Resuscitation 95 (2015) 249–263

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European Resuscitation Council Guidelines for Resuscitation 2015
Section 7. Resuscitation and support of transition of babies at birth


Jonathan Wyllie
, Jos Bruinenberg , Charles Christoph Roehr
Daniele Trevisanuto , Berndt Urlesberger


Department of Neonatology, The James Cook University Hospital, Middlesbrough,
UK Department of Paediatrics, Sint Elisabeth Hospital, Tilburg, The Netherlands
Department of Women and Children’s’ Health, Padua University, Azienda Ospediliera di Padova, Padua, Italy
Department of Neonatology, Charité Universitätsmedizin, Berlin, Berlin, Germany
Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
Department of Neonatology, Medizinische Fakultät Carl Gustav Carus, TU Dresden,
Germany Division of Neonatology, Medical University Graz, Graz, Austria


, Mario Rüdiger ,

The following guidelines for resuscitation at birth have been developed during the process that culminated in the 2015
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment


Recommendations (CoSTR, 2015).
They are an extension of the guidelines already published by the ERC and take
into account recommendations made by other national and international organisations and previously evaluated


Summary of changes since 2010 guidelines
The following are the main changes that have been made to the guidelines for resuscitation at birth in 2015:
• Support of transition: Recognising the unique situation of the baby at birth, who rarely requires ‘resuscitation’ but
sometimes needs medical help during the process of postnatal transition. The term ‘support of transition’ has been
introduced to better distinguish between interventions that are needed to restore vital organ functions (resuscitation) or
to support transition.
• Cord clamping: For uncompromised babies, a delay in cord clamping of at least 1 min from the complete delivery of the
infant, is now recommended for term and preterm babies. As yet there is insufficient evidence to recommend an
appropriate time for clamping the cord in babies who require resuscitation at birth.

• Temperature: The temperature of newly born nonasphyxiated infants should be maintained between 36.5 C and 37.5
C after birth. The importance of achieving this has been highlighted and

Corresponding author.
E-mail address: (J. Wyllie).

reinforced because of the strong association with mortality and morbidity. The admission temperature should be
recorded as a predictor of outcomes as well as a quality indicator.
Maintenance of temperature: At <32 weeks gestation, a combination of interventions may be required to maintain the

temperature between 36.5 C and 37.5 C after delivery through admission and stabilisation. These may include
warmed humidified respiratory gases, increased room temperature plus plastic wrapping of body and head, plus thermal
mattress or a thermal mattress alone, all of which have been effective in reducing hypothermia.

Optimal assessment of heart rate: It is suggested in babies requiring resuscitation that the ECG can be used to provide
a rapid and accurate estimation of heart rate.
Meconium: Tracheal intubation should not be routine in the presence of meconium and should only be performed for
suspected tracheal obstruction. The emphasis should be on initiating ventilation within the first minute of life in
nonbreathing or ineffectively breathing infants and this should not be delayed.
Air/Oxygen: Ventilatory support of term infants should start with air. For preterm infants, either air or a low concentration
of oxygen (up to 30%) should be used initially. If, despite effective ventilation, oxygenation (ideally guided by oximetry)
remains unacceptable, use of a higher concentration of oxygen should be considered.
Continuous Positive Airways Pressure (CPAP): Initial respiratory support of spontaneously breathing preterm infants
with respiratory distress may be provided by CPAP rather than intubation.

The guidelines that follow do not define the only way that resuscitation at birth should be achieved; they merely
represent a widely accepted view of how resuscitation at birth can be carried out both safely and effectively (Fig. 7.1).
0300-9572/© 2015 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved.

breathing and heart rate If gasping or not breathing: .Maintain Temperature 250 J. Wyllie et al. / Resuscitation 95 (2015) 249–263 (Antenatal counselling) Team briefing and equipment check Birth Dry the baby Maintain normal temperature Start the clock or note the time Assess (tone).

Open the airway Give 5 inflation breaths Consider SpO2 ± ECG monitoring Reassess If no increase in heart rate look for chest movement If chest not moving: Recheck head position Consider 2-person airway control and other airway manoeuvres Repeat inflation breaths SpO2 monitoring ± ECG monitoring Look for a response 60 s Acceptable pre-ductal SpO2 2 min 60% 3 min 70% 4 min 80% 5 min 85% 10 min 90% When the chest is moving: If heart rate is not detectable or very slow (< 60 min-1) Start chest compressions Coordinate compressions with PPV (3:1) Reassess heart rate every 30 seconds If heart rate is not detectable Increase oxygen (Guidedby oximetry if available) If no increase in heart rate look for chest movement or very slow (< 60 min-1) consider venous access and drugs Discuss with parents and debrief team .

At All Times Ask: Do You Need Help? .

1. J. PPV: positive pressure ventilation.Fig. Wyllie et al. ECG: electrocardiograph. Newborn life support algorithm. / Resuscitation 95 (2015) 249–263 Preparation Planned home deliveries 251 . SpO2 : transcutaneous pulse oximetry. 7.

