) |
Limp |
Some flexion of extremities |
Active |
| Respiratory effort |
Absent |
Slow/irregular |
Strong cry |
Newborn Life Support (NLS) algorithm
- Consider the need for help; if needed, ask for help immediately.
- Dry the baby
- Maintain normal temperature
- Start the clock or note the time
- Assess tone, breathing and heart rate
- If gasping or not breathing:
- Open the airway
- Give five inflation breaths
- Consider SpO2 +/- ECG monitoring
- Reassess:
- If no increase in heart rate, look for chest movement during inflation
- If chest is not moving:
-
- Recheck head position
- Consider 2-person airway control and other airway manoeuvres
- Repeat inflation breaths
- SpO2 +/- ECG monitoring
- Look for a response
- When the chest is moving:
- If heart rate is not detectable or very slow (< 60/min), ventilate for 30 seconds
- Reassess heart rate:
- If heart rate is still < 60/min, start chest compressions, coordinating with ventilation breaths in a ratio of 3:1
- Reassess heart rate every 30 seconds:
- If heart rate is not detectable or very slow (< 60/min), consider venous access and drugs
Airway
Before the infant can breathe effectively the airway must be open. The best way to achieve this is to place the infant on his back with the head in the neutral position (i.e. with the neck neither flexed nor extended). Most newborn infants will have a relatively prominent occiput, which will tend to flex the neck if the infant is placed on his back on a flat surface. This can be avoided by placing some support under the shoulders of the infant, but take care not to overextend the neck. If the infant is very floppy (i.e. has no or very little tone) it is usually necessary to support the jaw with a jaw thrust. These manoeuvres will be effective for the majority of infants requiring airway stabilisation at birth.
Airway suction immediately following birth should be reserved for infants who have obvious airway obstruction that cannot be rectified by appropriate positioning and in whom material is seen in the airway. Rarely, material (e.g. mucus, blood, meconium, vernix) may be blocking the oropharynx or trachea. In these situations, direct visualisation and suction of the oropharynx should be performed. For tracheal obstruction, intubation and suction during withdrawal of the endotracheal tube may be effective. This latter manoeuvre should only be performed by appropriately trained staff and, if performed, should not unduly delay the onset of inflation breaths and subsequent ventilation.
Breathing
Most infants have a good heart rate after birth and establish breathing by about 90 s. If the infant is not breathing adequately aerate the lungs by giving 5 inflation breaths, preferably using air. Until now the infant's lungs will have been filled with fluid. Aeration of the lungs in these circumstances is likely to require sustained application of pressures of about 30 cm H2O for 2–3 s; these are 'inflation breaths'. Begin with lower pressures (20–25 cm H2O) in preterm infants. Use positive end-expiratory pressure (PEEP) of 4–5 cm H2O if possible.
If the heart rate was below 100 min-1 initially then it should rapidly increase as oxygenated blood reaches the heart.
- If the heart rate does increase then you can assume that you have successfully aerated the lungs.
- If the heart rate increases but the infant does not start breathing for himself, then continue ventilations at a rate of about 30–40 min-1 until the infant starts to breathe on his own.
- If the heart rate does not increase following inflation breaths, then either you have not aerated the lungs or the infant needs more than lung aeration alone. By far the most likely is that you have failed to aerate the lungs effectively. If the heart rate does not increase, and the chest does not passively move with each inflation breath, then you have not aerated the lungs.
- If the lungs have not been aerated, check that the infant's head and neck are in the neutral position; that your inflation breaths are at the correct pressure and applied for sufficient time (2–3 s inspiration); that there is no face mask leak; and that the chest moves with each breath.
- If the chest still does not move, ask for help in maintaining the airway and consider an obstruction in the oropharynx or trachea, which may be removable by suction under direct vision. An oropharyngeal airway may be helpful.
- If the heart remains slow (less than 60 min-1) or absent after 5 effective inflation breaths and 30 seconds of effective ventilation, start chest compressions.
If you are dealing with a preterm infant then initial CPAP of approximately 5 cm H2O, either via a face mask or via a CPAP machine, is an acceptable form of support in infants who are breathing but who show signs of, or are at risk of developing, respiratory distress. In preterm infants who do not breathe or breathe inadequately, you should use PEEP with your inflation breaths and ventilations as the lungs in these infants are more likely to collapse again at the end of a breath; using PEEP prevents this.
Resuscitation of term infants should commence in air. For preterm infants, a low concentration of oxygen (21–30%) should be used initially for resuscitation at birth. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered. Blended oxygen and air should be given judiciously and its use guided by pulse oximetry. If chest compressions are administered, supplemental oxygen should be increased.
Circulation
Almost all infants needing help at birth will respond to successful lung inflation with an increase in heart rate within 30 seconds followed quickly by normal breathing. However, in some cases chest compression is necessary. Chest compression should be started only when you are sure that the lungs have been aerated successfully.
In infants, the most efficient method of delivering chest compression is to grip the chest in both hands in such a way that the two thumbs can press on the lower third of the sternum, just below an imaginary line joining the nipples, with the fingers over the spine at the back. Compress the chest quickly and firmly, reducing the anteroposterior diameter of the chest by about one third.
The ratio of compressions to inflations in newborn resuscitation is 3:1.
Chest compressions move oxygenated blood from the lungs back to the heart. Allow enough time during the relaxation phase of each compression cycle for the heart to refill with blood. Ensure that the chest is inflating with each breath. You should increase the oxygen concentration if you have reached this stage of resuscitation. You should also have called for help, and a pulse oximeter, if not already in use, will be helpful in monitoring how you are doing.
Do not use asynchronous compressions, even if the infant has a tracheal tube placed, as maintaining air entry into the lung remains as important now as it was during the initial aeration. Compressing the chest during a ventilation breath may reduce air entry, which may be harmful.
In a very few infants (less than one in every thousand births) inflation of the lungs and effective chest compression will not be sufficient to produce an effective circulation. In these circumstances drugs may be helpful.
Drugs
Drugs are needed rarely and only if there is no significant cardiac output despite effective lung inflation and chest compression. The outlook for most infants at this stage is poor although a small number have had good outcomes after a return of spontaneous circulation followed by therapeutic hypothermia.
The drugs used include adrenaline (1:10,000), occasionally sodium bicarbonate (ideally 4.2%), and glucose (10%). All resuscitation drugs are best delivered via an umbilical venous catheter or if this is not possible through an intraosseous needle.
When to stop resuscitation
In a newly-born infant with no detectable cardiac activity, and with cardiac activity that remains undetectable for 10 min, it is appropriate to consider stopping resuscitation. The decision to continue resuscitation efforts beyond 10 min with no cardiac activity is often complex and may be influenced by issues such as the availability of therapeutic hypothermia and intensive care facilities, the presumed aetiology of the arrest, the gestation of the infant, the presence or absence of complications, and the parents’ previous expressed feelings about acceptable risk of morbidity. The difficulty of this decision-making emphasises the need for senior help to be sought as soon as possible.
Where a heart rate has persisted at less than 60 min-1 without improvement, during 10–15 min of continuous resuscitation, the decision to stop is much less clear. No evidence is available to recommend a universal approach beyond evaluation of the situation on a case-by-case basis by the resuscitating team and senior clinicians.
