History and World Practice

1. Changes in Delivery Room Practices
for Newborn Infants across the world
Dr Julian Eason
Consultant Neonatologist
University Hospital Plymouth NHS Trust
England

2. Introduction
Question?
• What is the point of developing sophisticated ventilators,
doing expensive trials and undertaking expensive
courses on ventilation management if irreversible
damage has been caused before the infant is even
admitted to the NICU?

3. International Liaison Committee
on Resuscitation
(2000/2005/2010/2015/2020)
Guide treatment recommendations

4. The Latest Paper from ILCOR
• Neonatal Life Support: 2020 International
Consensus on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science
With Treatment Recommendations
• Myra H. Wyckoff, Jonathan Wyllie, Khalid Aziz, Maria Fernanda de Almeida, Jorge Fabres, Joe
Fawke, Ruth Guinsburg, Shigeharu Hosono, Tetsuya Isayama, Vishal S. Kapadia, Han-Suk
Kim, Helen G. Liley, Christopher J.D. McKinlay, Lindsay Mildenhall, Jeffrey M. Perlman, Yacov
Rabi, Charles C. Roehr, Georg M. Schmölzer, Edgardo Szyld, Daniele Trevisanuto, Sithembiso
Velaphi and Gary M. Weiner
• Circulation. 2020;142:S185–S221
• https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000000895

5. Resus around the word
• UK – NLS
• Europe – Euro NLS
• Middle East – Euro NLS/NRP
• Vietnam – Euro NLS/NRP
• South Afica – SA NR
• USA/Canada – NRP
• Australia/New Zealand – ANZCOR NLS

6. Resus around the world
www.resus.co.za
2021 2021
Provide warmth
Clear airway if necessary
Dry and stimulate
(Don’t dry if < 30 weeks – wrap preterm baby’s torso in plastic bag)
Note the time
Start ventilating with room air (Rate: 30-40/min)
Use oxygen if preterm starting at 30-40%
Connect to pulse oximeter if available, avoid hyperoxia
Ensure chest rise with each breath
Ventilate with supplemental oxygen as required
Continue ventilating with supplemental oxygen as required
Consider intubation
Start chest compressions with coordinated ventilation
(3 compressions: 1 breath)
Each cycle should take 2 seconds
Continue compressions and ventilation
Give 0.1-0.3ml/kg Adrenaline IV (1:10 000 dilution)
(1ml/kg Adrenaline ETT (1:10 000 dilution) only if no IV access)
May repeat Adrenaline IV after 3-5 minutes
Correct hypovolaemia if necessary
(10ml/kg normal saline over 5-10 minutes)
Consider pneumothorax/Check glucose
Newborn Resuscitation
Algorithm
Assess breathing/crying and/or
heart rate
Gasping, apnoeic or heart rate < 100?
Heart rate < 100?
Heart rate < 60?
Heart rate < 60?
Assess breathing, heart rate and SATS/colour
every 30-60s
Assess breathing, heart rate and SATS/colour
every 30-60 seconds
Assess breathing, heart rate and SATS/colour
every 30-60 seconds
Term gestation?
Breathing? Good tone?
Routine care with mother
If ongoing respiratory distress
- consider CPAP
Yes
Yes
Yes
Yes
No
Yes
MAINTAIN
NORMOTHERMIA
GOLDEN
MINUTE
(BIRTH
–
60
sec)
Oxygen administration
Use blended oxygen if available
to achieve targeted
pre-ductal sats
Alternatively:
Bag with no O2 = 21%
Bag with O2 = 40%
Bag with O2 + res ervoir bag ≈ 100%
Normal pre-ductal
sats after birth
(right hand or ear)
1 min: > 60%
2 min: > 65%
3 min: > 70%
4 min: > 75%
5 min: > 80%
> 10 min: 90-95%
Post-resuscitation care
Maintain normothermia:
36.5-37.5° C
Consider induced hypothermia
where available according
to protocol
If ongoing respiratory distress
consider nasal CPAP and surfactant
as required according to protocol
Maintain sats 90-95%
SA
USA
UK Aus/NZ