of 97. and cessation of the placental circulation bring about this transition. requires anatomic and physiological adjustments to achieve the conversion from placental gas exchange with intrauterine lungs filled with fluid. because of the distance from further assistance. 2% were intubated to support respiratory function and 0. However. Ideally. teaching the standards and skills required for resuscitation of the newborn is therefore essential for any institution or clinical area in which deliveries may occur. the overwhelming majority will require only assisted lung aeration. When a birth takes place in a nondesignated delivery area. the recommended minimum set of equipment includes a device for safe assisted lung aeration and subsequent ventilation of an appropriate size for the newborn. Continued experiential learning and practice is necessary to maintain skills.The fetal to neonatal transition. only 10 per 1000 (1%) 8 babies of 2. with other resuscitation equipment immediately available. A tiny minority may need a brief period of chest compressions in addition to lung aeration. the care of the baby should be their sole responsibility. therefore. All equipment must be regularly checked and tested. A structured educational programme. should not compromise the standard of initial assessment. about 2 per 1000 (0. to pulmonary respiration with aerated lungs. 5–7 However. Equipment and environment Unlike adult cardiopulmonary resuscitation (CPR). two trained professionals should be present at all home deliveries. babies delivering before 35 weeks gestation. but the decision to undergo a planned home delivery. Of these. approximately 3% initiated respirations following positive pressure ventilation. a sterile instrument for cutting and clamping the umbilical cord and clean gloves for the attendant and assistants. 90% responded to mask ventilation alone while the remaining 10% appeared not to respond to mask inflation and therefore were intubated at birth. responded to mask inflation of the lungs and only 2 per 1000 appeared to need intubation. .e. those born after 32 weeks gestation and following an apparently normal labour. stabilisation or resuscitation at birth. Should there be any need for intervention. personnel trained in newborn life support should be easily available for every delivery. based on current practice and clinical audit. resuscitation at birth is often a predictable event. Whenever there is sufficient time. draught free area with a flat resuscitation surface placed below a radiant heater (if in hospital). once agreed with medical and midwifery staff. specially trained personnel should be present with at least one person experienced in tracheal intubation. Unexpected deliveries outside hospital are most likely to involve emergency services that should plan for such events. maternal 9 infection and multiple pregnancies. the initiation of air breathing.1% received chest compressions and/or adrenaline. Resuscitation should take place in a warm. if no support is given. In a retrospective study.648 babies born in Sweden in one year. The absorption of lung fluid. might subsequently result in a need for resuscitation. There was almost no need for cardiac compressions. warm dry towels and blankets. the aeration of the lungs. elective caesarean delivery at term does not increase the risk of needing newborn resuscitation in the absence 14–17 of other risk factors. approximately 85% of babies born at term initiated spontaneous respirations within 10 to 30 s of birth. Local guidelines indicating who should attend deliveries should be developed. babies delivering vaginally by the breech.2%) appeared to need resuscitation or help with transition at delivery. an additional 10% responded during drying and stimulation. this is not always the case. well lit. It is also important to prepare the family in cases where it is likely that resuscitation might be required. caesarean delivery is associated with an increased risk of problems 10–13 with respiratory transition at birth requiring medical interventions especially for deliveries before 39 weeks gestation. Although it is sometimes possible to predict the need for resuscitation or stabilisation before a baby is born. and this must be made clear to the mother at the time plans for home delivery are made. Of those needing any help. Recommendations as to who should attend a planned home delivery vary from country to country. i. In deliveries with a known increased risk of problems. Most of those. one of these must be fully trained and experienced in providing mask ventilation and chest compressions in the newborn. Each institution should have a protocol in place for rapidly mobilising a team with competent resuscitation skills for any birth. but a few more have problems with this perinatal transition. A minority of infants require resuscitation at birth. Any newborn may potentially develop problems during birth. Furthermore. 8 per 1000. which. which occurs at the time of birth.5 kg or more appeared to need any resuscitation at delivery. Resuscitation or support of transition is more likely to be needed by babies with intrapartum evidence of significant fetal compromise. It is therefore possible to prepare the environment and the equipment before delivery of the baby. There will inevitably be some limitations to resuscitation of a newborn baby in the home. the team attending the delivery should be briefed before delivery and clear role assignment should be defined. The same study tried to assess the unexpected need for resuscitation at birth and found that for low risk babies.

22 They have also suggested greater 21 use of phototherapy for jaundice in the delayed group but this was not found in a randomised controlled trial.25 as well as of late onset sepsis. Experimental evidence from similarly treated lambs suggest the same holds true for premature newborn. including higher mean blood pressure and haemoglobin on admission. incidence of intraventricular haemorrhage and periventricular leukomalacia 23 Some studies have suggested a reduced 22.Timing of clamping the umbilical cord Cineradiographic studies of babies taking their first breath at delivery showed that those whose cords were clamped prior to this had an immediate decrease in the size of the heart during the subsequent three or four cardiac cycles. 21. 23 There were also fewer blood transfusions in the ensuing weeks. 19 20 Studies of delayed clamping have shown an improvement in iron status and a number of other haematological indices over the next 3–6 months and a reduced need for transfusion in preterm infants. compared to controls. 18 Brady et al drew attention to the occurrence of a bradycardia apparently induced by clamping the cord before the first breath and noted that this did not occur in babies where clamping occurred after breathing was established. The initial decrease in size could be interpreted as the significantly increased pulmonary blood flow following the decrease in pulmonary vascular resistance upon lung aeration.24. A systematic review on delayed cord clamping and cord milking in preterm infants found improved stability in the immediate postnatal period. as a consequence. The subsequent increase in size would. be caused by the blood returning to the heart from the lung. The heart then increased in size to almost the same size as the fetal heart. 24 .

