Most newborns will cry shortly after birth, begin breathing normally and require no resuscitation. Resuscitation is only required when problems affect their breathing, heart rate, tone or colour.
The Resuscitation Council UK provides guidelines and an algorithm for newborn resuscitation. This section covers the principles for understanding and exam purposes. Managing unwell patients requires formal training and senior support. At all times, consider the need for additional help.
Where possible problems are anticipated at birth (e.g., premature labour or an unwell mother), a dedicated person or team (e.g., paediatric doctors) responsible for neonatal resuscitation (if required) will be called to attend the birth.
Hypoxia
Hypoxia (low oxygen) is a key concern in newborn resuscitation. Normal labour and birth involve a certain amount of fetal hypoxia (low oxygen). During contractions, gaseous exchange is reduced in the placenta, leading to reduced oxygen saturation.
Extended or severe hypoxia can lead to:
- Anaerobic respiration
- Bradycardia (low fetal heart rate)
- Reduced consciousness
- Reduced respiratory effort (further worsening the hypoxia)
- Hypoxic-ischaemic encephalopathy (HIE), potentially leading to cerebral palsy
APGAR Score
The APGAR score is calculated 1, 5 and 10 minutes after birth. It assesses the overall well-being and progress of the baby in the immediate postnatal period. It is measured out of 10. The lowest score is 0, and the highest is 10.
|
Finding |
0 |
1 |
2 |
|
Appearance (skin colour) |
Centrally blue / pale |
Blue extremities |
Pink |
|
Pulse |
Absent |
Below 100 |
Above 100 |
|
Grimace (stimulation response) |
No response |
Little response |
Good response |
|
Activity (muslce tone) |
Floppy |
Flexed arms and legs |
Active |
|
Respiration |
Absent |
Slow / irregular |
Strong / crying |
Delayed Umbilical Cord Clamping
A significant volume of fetal blood remains in the placenta at birth. Delayed clamping of the umbilical cord gives time for this blood to enter the newborn’s circulation, known as placental transfusion. Delaying cord clamping helps to:
- Increased haemoglobin and iron stores
- More stable blood pressure
- Reduced risk of intraventricular haemorrhage
- Reduced risk of necrotising enterocolitis
- Reduced mortality in preterm newborns
Delayed cord clamping increases the risk of neonatal jaundice requiring phototherapy.
Current guidelines recommend a delay of at least 60 seconds from birth in newborns that do not require immediate transfer for resuscitation.
Principles of Neonatal Resuscitation
A timer is started at birth. The newborn is continuously assessed for their:
- Tone
- Breathing effort
- Heart rate
- Colour
Dry and warm the newborn as quickly as possible. Hypothermia (reduced body temperature) is a risk due to wet skin and a large surface-area-to-volume ratio. Drying with a towel helps stimulate breathing. The baby is kept warm under a heat lamp. Preterm newborns under 32 weeks are placed in polyethylene wrapping (plastic bag) while still wet (with their face exposed). Their temperature is closely monitored and kept between 36.5 and 37.5°C.
Support breathing (if necessary) by:
- Simulating the newborn (e.g., drying with a towel)
- Placing their head in a neutral position to keep the airway open (a towel under the shoulders can help)
- Checking for airway obstruction (e.g., meconium) and consider aspiration under direct visualisation
Inflation breaths are given when the neonate is gasping or not breathing despite adequate initial simulation:
- Five inflation breaths (lasting 2-3 seconds each) are given to stimulate breathing and heart rate
- If there is no heart rate response or chest movement, recheck mask size and technique and give five more breaths
- If the heart rate remains low, continuous ventilation breaths can be used (30 per minute, 1 second inflation time)
- Further measures include inserting a tracheal tube (intubation) or laryngeal mask
Good technique is essential in delivering effective inflation breaths. Maintaining a neutral head position and getting a good seal around the mouth and nose is critical. A rise and fall should be seen in the chest. For inflation breaths:
- Air is used in term or near term newborns
- Additional oxygen is used in preterm newborns (up to 30% FiO2)
Oxygen saturations can be monitored throughout resuscitation if there are concerns about breathing. Aim for a gradual rise in oxygen saturation, not exceeding 95%.
Chest compressions are started if the heart rate remains below 60 bpm despite resuscitation and inflation breaths. Chest compressions are performed at a 3:1 ratio with ventilation breaths.
Intubation, intravenous medications (e.g., adrenaline and glucose) and therapeutic hypothermia may be required in severe situations.
Last updated May 2025
Now, head over to members.zerotofinals.com and test your knowledge of this content. Testing yourself helps identify what you missed and strengthens your understanding and retention.