7. Edited Resuscitation History
• Chinese philosopher ‘Hwang Ti’ 2698 noted more premature babies
die
• 1472 Mouth to mouth described in a newborn infant in western
literature
• 1745 Midwives in UK were using mouth to mouth on babies but was
not recognised by doctors!
• 1850-1890 resuscitation included the following:
• Swinging the infant
• Squeezing the chest
• Shaking, rubbing and slapping
• Electric shocks
• Oral stimulants (strychnine)

8. Oxygen Disaster!
• 1942-1954 over 12,000 moderately premature infants
blinded by Retrolental Fibroplasia from Oxygen
• Stevie Wonder
• Many infant still damaged now as resuscitation is
performed in 100% oxygen still causing damage even
after a short exposure
• Blenders are extremely important

9. The Umbilical Cord - History
• 1801 Darwin (Evolution) wrote early clamping is harmful
• 1899 Surgical clamp introduced to decrease infection??
• 1900’s Early clamp to stop chloroform crossing placenta
• 1953 Unfortunately Virginia Apgar creates a great score but wanted
early cord clamping
• 1941 First studies showing early cord clamping is harmful –
Anaemia
• 2009 UK now majority delay clamping in term infants
• NLS 2010 NRP 2017

10. European RDS Guidelines 2019
Sweet DG1, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, Speer
CP, Vento M, Visser GH, Halliday HL.
• Latest Consensus
Strength of Evidence
A-D
Strength of
Recommendation
1 or 2

11. Delivery Room Stabilisation
Considerations
• Cord clamping?
• CPAP?
• Sustained inflation?
• Oxygen / Air?
• Saturations?
• Surfactant?
• Thermal control

12. Recommendations
• Delay clamping the umbilical cord for at least 60 s to promote
placento-fetal transfusion (A1)
• In spontaneously breathing babies, stabilise with CPAP of at least 6
cm H2O via mask or nasal prongs (B1).
• Do not use SI (>5s) as there is no long-term benefit (B1).

13. Recommendation
• Oxygen for resuscitation should be controlled using a blender:
• FiO2 0.30 for babies <28 weeks’ gestation
• FiO2 0.21–0.30 for those 28–31 weeks
• FiO2 0.21 for 32 weeks’ gestation and above.
• FiO2 adjustments up or down should be guided by pulse oximetry
(B2).
• For infants <32 weeks’ gestation, SpO2 of 80% or more (and heart
rate >100/min) should be achieved within 5 min (C2).

14. Recommendations
• Intubation should be reserved for babies not responding to positive
pressure ventilation via face mask or nasal prongs (A1).
• Preterm babies who require intubation for stabilisation should be
given surfactant (B1).
• Plastic bags or occlusive wrapping under radiant warmers should be
used during stabilisation in the delivery suite for babies <28 weeks’
gestation to reduce the risk of hypothermia (A1).

15. Resuscitation
in
practice

16. NLS Latest updates for 2021
• Umbilical cord
• Delay cord clamping for 60 seconds
• If not possible then milk the cord if > 28 weeks
• This has shown to reduce transfusions and need
for less inotropic support

17. Inflation and Ventilation breaths
• Pressures have increased
• <32 weeks 25 cm H2O
• >32 weeks 30 cm H2O
• PEEP at 5cm for all

18. Laryngeal Masks (LMA)
• LMA’s better than bag and mask
• Can help reduce intubation
• Suggest more use to be made in infants >34
weeks or > 2kg

19. Oxygen: Start Low
• > 32 weeks start in Air
• 28 – 32 weeks start Air - 30%
• <28 weeks start in 30%
• If heart rate not increased after 30 seconds of chest
compressions then increase to 100% Oxygen

20. Saturations
• Pulse oximeter on right wrist
• Simple targets

21. Thick Meconium
• Do not rush to suction
• If apnoeic then do not delay ventilation

22. Adrenaline
• 20 micrograms/kg
• (0.2 mL/kg of 1:10,000 adrenaline (1000
micrograms in 10 mL).
• Eg 3kg baby = 0.6ml
• This should be repeated every 3-5 minutes as
needed.