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Dry the term baby immediately after delivery.105 associated with a progression of cerebral injury.27.No human studies have yet addressed the effect of delaying cord clamping on babies apparently needing resuscitation at birth because such babies have been excluded from previous studies.77.107 resuscitation.66.85 70.49 28%. may require a combination of further interventions to maintain the temperature ◦ ◦ between 36. (and Virginia Apgar herself found that heart rate was the most 106 important predictor of immediate outcome). and the admission temperature of newborn non asphyxiated infants is a strong predictor of 31–65 mortality at all gestations and in all settings.86.49. For each 1 C decrease in admission temperature below this range there is an associated increase in mortality by 1.70–74 31.55.5 C after ◦ birth. Infants born to febrile mothers have a higher incidence of perinatal respiratory depression. without drying the baby beforehand.81 • • If the baby needs support in transition or resuscitation then place the baby on a warm surface under a preheated radiant warmer.80 For babies less than 28 weeks gestation the delivery room temperature should be >25 ◦ C. repeated assessment particularly of heart rate and.74–79 49 support hypoglycaemia and in some studies late onset sepsis.94 Alternatively. 95–101 They should be covered and protected from draughts. The association between hypothermia and mortality has been known for 30 more than a century. Whilst maintenance of a baby’s temperature is important. can indicate whether the baby is responding or whether further efforts are needed.48. A similar delay should be applied to preterm babies not requiring immediate resuscitation after birth.79. which have all been effective in reducing hypothermia.35. Preterm infants are especially vulnerable and hypothermia is also 35.5 C after delivery through admission and stabilisation. 93.83 • • polyethylene wrapping. Umbilical cord milking may prove an alternative in these infants although there is 1. can identify babies needing resuscitation. Cover the head and body of the baby. However. ◦ ◦ The temperature of newly born non asphyxiated infants should be maintained between 36. this should be monitored in order to avoid hyperthermia ◦ (>38. neonatal seizures.72. In addition. Animal studies indicate that hyperthermia during or following ischaemia is 104. namely respiratory rate. Delaying umbilical cord clamping for at least 1 min is recommended for newborn infants not requiring resuscitation. Prevent heat loss: 80 52 • • Protect the baby from draughts. individual components of the score. with a warm and dry towel to prevent further heat loss. ◦ 1. place the baby skin to skin with mother and cover both with a towel. admission temperature and urine output when compared to delayed cord clamping (>30 s) in babies born by caesarean section. These may include warmed humidified 84. Until more evidence is available. 27 Compromised babies are particularly vulnerable.82. .0 C). although these differences were not observed in infants born 26 vaginally. babies <32 weeks gestation.5 C and 37. apart from the face. Umbilical cord milking produces improved short term haematological outcomes. Babies born unexpectedly outside a normal delivery environment may benefit from placement in a food grade plastic bag after drying and then swaddling. if assessed rapidly. Alternatively. to a lesser extent breathing.2 currently not enough evidence available to recommended this as a routine measure.37. Temperature control Naked.5 C and 37. Exposure of the newborn to cold stress will lower arterial oxygen 28 29 tension and increase metabolic acidosis. increased room temperature plus cap plus thermal mattress or thermal mattress 88–92 alone. infants who are not breathing or crying may require the umbilical cord to be clamped.42. 102. All babies less than 32 weeks gestation should have the head and body of the baby (apart from the face) covered with 73.2. and also placed under a radiant heater. Initial assessment The Apgar score was not designed to be assembled and ascribed in order to then identify babies in need of 106. Furthermore.2.87 respiratory gases. • Keep the delivery room warm at 23–25 C.66–69 associated with serious morbidities such as intraventricular haemorrhage need for respiratory 31. well newborns >30 weeks gestation may be dried and nursed with skin to skin contact or kangaroo mother care to maintain their temperature whilst they are transferred.103 early mortality and cerebral palsy.60. newborn babies cannot maintain their body temperature in a room that feels comfortably warm for adults. so that resuscitation measures can commence promptly. wet.48. Make certain windows closed and airconditioning appropriately programmed. heart rate and tone. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.

evaluate the rate. Tone A very floppy baby is likely to be unconscious and will need ventilatory support. indicate hypoxaemia. Several studies have demonstrated that ECG is faster than pulse oximetry and more reliable. Persistent pallor despite ventilation may indicate significant acidosis or rarely hypovolaemia. Wyllie et al. Heart rate is initially most rapidly and accurately assessed by 108 109–112 listening to the apex beat with a stethoscope or by using an electrocardiograph. Although colour is a poor method of judging oxygenation. J. / Resuscitation 95 (2015) 249–263 253 . the use of ECG does not replace the need to use pulse oximetry to assess the newborn baby’s oxygenation. especially in the first 2 min after 110–115 birth. Heart rate Immediately after birth the heart rate is assessed to evaluate the condition of the baby and subsequently is the most sensitive indicator of a successful response to interventions. which is better assessed using pulse oximetry if possible. If so. A healthy baby is born blue but starts to become pink within 30 s of the onset of effective breathing.113 100 beats per minute (bpm) and clinical assessment may underestimate the heart rate.Breathing Check whether the baby is breathing. Peripheral cyanosis is common and does not. by itself. however. Feeling the pulse in the base of the umbilical cord is often effective but can be misleading because cord pulsation is only reliable if found to be more than 108 108. check preductal oxygenation with a pulse oximeter. it should not be ignored: if a baby appears blue. For babies requiring 111 resuscitation and/or continued respiratory support.109. a modern pulse oximeter can give an accurate heart rate. depth and symmetry of breathing together with any evidence of an abnormal breathing pattern such as gasping or grunting. Colour 116 Colour is a poor means of judging oxygenation.

Dry and wrap. pneumothorax. Newborn life support Commence newborn life support if initial assessment shows that the baby has failed to establish adequate regular −1 normal breathing. remain hypoxaemic. This baby will usually improve with mask inflation but if this does not increase the heart rate adequately. more complex interventions will be futile unless these two first steps have been successfully completed. It remains important to ensure the baby’s temperature is maintained. Preterm babies may be breathing and showing signs of respiratory distress in which case they should be supported initially with CPAP. (3) Breathing inadequately or apnoeic. or has a heart rate of less than 100 min (Fig.2. Fig. There is no need for immediate clamping of the cord. Once this has been successfully accomplished the baby may also need chest compressions. further support will be required. Normal or reduced tone. wrapping in a warm towel and. Low or undetectable heart rate. Often pale suggesting poor perfusion. lung inflation and ventilation. 7.Tactile stimulation Drying the baby usually produces enough stimulation to induce effective breathing. Heart rate higher than 100 min −1 . though breathing with a good heart rate. Good tone.1). diaphragmatic hernia or surfactant deficiency. may rarely also require ventilations. Heart rate less than 100 min −1 . where appropriate. and may be put to the breast at this stage.2). Classification according to initial assessment On the basis of the initial assessment. There remains a very rare group of babies who. Floppy. This baby requires no intervention other than drying. (2) Breathing inadequately or apnoeic. Avoid more vigorous methods of stimulation. If the baby fails to establish spontaneous and effective breaths following a brief period of stimulation. and perhaps drugs. congenital pneumonia. 117 . Furthermore. Newborn with head in neutral position. 7. The supine position for airway management is traditional but sidelying has also been used for assessment and routine delivery room management of term newborns but not for resuscitation. The baby will remain warm through skin to skin contact with mother under a cover. Opening the airway and aerating the lungs is usually all that is necessary. the baby can be placed into one of three groups: (1) Vigorous breathing or crying. 7. In floppy babies application of jaw thrust or the use of an appropriately sized oropharyngeal airway may be essential in opening the airway. Airway Place the baby on his or her back with the head in a neutral position (Fig. This baby will then require immediate airway control. This group includes a range of possible diagnoses such as cyanotic congenital heart disease. A 2 cm thickness of the blanket or towel placed under the baby’s shoulder may be helpful in maintaining proper head position. handing to the mother. Dry and wrap.

