10.2 Neonatal Resuscitation: Resuscitation Council UK NLS Algorithm

Neonatal Resuscitation: Resuscitation Council UK NLS Algorithm

The transition from fetal intrauterine existence to independent extrauterine life is the most complex physiological adaptation encountered in human biology. While approximately 85% of term neonates breathe spontaneously within 10 to 30 seconds of birth, roughly 10% require tactile stimulation and basic thermal support, and approximately 1% require advanced neonatal resuscitation. In the United Kingdom, clinical practice is defined by the Resuscitation Council UK Newborn Life Support (NLS) guidelines. Midwives must understand that neonatal arrest is fundamentally hypoxic and respiratory in origin—unlike adult cardiac arrest, which is predominantly arrhythmic. Consequently, establishing effective pulmonary ventilation is the single most critical, life-saving determinant of success.

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The "Golden Minute" & Immediate Assessment at Birth

The Golden Minute represents the first 60 seconds of postnatal life, during which the attending midwife must complete the initial rapid assessment, execute primary thermal and positioning care, and determine whether positive-pressure ventilation is required.

The Clinical Assessment Triad

Immediately at birth, the midwife assesses three vital clinical parameters:

1. Tone: Is the infant active, flexed, and vigorous, or limp and completely flaccid?
2. Breathing: Is the infant crying vigorously, breathing regularly, gasping irregularly, or completely apnoeic?
3. Heart Rate: Is the heart rate >100 bpm, 60 to 100 bpm, or <60 bpm?

                      ┌────────────────────────────────────────┐
                      │     THE NLS CLINICAL ASSESSMENT TRIAD  │
                      └───────────────────┬────────────────────┘
                                          │
         ┌────────────────────────────────┼────────────────────────────────┐
         ▼                                ▼                                ▼
┌─────────────────┐              ┌─────────────────┐              ┌─────────────────┐
│      TONE       │              │    BREATHING    │              │   HEART RATE    │
│ • Normal:       │              │ • Normal:       │              │ • Auscultate    │
│   active, flexed│              │   regular cry   │              │   apex with     │
│ • Compromised:  │              │ • Abnormal:     │              │   stethoscope   │
│   flaccid, limp │              │   gasping /     │              │ • >100: Normal  │
│                 │              │   apnoea        │              │ • <60: Critical │
└─────────────────┘              └─────────────────┘              └─────────────────┘

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Thermal Care, Drying & Tactile Stimulation

Neonates possess an exceptionally high body surface area-to-mass ratio and thin epidermal barriers, predisposing them to catastrophic evaporative and convective heat loss. Hypothermia rapidly increases oxygen consumption, precipitates pulmonary vasoconstriction, impairs surfactant production, and worsens metabolic acidosis.

Thermal Protocols by Gestational Age

• Term and Near-Term Infants (≥32 weeks):
  • Immediately place the infant onto warm, pre-heated towels under an overhead radiant warmer.
  • Thoroughly dry the infant's skin, paying careful attention to the head and scalp.
  • Discard the damp, cold towels immediately and wrap the infant in clean, warm, dry towels.
  • Apply a pre-warmed knitted or cotton hat to prevent cranial heat loss (the head accounts for 20% of the infant's surface area).
  • Gentle tactile stimulation is achieved during the drying process, or by gently flicking the soles of the feet or rubbing the back once or twice. Prolonged or aggressive physical stimulation of an apnoeic infant is ineffective, wastes vital seconds, and is strictly contraindicated.
• Very Preterm Infants (<32 weeks):
  • DO NOT DRY THE BODY. Immediately place the infant up to their neck into a sterile, food-grade transparent polyethylene plastic bag or wrap without drying.
  • Place under a radiant warmer with the head exposed, dried, and covered with a warm hat.
  • The plastic wrap creates a humid microclimate that abolishes evaporative heat loss.

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Airway Positioning & Indications for Suctioning

The Neutral Head Position

The neonatal occiput is proportionally large and prominent. When a newborn is placed supine on a flat surface, the large occiput naturally forces the cervical spine into hyperflexion, occluding the narrow pharyngeal airway. Conversely, over-extending the neck (hyperextension) causes the soft, cartilaginous infantile trachea to collapse.

• The midwife must place the head in the neutral ("sniffing the morning air") position, with the neck slightly extended so that the nose and mouth point directly upwards.
• A small shoulder roll (a folded towel 1 to 2 cm in thickness placed beneath the infant's shoulders) supports thoracic elevation and maintains neutral airway alignment during ongoing care.

