The new European resuscitation council guidelines on newborn resuscitation and support of the transition of infants at birth: An educational article

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This article uses a fictional case to illustrate the main changes to the European Resuscitation Council’s updated “Newborn Resuscitation and Support of the Transition of the Infants at Birth” which was updated in 2021 (The Australian Resuscitation Council Guidelines were also updated in 2021)

The updated flowsheet is in the article and outlines the resuscitation of the neonate, both term and preterm. For term neonates, the guidelines are:

• Dry wrap, stimulate and assess for tone, breathing and heart rate, ensure kept warm throughout
• Open the airway and apply 5 inflation breaths with a pressure of 30 cmH₂0 and an inspired oxygen of 21%, during this time ensure monitoring is placed to measure HR and SpO₂
• Reassess, initiate further airway support if required – this may involve suctioning, insertion of an LMA or intubation
• Repeat 5 inflation breaths and monitor chest expansion
• Reassess, if HR <60 commence chest compression by encircling the thorax and overlapping the thumbs on the lower half of the sternum. Compressions should be performed at a ratio of 3 compressions to 1 ventilation. Increase inspired oxygen to 100% (Aims for oxygen saturation are 68% at 2 mins, 85% at 5 minutes and 90% at 10 minutes)
• Reassess every 30 seconds and if ongoing resuscitation required, consider vascular access (umbilical vein cannula recommended as first line and intraosseous access as second line) and drugs – adrenaline 10-30mcg/kg IV/IO or 50-100mcg/kg via endotracheal tube if no vascular access, repeated every 3-5 minutes
• Ensure monitoring of hypo and hyperglycaemia, if it is a prolonged resuscitation 2.5mls/kg of 10% dextrose can be given

The main changes to the previous guidelines are:

1. Delaying the umbilical cord clamp for at least 60 seconds to transfer approximately 30ml/kg of blood from the placenta, if this is not possible consider milking the cord
2. Immediate ventilatory support via a facemask is prioritised over suctioning
3. An initial inspired oxygen of 21%, increase to 100% if chest compressions required
4. Inflation pressure should be 30 cmH₂0
5. Chest compressions should be performed by encircling the thorax and overlapping the thumbs on the lower half of the sternum
6. Resuscitation should be continued for 20 minutes, as outcomes are not necessarily poor even if there is an undetectable HR at 10 minutes

For preterm infants:

• Place in a plastic wrap undried if <32 weeks gestation
• Inspired oxygen should be 21% if >32 weeks, 21-30% if 28-31 weeks, 30% if <28 weeks
• Do not milk the cord if <28 weeks
• Inflation pressures should be 25 cmH₂0 (not less)

Reviewed by Dr Shona Chung