Suction is needed only if the airway is obstructed. Two multicentre randomised controlled trials showed that routine elective 126 intubation and tracheal suctioning of these infants.135 Initial breaths and assisted ventilation After initial steps at birth. In term babies. Tracheal intubation should not be 128–132 routine in the presence of meconium and should only be performed for suspected tracheal obstruction. viscous meconium in a nonvigorous baby is the only indication for initially considering visualising the oropharynx and suctioning material. The much less common finding of very thick meconium stained liquor at birth is an indicator of perinatal distress and should alert to the potential need for resuscitation. connected to a suction source not exceeding −150 mmHg. did not reduce MAS and that suctioning the nose and mouth of such babies on the perineum and before delivery of the shoulders (intrapartum suctioning) was 127 ineffective. However. 128 The presence of thick. or a paediatric Yankauer sucker. 122.125 other studies failed to find any evidence of benefit from this practice.3).118 There is no need to remove lung fluid from the oropharynx routinely. 7. lung aeration is the priority and must not be delayed (Fig. lung inflation is a 136 The primary measure of adequate initial . if vigorous at birth. respiratory support should start with air. thick tenacious mucus or vernix even in deliveries where meconium staining is not present.123 Furthermore 124. aggressive pharyngeal suction can delay the onset of spontaneous breathing and cause laryngeal spasm and vagal bradycardia. 133 The routine administration of surfactant or bronchial 134. which might obstruct the airway. A small RCT has recently demonstrated no difference in the incidence of MAS between patients receiving tracheal intubation followed by suctioning and those not intubated. However. Lightly meconium stained liquor is common and does not. if breathing efforts are absent or inadequate. Hence intrapartum suctioning and routine intubation and suctioning of vigorous infants born through meconium stained liquor are not recommended. If suctioning is attempted use a 12–14 FG suction catheter. studies supporting this view were based on a comparison of suctioning on the outcome of a group of babies with the outcome of historical controls. in general. give rise to much difficulty with transition. 119–121 Meconium For over 30 years it was hoped that clearing meconium from the airway of babies at birth would reduce the incidence and severity of meconium aspiration syndrome (MAS). lavage with either saline or surfactant is not recommended. Obstruction may be caused by particulate meconium but can also be caused by blood clots. The emphasis should be on initiating ventilation within the first minute of life in nonbreathing or ineffectively breathing infants and this should not be delayed.

Wyllie et al.254 J. / Resuscitation 95 (2015) 249–263 .

This will usually help lung 137. Efficacy of the intervention can be estimated by a prompt increase in heart rate or observing the chest rise. Without adequate lung aeration.141. 145 Alternatively using a two person approach to mask ventilation reduces mask leak in term and 146. until there is adequate spontaneous breathing. confirm lung aeration and ventilation before progressing to circulatory support. if these are present then lung aeration has been achieved. Mask ventilation of newborn. 149 145– In this case. If these are absent then airway control and lung aeration has not been confirmed. 7.142 expansion. Most babies needing respiratory support at birth will respond with a rapid increase in heart rate within 30 s of lung inflation. If the heart rate increases but the baby is not breathing adequately. Adequate passive ventilation is usually indicated by either a rapidly increasing heart rate or a heart rate that is −1 maintained faster than 100 beats min . Continue ventilatory support until the baby has established normal regular breathing. If this is not obtained it is likely that repositioning of the airway or mask will be required and. In term infants. Mask leak.9 kPa) with a mean of 20 cm H 2 O. rarely. ventilate at a rate of about 30 breaths −1 min allowing approximately 1 s for each inflation. therefore. inflation time and flow required to establish an effective FRC has not been determined. but this requires training and experience.142 cm H2 O (1.Fig. higher inspiratory pressures may be needed. Look for passive chest movement in time with inflation efforts. are all possible reasons. The optimum pressure. prompt improvement in heart rate. If the baby does not respond in this way the most likely cause is inadequate airway control or inadequate ventilation. The pressure required to aerate the fluid filled lungs of newborn babies requiring resuscitation is 15–30 137.5–2. chest compressions will be ineffective. reevaluate the airway position and deliver inflation breaths while summoning a colleague with intubation skills. which may need correction.147 preterm infants. inappropriate airway position and airway obstruction. consider repositioning the mask to correct for leakage and/or reposition the baby’s head to correct for airway obstruction. 137–141 spontaneous or assisted initial inflations create a functional residual capacity (FRC). . If the heart rate is not improving assess the chest wall movement. Some practitioners will ensure airway control by tracheal intubation.3. For the first five positive pressure inflations maintain the initial inflation pressure for 2–3 s. For term babies use an inflation pressure of 30 cm H 2 O 143. If this skill is not available and the heart rate is decreasing.144 and 20–25 cm H2 O in preterm babies.