   HYPERFLEXION (Wrong)            NEUTRAL POSITION (Correct)          HYPEREXTENSION (Wrong)
      Pharynx occluded             "Sniffing the morning air"           Trachea collapsed
          [ Head ]                           [ Head ]                        [ Head ]
             \                                  |                                /
            [ Neck ]                         [ Neck ]                         [ Neck ]
               |                                |                                |
           [ Body ]                         [ Body ]                         [ Body ]

Suctioning Policy: Routine Suctioning is Obsolete

National and international resuscitation bodies have completely removed routine airway suctioning from neonatal guidelines:

• Routine suctioning is harmful: Introducing a suction catheter into the oropharynx can induce severe reflex vagal bradycardia, laryngeal spasm, cardiac arrhythmias, and mucosal trauma.
• Meconium-stained amniotic fluid: The presence of meconium-stained liquor (whether thin or thick) is no longer an indication for routine or intrapartum suctioning if the infant is vigorous. Even in non-vigorous (flaccid, apnoeic) infants born through meconium, immediate priority must be given to establishing lung inflation, not blind suctioning.
• Indications for Suction: Suctioning is reserved strictly for infants whose airway is visibly occluded by thick secretions, particulate meconium, or blood clots. Oropharyngeal suction must be performed only under direct vision, using a wide-bore catheter at a modest negative pressure set by local policy, for as short a time as possible. Rarely, if there is no chest movement despite airway manoeuvres, tracheal suction may be needed to clear an obstruction below the vocal cords.

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Establishing Breathing: The Five Inflation Breaths

If the newborn is apnoeic, gasping irregularly, or has a heart rate <100 bpm by 60 seconds of life despite airway positioning and stimulation, the midwife must immediately initiate positive-pressure lung inflation.

The Five Inflation Breaths

In utero, the fetal alveolar spaces are filled with fetal lung fluid. Expanding these fluid-filled alveoli and establishing Functional Residual Capacity (FRC) requires overcoming fluid surface tension and high airway resistance.

• The midwife administers five initial inflation breaths using a manual resuscitation bag with a pressure-relief valve or a T-piece mechanical resuscitator.
• Inspiratory Time: Each breath must be sustained for 2 to 3 seconds (unlike the rapid 0.5–1 second breaths used in adult resuscitation).
• Inflation Pressures:
  • Infants ≥32 Weeks: starting inflation pressure of 30 cmH2O.
  • Infants <32 Weeks: starting inflation pressure of 25 cmH2O to minimise lung injury.
  • PEEP: RCUK 2025 recommends starting PEEP (or CPAP) at 6 cmH2O. If the chest does not move despite airway opening, inflation pressure is increased, then reduced once chest movement and improvement are seen.

Oxygen Concentration & Pulse Oximetry Targets

• Term and Near-Term Infants (≥32 weeks): Initiate resuscitation in room air (21% O2). Extensive randomized trials have demonstrated that resuscitating term infants with 100% oxygen increases mortality, prolongs time to spontaneous respiration, and generates toxic reactive oxygen species (ROS) that induce reperfusion injury in the brain, myocardium, and lungs.
• Preterm Infants (<32 weeks): Start with at least 30% oxygen using an oxygen-air blender (RCUK 2025), then titrate to saturations.
• Pulse Oximetry: Attach the sensor to the right wrist or palm (pre-ductal arterial circulation supplying the right radial artery, reflecting brain and coronary oxygenation before mixing occurs across the ductus arteriosus). Check oxygen and saturations every 30 seconds and titrate inspired oxygen to the acceptable right-hand (pre-ductal) saturations in the RCUK 2025 guideline, reducing oxygen if saturations exceed 95%:

RCUK advises avoiding saturations below 80% and/or bradycardia at 5 minutes of age.

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Reassessment & Airway Troubleshooting

Following the 5 inflation breaths, the midwife immediately reassesses the heart rate and observes for visible chest expansion.

If the Heart Rate Rises >100 bpm

A rapid rise in heart rate is the most sensitive confirmation that the lungs have successfully inflated. The midwife transitions to ventilation breaths (regular breaths delivered at a rate of about 30 breaths per minute, with an inspiratory time of approximately 1 second) until the infant establishes regular spontaneous respiratory effort.

If the Chest Fails to Rise & Heart Rate Remains Low

If there is no chest wall movement, ventilation has failed. DO NOT COMMENCE CHEST COMPRESSIONS. The Resuscitation Council UK emphatically states that chest compressions are futile and harmful if the lungs remain unexpanded.

