Newborn Resuscitation & Support of Transition at Birth (ERC 2025): Complete UK Clinical Guide

Newborn resuscitation and suppo…

The European Resuscitation Council (ERC) 2025 Newborn Resuscitation Guidelines provide the most up-to-date evidence-based framework for managing infants at birth — covering delivery room care, advanced resuscitation, post-resuscitation management, ethical decisions, and out-of-hospital births.

This comprehensive, SEO-optimised blog summarises the full guidance for clinicians working in:

• Neonatology
• Emergency Medicine
• Paediatrics
• Midwifery
• Pre-hospital and retrieval services

Core Principles of Newborn Resuscitation (2025 Update)

The 2025 guideline reinforces several central themes:

✔ Effective ventilation is the priority
 ✔ Heart rate guides intervention
 ✔ Thermal control is critical
 ✔ Delayed cord clamping is strongly encouraged
 ✔ Avoid unnecessary interventions
 ✔ Use structured team briefings and human-factor principles
 ✔ Precision oxygen targeting is essential

The guideline acknowledges limited high-quality data in extremely preterm infants (<25 weeks) but remains applicable in this population 
Newborn resuscitation and suppo….

Before Birth: Risk Factors & Team Preparation

Common Risk Factors for Resuscitation

Antepartum

• <37 weeks gestation
• Multiple pregnancy
• Intrauterine growth restriction
• Maternal infection
• Pre-eclampsia
• Gestational diabetes
• High BMI
• Lack of antenatal steroids

Intrapartum

• Meconium-stained liquor
• Emergency C-section
• General anaesthesia
• Significant bleeding
• Vaginal breech
• Out-of-hospital birth

Every birth requires preparedness. Institutions must ensure trained staff proportionate to risk are present 
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Team Briefing & Human Factors

Before delivery:

• Assign roles clearly
• Check equipment
• Plan cord management
• Prepare parents
• Use checklists or cognitive aids

Annual training minimum is recommended, with 3–6 monthly booster sessions to prevent skill decay 
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Thermal Control: A Major 2025 Emphasis

Target temperature:
 36.5–37.5°C

≥32 weeks

• Dry immediately
• Remove wet towels
• Apply hat
• Skin-to-skin if stable

<32 weeks

• Dry head only
• Place body in plastic wrap without drying
• Use radiant warmer
• Increase room temperature (>25°C if ≤28 weeks)

Hypothermia is strongly associated with worse outcomes. Avoid hyperthermia when multiple warming methods are used 
Newborn resuscitation and suppo….

Delayed Cord Clamping (DCC)

Strong emphasis in 2025:

• Aim for ≥60 seconds in all infants
• Perform during initial assessment
• If urgent intervention required → clamp <30 seconds

Cord milking:

• ❌ Not recommended <28 weeks
• ✔ May be considered ≥28 weeks if DCC not possible

Initial Assessment at Birth

Assess during delayed cord clamping where possible:

• Breathing
• Heart rate
• Tone

Reassess every 30 seconds.

Important change:

• Reduced reliance on skin colour
• ECG increasingly recognised for accurate HR monitoring 
  Newborn resuscitation and suppo….

Airway & Ventilation: The Cornerstone

If infant is apnoeic, gasping, or HR <100:

Deliver 5 inflation breaths (2–3 seconds each)

Starting pressures:

• ≥32 weeks: 30 cm H₂O
• <32 weeks: 25 cm H₂O

If no chest rise:

• Reposition
• Reapply mask
• Use alternative airway
• Increase pressure incrementally (rarely >40 cm H₂O)

Reduce pressure once chest rise achieved.

Oxygen Strategy by Gestation

≥32 weeks

Start at 21% oxygen

<32 weeks

Start at ≥30% oxygen

Target SpO₂:

• 3 min: 70–75%
• 5 min: 80–85%
• 10 min: 85–95%

Avoid hypoxia and hyperoxia.

CPAP & PEEP

Start CPAP at 6 cm H₂O for:

• Spontaneously breathing <32 weeks with distress
• ≥32 weeks needing supplemental oxygen

Use PEEP 6 cm H₂O during positive pressure ventilation.

Advanced Airway Management

• Two-person jaw thrust preferred
• Supraglottic airway (SGA) if mask ineffective
• Consider tracheal intubation if prolonged ventilation or compressions
• Video laryngoscopy recommended when available
• Confirm placement with exhaled CO₂ (note false negatives in low output states)

Routine suctioning is NOT recommended unless obstruction suspected.

Chest Compressions

Start if HR <60 after 30 seconds of effective ventilation.

Use:

• 3:1 compression-to-ventilation ratio
• Two-thumb encircling technique
• 90 compressions + 30 ventilations per minute

Increase oxygen to 100%.

Reassess HR every 30 seconds.

Stop compressions once HR >60.

Vascular Access

Preferred route:
 ✔ Umbilical venous catheter (UVC)

Alternative:
 ✔ Intraosseous (IO) access

IO is often first-line in out-of-hospital settings.

Drugs in 2025 Update

Adrenaline

• 20 mcg/kg IV
• Repeat every 4 minutes
• IO acceptable alternative
• Endotracheal dose only if no IV/IO access

Glucose

Check levels.
 Treat only if low:

• 2 mL/kg of 10% glucose

Volume

10 mL/kg isotonic crystalloid or O-negative blood if blood loss suspected.

Bicarbonate

❌ Removed from resuscitation algorithm.

Post-Resuscitation Care

Priorities:

• Maintain temperature 36.5–37.5°C
• Monitor glucose closely
• Avoid hypo/hyperglycaemia
• Avoid hyperoxia
• Avoid hypocapnia

Therapeutic Hypothermia

For eligible term infants with evidence of hypoxic-ischaemic encephalopathy:

• Cool to 33–34°C
• Strict eligibility criteria required
• Do NOT initiate cooling in out-of-hospital settings

Out-of-Hospital Births

Higher risk of hypothermia.

Key points:

• Early proactive thermal control
• Resuscitate in air unless compressions required
• Use 100% oxygen during compressions
• IO access preferred
• Transport all resuscitated infants to hospital
• Therapeutic hypothermia not started pre-hospital

Telemedicine may support remote decision-making 
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Withholding or Discontinuing Resuscitation

If HR absent >20 minutes despite full resuscitation and reversible causes excluded:
 → Consider stopping.

In extremely preterm infants:

• Individualised decisions
• Parental involvement critical

If gestation >24 weeks in high-resource settings:

• Resuscitation usually indicated

Palliative care support is recommended where survival-focused care is not appropriate.

Documentation & Debriefing

• Record time-based HR and breathing
• Document APGAR and interventions
• Record discussions with parents
• Conduct structured team debrief

Family-centred care is emphasised throughout.

2025 Guideline Key Shifts

• Greater emphasis on delayed cord clamping
• Precision oxygen targeting
• Removal of bicarbonate
• Stronger focus on thermal management
• Increased use of ECG for HR
• Human factors & team briefing highlighted
• Clearer out-of-hospital guidance

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Final Clinical Summary

The ERC 2025 newborn resuscitation guideline reinforces a simple but critical principle:

Effective ventilation, guided by accurate heart rate assessment, saves lives.

Thermal stability, precision oxygen targeting, structured team preparation, and thoughtful ethical decision-making are now more central than ever.

For clinicians involved in delivery room care or neonatal emergencies, mastery of this algorithm is essential.