166 159.2.166 or retinopathy of prematurity. they should be weaned as soon as possible. 156.165. 157 Sustained inflations (SI) > 5 s Several animal studies have suggested that a longer SI may be beneficial for establishing functional residual capacity at birth during transition from a fluidfilled to airfilled lung. the high concentration was not associated with any improvement in survival. Modern pulse oximetery.155 150. / Resuscitation 95 (2015) 249–263 A reliable 255 . 144 However. 159. or air leak. if increased oxygen concentrations are used 136. using neonatal probes.162. details of the most appropriate length and pressure of inflation.162. Oxygen saturations (3rd. 158 therefore. Resuscitation of preterm infants less than 35 weeks gestation at birth should be initiated in air or low 1. If. 50th.164–166 intraventricular haemorrhage increase in markers of oxidative stress.159 Preterm babies. 7. 7.151 152– Review of the literature in 2015 disclosed three RCTs which demonstrated that initial SI reduced the need for mechanical ventilation. The administered oxygen concentration should be titrated to achieve acceptable preductal oxygen saturations approximating to the 25th percentile in healthy term babies immediately after 156. In a meta analysis of seven randomized trials comparing initiation of resuscitation with high (>65%) or low (21–30%) oxygen 159. 1. 7. 10th.4). to suggest routine application of SI of greater than 5 s duration to the transitioning newborn. 154 and two cohort studies. provides reliable readings of heart rate and 167.162. It was the consensus of the COSTR reviewers that there was inadequate study of the safety. 159.Fig. One cohort study suggested that the need for intubation was less following SI.161–166 concentrations.157 High concentrations of oxygen are associated with an increased mortality and delay in time of onset of spontaneous breathing. 25th.160 concentration oxygen (21–30%).4. bronchopulmonary dysplasia. Reproduced with permission from. despite effective ventilation. there is no increase in heart rate or oxygenation (guided by oximetry wherever possible) remains unacceptable. use a higher concentration of oxygen to achieve an adequate preductal oxygen saturation. There was an 159 Pulse oximetry.4). and longterm effects. should only be considered in individual clinical circumstances or in a research setting. In term infants receiving respiratory support at birth with positive pressure ventilation (PPV). Wyllie et al. and 97th SpO 2 percentiles) in healthy infants at birth without medical intervention. bronchopulmonary dysplasia.2 Sustained inflations >5 s Air/Oxygen Term babies. no benefit was found for reduction of mortality. 90th. 144.157 birth (Fig. 75th. it is best to begin with air (21%) as opposed to 100% oxygen.136.168 transcutaneous oxygen saturation within 1–2 min of birth (Fig. J.

200 .192–195 196 Respiratory function monitors measuring inspiratory pressures and tidal volumes and exhaled carbon dioxide 197. Values are lower in those born by Caesarean delivery. approximately 80% of those born preterm.1 and 7.187 generated may exceed the value specified by the manufacturer if compressed vigorously. Two randomised To avoid this some institutions are using nasopharyngeal prongs to deliver respiratory Table 1 Oral tracheal tube lengths by gestation. Pulse oximetry should be used to avoid excessive use of oxygen as well as to direct its judicious use ( Figs. a selfinflating bag or with a T-piece mechanical device designed to regulate pressure. Laryngeal mask airway 199.g. compliance and gas exchange.4). Uncompromised babies born at term at sea level 169 156 have SpO2 ∼60% during labour. and 80167 90% of those apparently requiring resuscitation. Transcutaneous oxygen saturations above the acceptable levels should prompt weaning of any supplemental oxygen. Face mask versus nasal prong A reported problem of using the facemask for newborn ventilation is mask leak caused by a failure of the seal between 145–148 the mask and the face. nasal airways.preductal reading can be obtained from >90% of normal term births. a flowinflating bag or a T-piece mechanical device. However. It is suggested that positive end expiratory pressure (PEEP) of ∼5 cm H2 O should be administered to 173 preterm newborn babies receiving PPV. 174 Animal studies show that preterm lungs are easily damaged by large volume inflations immediately after birth and 175. those born at 171 172 157 altitude and those managed with delayed cord clamping. selfinflating bags are the only devices. 7. support. all designed to regulate pressure or limit pressure applied to the airway can be used to ventilate a newborn. within 2 min of birth. need for resuscitation or bronchopulmonary dysplasia they were 181.176 suggest that maintaining a PEEP immediately after birth may protect against lung damage although some evidence 177 178–180 suggests no benefit. nor risks attributed to their use have so far been identified. However.182 underpowered for these outcomes. which increases to >90% by 10 min. Two human newborn RCTs demonstrated no improvement in mortality. Those born preterm may take longer to reach >90%. Gestation (weeks) ETT at lips (cm) 23–24 25–26 27–29 30–32 33–34 35–37 38–40 5·5 6·0 6·5 7·0 7·5 8·0 8·5 41–43 9·0 trials in preterm infants have compared the efficacy and did not find any difference between the methods.198 monitors to assess ventilation have been used but there is no evidence that they affect outcomes. The 25th percentile is approximately 40% at 157 170 birth and increases to ∼80% at 10 min. laryngeal masks) during PPV in the delivery room has not been reported. tidal volumes and long inspiratory times are achieved more consistently in mechanical models when using Tpiece devices than when using bags. which can be used in the absence of compressed gas but cannot deliver continuous positive airway pressure (CPAP) and may not be able to achieve PEEP even with a PEEP valve in place 189. 187–190 although the clinical implications are not clear. 181–185 The blow-off valves of selfinflating bags are flowdependent and pressures 186. More training is required to 191 provide an appropriate pressure using flowinflating bags compared with selfinflating bags. Positive end expiratory pressure All term and preterm babies who remain apnoeic despite initial steps must receive positive pressure ventilation after initial lung inflation. Neither additional benefit above clinical assessment alone. PEEP also improves lung aeration. Target inflation pressures. A selfinflating bag. The use of exhaled CO2 detectors to assess ventilation with other interfaces (e. one of the trials suggested that PEEP reduced the amount of 182 supplementary oxygen required. Assisted ventilation devices Effective ventilation can be achieved with a flowinflating..