23. Temperature
• Aim for 36.5 – 37.5 OC
• For infants >32 weeks used humidified gases
where possible

24. So NLS or NRP?
(minor differences)
• Intubation
– NLS intubate if you can or use Laryngeal Mask
Airway
– NRP intubate before massage
• NLS 2-3 second inflation (T-piece or BVM) before
ventilation breaths
• NRP normal length ventilation breaths but must measure
to 25cm H20 (Use BVM so must have a manometer to
measure the pressure)

25. NLS or NRP?
• There are no formal studies comparing the two methods
so no evidence that either method is better
• NLS – Quality control for teaching, and centres with
inspectors reviewing teaching centres. Recognised
internationally.
• NRP – Anyone with NRP can teach with online instructor
training. If not an official AHA centre then practicing card
will not be issued. Course may not be recognised
overseas.

26. Manuals
NLS
• £45
• 228 pages
NRP
• £61
• 361 pages

27. This is the outcome we want

28. Thank you

29. NLS

30. Khalid Aziz. Circulation. Part 5: Neonatal Resuscitation: 2020
American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care, Volume: 142,
Issue: 16_suppl_2, Pages: S524-S550, DOI:
(10.1161/CIR.0000000000000902)
© 2020 American Heart Association, Inc., and American Academy
of Pediatrics
NRP

31. Aus/NZ

32. South Africa
www.resus.co.za
2021 2021
Provide warmth
Clear airway if necessary
Dry and stimulate
(Don’t dry if < 30 weeks – wrap preterm baby’s torso in plastic bag)
Note the time
Start ventilating with room air (Rate: 30-40/min)
Use oxygen if preterm starting at 30-40%
Connect to pulse oximeter if available, avoid hyperoxia
Ensure chest rise with each breath
Ventilate with supplemental oxygen as required
Continue ventilating with supplemental oxygen as required
Consider intubation
Start chest compressions with coordinated ventilation
(3 compressions: 1 breath)
Each cycle should take 2 seconds
Continue compressions and ventilation
Give 0.1-0.3ml/kg Adrenaline IV (1:10 000 dilution)
(1ml/kg Adrenaline ETT (1:10 000 dilution) only if no IV access)
May repeat Adrenaline IV after 3-5 minutes
Correct hypovolaemia if necessary
(10ml/kg normal saline over 5-10 minutes)
Consider pneumothorax/Check glucose
Newborn Resuscitation
Algorithm
Assess breathing/crying and/or
heart rate
Gasping, apnoeic or heart rate < 100?
Heart rate < 100?
Heart rate < 60?
Heart rate < 60?
Assess breathing, heart rate and SATS/colour
every 30-60s
Assess breathing, heart rate and SATS/colour
every 30-60 seconds
Assess breathing, heart rate and SATS/colour
every 30-60 seconds
Term gestation?
Breathing? Good tone?
Routine care with mother
If ongoing respiratory distress
- consider CPAP
Yes
Yes
Yes
Yes
No
Yes
MAINTAIN
NORMOTHERMIA
GOLDEN
MINUTE
(BIRTH
–
60
sec)
Oxygen administration
Use blended oxygen if available
to achieve targeted
pre-ductal sats
Alternatively:
Bag with no O2 = 21%
Bag with O2 = 40%
Bag with O2 + res ervoir bag ≈ 100%
Normal pre-ductal
sats after birth
(right hand or ear)
1 min: > 60%
2 min: > 65%
3 min: > 70%
4 min: > 75%
5 min: > 80%
> 10 min: 90-95%
Post-resuscitation care
Maintain normothermia:
36.5-37.5° C
Consider induced hypothermia
where available according
to protocol
If ongoing respiratory distress
consider nasal CPAP and surfactant
as required according to protocol
Maintain sats 90-95%

33. References
ILCOR Circulation. 2020;142:S185–S221
Newborn Life Support 8th Ed 2021
Neonatal Resuscitation Programme 8th Ed 2021
European Resuscitation Gyidelines
Neonatal Mortality after 21% or 100% O2 resusctiation Saugstad, Ramji, Soll, Vento.
Neonatology 2008