The team must systematically execute airway troubleshooting:

1. Re-check Head Position: Ensure the head is in the neutral "sniffing" position.
2. Two-Person Airway Control: Enlist a second team member. Person 1 uses both hands to perform a bilateral jaw thrust and maintain a tight circular mask seal around the mouth and nose; Person 2 operates the resuscitation bag or T-piece.
3. Inspect Airway & Suction: Open the mouth, inspect the pharynx under direct vision with a laryngoscope, and suction obstructing secretions.
4. Oropharyngeal (Guedel) Airway: Insert an appropriately sized Guedel airway (Size 000 for extreme preterms, Size 00 for preterms, Size 0 for term infants). In neonates, the Guedel is inserted with the concavity facing downwards, using a tongue depressor to hold the tongue flat. Do not rotate the airway 180° as in adults, which lacerates the delicate neonatal soft palate.
5. Supraglottic Airway Device / Laryngeal Mask Airway (LMA): A Size 1 i-gel or classic LMA is highly effective for term and near-term infants (weight ≥1.5–2 kg) when face-mask ventilation fails.
6. Endotracheal Intubation: An experienced practitioner performs tracheal intubation using an uncuffed endotracheal tube (size 2.5 mm for <1 kg; 3.0 mm for 1–2 kg; 3.5 mm for >2 kg).
7. Re-attempt 5 Inflation Breaths: Re-apply inflation breaths, confirming bilateral symmetrical chest rise before proceeding.

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External Chest Compressions

Chest compressions are indicated only when the heart rate remains <60 bpm despite verified, adequate chest expansion during inflation breaths.

                    ┌──────────────────────────────────────────────┐
                    │          CHEST COMPRESSION PROTOCOL          │
                    └──────────────────────┬───────────────────────┘
                                           │
         ┌─────────────────────────────────┴─────────────────────────────────┐
         ▼                                                                   ▼
┌──────────────────────────────────┐               ┌──────────────────────────────────┐
│         TECHNIQUE & DEPTH        │               │       RATIO & COORDINATION       │
│ • Two-thumb encircling-hands     │               │ • 3:1 ratio (compressions:breaths)│
│ • Lower third of sternum         │               │ • 90 compressions + 30 breaths   │
│ • Just below intermammary line   │               │   = 120 total events / minute    │
│ • Depress 1/3 AP chest diameter  │               │ • Synchronized, unhurried cycle  │
│ • Complete chest recoil          │               │ • Increase oxygen to 100%        │
└──────────────────────────────────┘               └──────────────────────────────────┘

Compression Technique

• Two-Thumb Encircling-Hands Technique: The preferred method. The rescuer places both thumbs side-by-side (or overlapping in very small infants) over the lower third of the sternum, immediately below an imaginary line joining the nipples (avoiding the xiphisternum). The remaining fingers encircle the infant's chest, supporting the thoracic spine.
• Depth of Compression: Depress the sternum by one-third of the anteroposterior (AP) diameter of the chest (approximately 1.5 to 2 cm in term infants). Ensure complete chest recoil between compressions without lifting thumbs off the sternum.

Synchronized Ratio (3:1) & Supplemental Oxygen

• 3:1 Ratio: Deliver 3 chest compressions followed by 1 ventilation breath, achieving 90 compressions and 30 ventilations per minute (120 total events per minute). A complete cycle takes 2 seconds: "One-and-Two-and-Three-and-Breathe".
• 100% Oxygen: As soon as external chest compressions are initiated, increase the delivered oxygen to 100% on the blender.
• Reassessment: Re-evaluate the heart rate by apex auscultation every 30 seconds. Discontinue compressions once the heart rate rises above 60 bpm, continuing ventilation breaths until HR >100 bpm and vigorous spontaneous breathing occurs.

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Emergency Vascular Access & Pharmacotherapy

If the heart rate remains <60 bpm despite high-quality chest compressions and synchronized ventilations with 100% oxygen, emergency vascular access and resuscitation medications must be instituted without delay.

Vascular Access Modalities

1. Emergency Umbilical Venous Catheterisation (UVC): The route of choice. Under aseptic technique, cut the umbilical cord stump transversely 1 to 2 cm above the abdominal wall. Identify the single, thin-walled, wide-lumen umbilical vein (typically located at the 12 o'clock position, contrasting with the two small, thick-walled, constricted umbilical arteries at 4 and 8 o'clock). Insert a 3.5 Fr or 5.0 Fr catheter 3 to 5 cm until blood aspirates freely. Secure at the skin level; do not advance further into the portal hepatic circulation.
2. Intraosseous (IO) Needle: If umbilical venous access cannot be achieved rapidly, insert a dedicated paediatric IO needle into the proximal anteromedial tibia (flat surface 1 to 2 cm below and medial to the tibial tuberosity).

Resuscitation Medications & Dosing Framework