as 208 marked on tracheal tubes by different manufacturers to aid correct placement. Exhaled CO2 detection is effective for confirmation of tracheal tube placement in infants. • Special circumstances (e.212 210 suggests oesophageal intubation but false negative readings have been reported during cardiac arrest and in VLBW infants .g. Tracheal tube placement must be assessed visually during intubation. The laryngeal mask airway has not been evaluated in the setting of meconium stained fluid. The LMA is recommended during resuscitation of term and preterm newborns ≥34 weeks gestation when tracheal intubation is unsuccessful or not feasible. It should be recognised that vocal cord guides. When. vary considerably. The laryngeal mask airway may be considered as an alternative to tracheal intubation as a secondary 201–206 airway for resuscitation among newborns weighing more than 2000 g or delivered ≥34 weeks gestation. or for the administration of emergency intratracheal medications. during chest compressions.. particularly if facemask ventilation is unsuccessful or tracheal intubation is unsuccessful or not feasible. after correction of mask technique and/or the baby’s head position. and positioning confirmed. a prompt increase in heart rate is a good indication that the tube is in the 209 tracheobronchial tree. Tracheal tube placement Tracheal intubation may be considered at several points during neonatal resuscitation: • • • When suctioning the lower airways to remove a presumed tracheal blockage. congenital diaphragmatic hernia or to give tracheal surfactant). however. to evaluate its use for newborns weighing <2000 gram or delivered <34 weeks gestation. 210–213 including VLBW infants and neonatal studies suggest that it confirms tracheal intubation in neonates with a cardiac 212–214 output more rapidly and more accurately than clinical assessment alone. One recent unblinded RCT demonstrated that following training with one type of LMA. The LMA may be considered as an alternative to a facemask for positive pressure ventilation among newborns weighing more than 2000 g or delivered ≥34 weeks 201 gestation.The laryngeal mask airway can be used in resuscitation of the newborn. its use was associated with less tracheal intubation and neonatal unit admission in comparison to those receiving ventilation via a 201 facemask. The use and timing of tracheal intubation will depend on the skill and experience of the available resuscitators. Following tracheal intubation and intermittent positive pressure. bagmask ventilation is ineffective or prolonged. There is limited evidence. When chest compressions are performed. Failure to detect exhaled CO 2 strongly 210. 207 Appropriate tube lengths based on gestation are shown in Table 1.

Wyllie et al. / Resuscitation 95 (2015) 249–263 .256 J.

Use a 3:1 compression to ventilation ratio. i. neonatal studies have excluded infants in need of extensive resuscitation. This technique generates higher blood 222–234 pressures and coronary artery perfusion with less fatigue than the previously used two finger technique. A 3:1 compression to ventilation ratio is used for resuscitation at birth where compromise of gas exchange is nearly always the primary cause of cardiovascular collapse. False positives may occur with colorimetric devices contaminated with adrenaline (epinephrine). but rescuers may consider using higher ratios (e. rather than intubation. the steps of trying to achieve return of spontaneous circulation using effective ventilation with low .220 Circulatory support Circulatory support with chest compressions is effective only if the lungs have first been successfully inflated. inability to detect exhaled CO 2 despite correct placement may lead to unnecessary extubation. 7. aiming to achieve approximately 120 events per minute. However.e. 247 However. surfactant 198 and atropine. Poor or absent pulmonary blood flow or tracheal obstruction may prevent detection of exhaled CO 2 despite correct tracheal tube placement. 216–218 CPAP in term infants at birth and further clinical studies are required. Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm tracheal placement in neonates with spontaneous circulation. the quality of the compressions and breaths are probably more 248 important than the rate. As ventilation is the most effective and important intervention in newborn resuscitation. 241–246 There are theoretical advantages to allowing a relaxation phase that is very slightly longer than the compression phase. The most effective technique for providing chest compressions is with two thumbs over the lower third of the sternum 221–224 with the fingers encircling the torso and supporting the back (Fig. 15:2) if the arrest is believed to be of cardiac origin. in critically ill infants with poor cardiac output. Other clinical indicators of correct tracheal tube placement include evaluation of condensed humidified gas during exhalation and presence or absence of chest movement. In a manikin study overlapping the thumbs on the sternum was more effective than positioning them adjacent but more likely to cause fatigue. There are few data to guide the appropriate use of 219. but these have not been evaluated systematically in newborn babies.4 CPAP Initial respiratory support of all spontaneously breathing preterm infants with respiratory distress may be provided by CPAP. Tracheal tube placement is identified correctly in nearly all patients who are not in cardiac 211 arrest .215 despite models suggesting efficacy. Three RCTs enrolling 2358 infants born at <30 weeks gestation demonstrated that CPAP is beneficial when compared to initial tracheal ventilation and PPV in reducing the rate of intubation and duration of mechanical ventilation without any short term disadvantages. 235 The sternum is compressed to a depth of approximately one third of the anterior posterior diameter of 225. Give −1 chest compressions if the heart rate is less than 60 beats min despite adequate ventilation.5). Compressions and ventilations should be coordinated to avoid simultaneous delivery. 3. and may be compromised by compressions. however.g. When resuscitation of a newborn baby has reached the stage of chest compressions.. it is vital to ensure that effective ventilation is occurring before commencing chest compressions.236–240 the chest allowing the chest wall to return to its relaxed position between compressions. approximately 90 compressions and 30 ventilations.

and establishing adequate ventilation is the most important step to −1 correct it. it would appear sensible to try increasing the supplementary oxygen concentration towards 100%. Discontinue chest compressions when the −1 spontaneous heart rate is faster than 60 beats min . 256–260 .2 Drugs Drugs are rarely indicated in resuscitation of the newly born infant. 7. There are no human studies to support this and animal studies demonstrate no 249–255 advantage to 100% oxygen during CPR. 7. current evidence does not 1. Thus. Adrenaline Despite the lack of human data it is reasonable to use adrenaline when adequate ventilation and chest compressions have failed to increase the heart rate above 60 beats min −1 . if the heart rate remains less than 60 beats min despite adequate ventilation and chest compressions. Exhaled carbon dioxide monitoring and pulse oximetry have been reported to be useful in determining the return of spontaneous circulation support the use of any single feedback device in a clinical setting. it is reasonable to consider the use of drugs. Newborn umbilical cord showing the arteries and veins.6. concentration oxygen should have been attempted. Bradycardia in the newborn infant is usually caused by inadequate lung inflation or profound hypoxia. Wyllie et al. 7. If 1 umbilical vein 2 umbilical arteries LEGS Fig. These are best given via a centrally positioned umbilical venous catheter (Fig.6). however.5. However. Ventilation and chest compression of newborn.Fig. / Resuscitation 95 (2015) 249–263 HEAD 257 . J. Check the heart rate after about 30 s and periodically thereafter.

