Newborn life-support principles — Rapid

Synopsis

Prepare safely for birth, support normal transition, prioritise effective lung inflation when a newborn is compromised, escalate through ventilation, compressions and drugs in the 2025 UK sequence, and provide temperature, glucose, family and post-resuscitation care.

Before birth brief the team, allocate roles, check warmer, gas supply, blender, suction, ventilation interfaces, oximeter, ECG, airway equipment, emergency access and drugs.
Aim for cord clamping after at least 60 seconds while warming, stimulating and assessing when safe; never delay necessary resuscitation that cannot be delivered with the cord intact.
Maintain 36.5–37.5°C. At less than 32 weeks, place the body in a polyethylene wrap without drying, dry and cover the head and use a preheated radiant warmer.
Initial assessment is breathing, heart rate and tone. Skin colour is not a reliable oxygen measure; use right-hand preductal pulse oximetry when support is required.
Open the airway in a neutral position with jaw thrust. Give 5 inflation breaths over 2–3 seconds each when apnoeic, gasping, ineffective or heart rate is below 100/min.
Starting inflation pressure is 30 cm H2O at 32 weeks or more and 25 cm H2O below 32 weeks; add PEEP about 6 cm H2O when possible and adjust to chest movement and response.
Start respiratory support in 21% oxygen at 32 weeks or more and at least 30% below 32 weeks, then titrate against preductal saturation and heart rate.
Acceptable right-hand saturations are approximately 70–75% at 3 minutes, 80–85% at 5 minutes and 85–95% at 10 minutes; avoid saturation below 80% with bradycardia at 5 minutes.
After successful lung inflation, give 15 ventilation breaths over 30 seconds and reassess. Continue about 30 breaths/min until regular breathing and heart rate above 100/min.
Start compressions only if heart rate remains below 60/min after 30 seconds of effective ventilation: use two thumbs, one-third chest depth and a 3:1 ratio for 90 compressions plus 30 breaths/min.
During compressions use 100% oxygen, secure an airway when skilled, seek umbilical venous or intraosseous access and reassess heart rate every 30 seconds.
If heart rate remains below 60/min after ventilation and compressions, give intravenous or intraosseous adrenaline 20 micrograms/kg and repeat every 4 minutes while correcting reversible causes.
Do not give routine bicarbonate or empirical glucose. Check glucose and give 10% glucose 2 mL/kg only when low; give 10 mL/kg blood or isotonic crystalloid when blood loss is suspected.
After recovery stabilise temperature, glucose, oxygenation and perfusion, assess HIE and other causes, document timings and support the family with an explanation and later debrief.

Key red flags

Absent or ineffective breathing, gasping, marked hypotonia or heart rate below 100/min requires immediate respiratory support rather than prolonged stimulation.

No chest movement and no heart-rate rise during inflation means ventilation is ineffective; correct airway, interface and pressure before starting compressions.

Heart rate below 60/min after at least 30 seconds of demonstrably effective ventilation requires 3:1 compressions, 100% oxygen and advanced help.

Pallor, poor response and a history of placental bleeding, cord rupture or fetomaternal haemorrhage suggests hypovolaemia and need for urgent volume replacement.

Unilateral breath sounds, sudden deterioration, poor ventilation pressure transmission or persistent cyanosis raises pneumothorax, airway obstruction or congenital anomaly.

Post-resuscitation seizures, encephalopathy, abnormal tone, persistent acidosis or multiorgan dysfunction requires urgent neonatal intensive care and therapeutic-hypothermia eligibility assessment.

Temperature outside 36.5–37.5°C, low glucose or wide glucose swings after resuscitation can worsen injury and require active correction and monitoring.

Investigation priorities

First-line monitoring: heart rate and breathingFirst stepFirst line

Determine whether transition is adequate and measure the response to every ventilation or compression cycle.

Management branches

PreparationBrief, warm and check

Birth is imminent or neonatal compromise is anticipated.

Review gestation, fetal condition, maternal history and agreed extent of care and summon an appropriately skilled team.
Allocate leadership, airway, monitoring, access, documentation and family support and check every item before birth.
Prepare gestation-specific thermal measures and plan delayed cord clamping without delaying any necessary intervention.

Key medicines

Adrenaline 1:10,000, 0.1 mg/mLIf heart rate remains below 60/min after effective ventilation and 30 seconds of compressions, give 20 micrograms/kg, equivalent to 0.2 mL/kg, by umbilical venous or intraosseous route; repeat every 4 minutes while indicated. If intubated without vascular access, give 100 micrograms/kg, 1 mL/kg, intratracheally as a bridge.Confirm concentration and weight calculation aloud. Intratracheal absorption is unreliable and vascular adrenaline should follow immediately when access is achieved. Do not give before effective ventilation, and look continuously for hypovolaemia, pneumothorax, obstruction or equipment failure.

Glucose 10%Check blood glucose during prolonged resuscitation where possible. If it is low, give 200 mg/kg, equivalent to 2 mL/kg of 10% glucose, intravenously or intraosseously, then provide gestation-appropriate infusion and repeat measurement under the neonatal protocol.Secure intravascular placement and avoid extravasation. Monitor for rebound hypoglycaemia, hyperglycaemia and rapid glucose swings. Do not confuse the 2025 NLS bolus with older 2.5 mL/kg protocols.

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