where withholding resuscitation 38. the potential reversibility of the situation.adrenaline is used. particularly when there has been the opportunity for discussion with parents. When resuscitating preterm infants volume is rarely needed and has been associated with intraventricular and pulmonary haemorrhages when large volumes are infused rapidly. There are insufficient data to recommend routine use of bicarbonate in resuscitation of the newly born. Bicarbonate If effective spontaneous cardiac output is not restored despite adequate ventilation and adequate chest compressions. In the absence of suitable blood (i.1 ml kg −1 of 1:10. The following guidelines must be interpreted according to current regional outcomes. 268 Opinions vary amongst providers. A recent study suggests that the institutional approach at the border of viability affects the subsequent results in surviving infants.4 −1 (0. parents and societies about the balance of benefits and 269. Social science studies indicate that parents desire a larger role in decisions to resuscitate and to continue life support in severely compromised babies. .261–265 required. Withholding resuscitation and discontinuation of life sustaining treatment during or following resuscitation are considered by many to be ethically equivalent and clinicians should not be hesitant to withdraw support when the possibility of functional survival is highly unlikely. Give a bolus of 10 ml kg initially.277–282 may be considered reasonable. Use of sodium bicarbonate is not recommended during brief CPR.000 adrenaline) should be administered with subsequent intravenous doses of 10–30 micrograms kg −1 (0. 1.7. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min. the gestation of the baby. If successful it may need to be repeated to maintain an improvement. Local survival and outcome data are important in appropriate counselling of parents. the availability of therapeutic hypothermia and the parents’ previous expressed feelings about 267. an initial dose 10 micrograms kg intravenously as soon as possible 1:10.000 adrenaline) if required. In this situation there is insufficient evidence about outcome to enable firm guidance on whether to withhold or to continue resuscitation.3 ml kg −1 of −1 The tracheal route is not recommended but if it is used. The decision to continue resuscitation efforts when the heart rate has been undetectable for longer than 10 min is often complex and may be influenced by issues such as the presumed aetiology.e. it should be given only after adequate ventilation and circulation is established with CPR. Withholding resuscitation It is possible to identify conditions associated with high mortality and poor outcome. The hyperosmolarity and carbon dioxide generating properties of sodium bicarbonate may impair myocardial and cerebral function. it may be appropriate to consider stopping resuscitation.270 disadvantages of using aggressive therapies in such babies. 60 min −1 The decision should be individualised.1–0. Neither the safety nor the efficacy of these higher tracheal doses has been studied. reversing intracardiac acidosis may improve myocardial function and achieve a spontaneous circulation.2. A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an 283 important goal. This is a rare event. If it is used during prolonged arrests unresponsive to other therapy. poor perfusion. There is no evidence to support the prospective use of any particular delivery room prognostic score presently described. weak pulse) and has 266 not responded adequately to other resuscitative measures then consider giving fluid. In cases where the heart rate is less than at birth and does not improve after 10 or 15 min of continuous and apparently adequate resuscitative efforts. Do not give these high doses intravenously.272. in preterm infants <25 weeks gestation.272–276 acceptable risk of morbidity. −1 may be Fluids If there has been suspected blood loss or the infant appears to be in shock (pale. 271 Discontinuing resuscitation Local and national committees will define recommendations for stopping resuscitation. it is highly likely that doses of 50–100 micrograms kg will be 3. isotonic crystalloid rather −1 than albumin is the solution of choice for restoring intravascular volume. A dose of 1–2 mmol kg given by slow intravenous injection after adequate ventilation and perfusion have been established. the choice is much less clear. over gestational age assessment alone. irradiated and leucocyte depleted group O Rh negative blood). Withholding or discontinuing resuscitation 267 Mortality and morbidity for newborns varies according to region and to availability of resources.136.

without coercion or pressure. and anomalies such as anencephaly and confirmed Trisomy 13 or 18. adhere to the routine local plan and. hand the baby to the mother at the earliest opportunity. resuscitation is not indicated. ask questions about details of the resuscitation and be informed about the support services available. Resuscitation is nearly always indicated in conditions associated with a high survival rate and acceptable morbidity. birth weight. Finally. 286 The members of the resuscitation team and family members. At delivery. If resuscitation is required inform the parents of the procedures undertaken and why they were required. and/or congenital anomalies are associated with almost certain early death. if possible.284 283 Communication with the parents It is important that the team caring for the newborn baby informs the parents of the baby’s progress. 285 European guidelines are supportive of family presence during cardiopulmonary resuscitation. 286 .277. This will generally include babies with gestational age of 25 weeks or above (unless there is evidence of fetal compromise such as intrauterine infection or hypoxia ischaemia) and those with most congenital malformations. In recent years healthcare professionals are increasingly offering family members the opportunity to remain present during CPR and this is more likely if resuscitation takes place within the delivery room. and • • unacceptably high morbidity is likely among the rare survivors. 38. Examples from the published literature include: extreme prematurity (gestational age less than 23 weeks and/or birth weight less than 400 g). When withdrawing or withholding resuscitation. In conditions associated with uncertain prognosis. • and where the anticipated burden to the child is high. It is recommended to provide a healthcare professional whose sole responsibility is to care for the family member. Parents’ wishes to be present during resuscitation should be supported where possible. make the decision about who should be present during resuscitation jointly.• Where gestation. Whilst this may not always be possible it should not mean the exclusion of the family member from the resuscitation. parental desires regarding resuscitation should be supported. care should be focused on the comfort and dignity of the baby and family. where there is borderline survival and a relatively high rate of morbidity. there should be an opportunity for the immediate relative to reflect.

Wyllie et al.258 J. / Resuscitation 95 (2015) 249–263 .

Animal data would strongly suggest that the effectiveness of cooling is related to early intervention. midwives. These are partly explained by a lack of agreement on how to score infants receiving medical interventions or being born preterm.Decisions to discontinue resuscitation should ideally involve senior paediatric staff. There is no evidence in human newborns that cooling is effective if started more than 6 h after birth. Post resuscitation care Babies who have required resuscitation may later deteriorate. where possible. the range of blood glucose concentration that is associated with the least brain injury following asphyxia and resuscitation cannot be defined based on available evidence. Carefully monitor for known adverse effects of cooling such as thrombocytopenia and hypotension. clear classification or grading of newborn infants” to be used “as a basis for discussion and comparison of the results of obstetric practices. commence within 6 h of birth. One clinical study demonstrated an 290 association between hypoglycaemia and poor neurological outcome following perinatal asphyxia. In adults. many of these have been following simulation training. Therefore a development of the score was recommended as follows: all parameters are scored according to the conditions regardless of the interventions needed to achieve the condition and considering whether being appropriate for gestational age. This Combined Apgar has been shown to predict outcome in preterm and term infants better than the conventional score. its applicability has been questioned due to large inter and intraobserver variations. Treatment should be consistent with the protocols used in the randomized clinical trials (i. Record carefully all discussions and decisions in the mother’s notes prior to delivery and in the baby’s records after birth.303. Commencing cooling treatment >6 h after birth is at the discretion of the treating team and should only be on an individualised basis. Studies of the effect of briefings or 305–310 debriefings following resuscitation have generally shown improved subsequent performance. continue for 72 h of birth and rewarm over at least 4 h). hyperglycaemia has been associated with a worse 288–292 outcome. Induced hypothermia Newly born infants born at term or nearterm with evolving moderate to severe hypoxic ischemic encephalopathy 296–301 should. 311 A structured analysis of perinatal management with . obstetricians and birth attendants before 283 delivery. which confirms data from animal studies some of which suggest it may be protective. for example in the case of severe congenital malformation. be offered therapeutic hypothermia. the infant should be maintained in or transferred to an environment in which close monitoring and anticipatory care can be provided. the decision to attempt resuscitation of an extremely preterm baby should be taken in close consultation with the parents and senior paediatric and obstetric staff. for research purposes and as a prognostic 302 tool. In addition. Glucose Hypoglycaemia was associated with adverse neurological outcome in a neonatal animal model of asphyxia and 287 resuscitation. in paediatric patients. Once adequate ventilation and circulation are established. types of maternal pain relief and the effects of resuscitation” (our emphasis). A method that seems to further improve the management in the delivery room is videotaping and subsequent analysis of the videos. Prognostic tools The Apgar score was proposed as a “simple. common. hyperglycaemia after hypoxiaischaemia does not appear to be 293 294 295 harmful.e. 106 Although widely used in clinical practice.304 Briefing/debriefing Prior to resuscitation it is important to discuss the responsibilities of each member of the team. However. All treated infants should be followed longitudinally. Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range. After the management in the delivery room a team debrief of the event using positive and constructive critique techniques should be conducted and personal bereavement counselling offered to those with a particular need. children and extremely low birth weight infants receiving intensive care. Where a difficulty has been foreseen. However. However. Whole body cooling and selective head cooling are both appropriate strategies. discuss the options and prognosis with the parents.289 areas of cerebral infarction and/or decreased survival compared to controls. Whenever possible. Cooling should be initiated and conducted under clearly defined protocols with treatment in neonatal intensive care facilities and with the capabilities for multidisciplinary care. the interventions needed to achieve the condition have to be scored as well. Newborn animals that were hypoglycaemic at the time of an anoxic or hypoxic ischemic insult had larger 288.

Ersdal HL. 4. 312 Regardless of the outcome. Arch Pediatr Adolesc Med 1995. Resuscitation 2010. Perlman JM. Wyllie J. Svensen E. Every opportunity should be taken to prepare parents for the possibility of a resuscitative effort when it is anticipated and to keep them informed as much as possible during and certainly after the resuscitation. 2.83:869–73. References 1. Resuscitation 2010. reducing the incidence of intraventricular haemorrhage in preterm infants. Conflicts of interest Jonathan Wyllie Berndt Urlesberger Charles Christoph Roehr Daniele Trevisanuto Jos Bruinenberg Mario Rüdiger No conflict of interest reported No conflict of interest reported Educational grant Fischer&Paykel and Medical advisor STEPHAN company No conflict of interest reported No conflict of interest reported Speakers honorarium Chiesi. Perlman JM. Early contact between parents and their baby is important. Kattwinkel J.81:1389–99. et al. J. Wyllie J. Perlman JM. Wyllie et al. Wyllie J. Resuscitation of babies at birth.81:Se260–87 [Suppl 1]. Richmond S. 3. 6. Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. witnessing the resuscitation of their baby may be distressing for parents. European resuscitation council guidelines for resus-citation 2010 section 7.95:e171–203. Risser R. 5. Early initiation of basic resuscita-tion interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observa-tional study. Cardiopulmonary resuscitation in the delivery room: associated clinical events. information should be given by a senior clinician. et al. Kattwinkel J.149:20–5. / Resuscitation 95 (2015) 249–263 259 . Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency car-diovascular care science with treatment has been shown to improve outcomes. In press. Perlman JM. Lyomark and Research grant SLE device Acknowledgements The Writing Group acknowledges the significant contributions to this chapter by the late Sam Richmond. Mduma E. Kattwinkel J. Circulation. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Whenever possible. Wyllie J. Resuscitation 2012. Resuscitation 2015. et al. Perlman JM.

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