🧠 Newborn Resuscitation & Support of Transition — Essential Updates for Final FRCEM Candidates

🌟 Introduction

Newborn resuscitation is a critical domain in Final FRCEM and RCEM Curriculum (2021 – Domain 7: Perinatal and Paediatric Care).
 The 2021 RCUK Newborn Life Support (NLS) guideline integrates ILCOR 2020 Consensus, emphasising evidence-based thermal control, airway support, oxygen titration, and ethical decision-making around continuation or cessation of resuscitation.

This post highlights the exam-relevant, high-yield points that every emergency physician should master.

🔹 1️⃣ Before Delivery — Preparation & Team Readiness

• Every delivery should have at least one clinician trained in Newborn Life Support (NLS) available.
• High-risk births (prematurity, growth restriction, abnormal CTG, meconium, instrumental delivery, placental bleed) require a designated resuscitation team.
• Checklists, pre-briefing and role allocation improve team coordination — a frequent SBA theme under “non-technical skills.”

Exam Hint: RCEM questions often present a non-reassuring CTG with limited staff — the correct action is to call for a trained resuscitation clinician before delivery, not after birth.

🔹 2️⃣ Thermal Control — First Intervention

• Aim for 36.5 – 37.5 °C.
• Delivery-room temperature ≥ 25 °C for infants ≤ 28 weeks.
• Term infants: Dry, wrap, cover head.
• Preterm < 32 weeks: Polyethylene wrap + radiant warmer (no drying).
• Monitor temperature as a quality indicator of care.

Exam Pearl: Polyethylene wrap without drying reduces evaporative heat loss in preterm infants — this is a favourite Final FRCEM trap.

🔹 3️⃣ Umbilical Cord Management

• Delay cord clamping ≥ 60 seconds where resuscitation is not urgent.
• Cord milking is an option for infants > 28 weeks if immediate clamping is required.
• If resuscitation is needed immediately, clamp early but prepare for rapid transfer to the resuscitaire.

SBA Example:

A term baby born through meconium with poor tone → the correct step is immediate cord clamping and resuscitation, not delayed clamping.

🔹 4️⃣ Initial Assessment – The Three Qs

Ask three questions within the first minute:

1️⃣ Is the baby term?
 2️⃣ Is the baby breathing or crying?
 3️⃣ Is tone good?

Classification and Actions

Transition                           Findings                                                       Immediate Actions

Satisfactory                  | Good tone, crying, HR ≥ 100                        | Delay cord clamp ≥ 60 s; dry and wrap
Incomplete                    | Weak respiration or HR < 100                      | Stimulate, maintain airway, start inflations
Poor/Failed                    | Floppy, apnoeic, HR < 60                             | Immediate cord clamp → move to resuscitaire → NLS algorithm

🔹 5️⃣ Airway & Breathing – First 60 Seconds Matter

• Start positive-pressure ventilation within 60 s if not breathing or HR < 100.
• Inflation pressures: Term 30 cm H₂O; Preterm 25 cm H₂O.
• Oxygen:
  • ≥ 32 wks → 21 % air
  • 28–32 wks → 21–30 %
  • < 28 wks → 30 %
• Re-assess HR every 30 s.
• If chest not rising → check seal and airway position before increasing pressure.

Exam Pearl: Routine airway suctioning in non-vigorous meconium-stained infants is not recommended — ventilation comes first.

🔹 6️⃣ Ventilation Failure – Escalation

• If mask ventilation ineffective → two-person technique, reposition head, or insert laryngeal mask (≥ 34 weeks).
• Tracheal intubation if ventilation fails or prolonged.
• Confirm tube placement with exhaled CO₂ detector.
• Always verify chest movement and rising HR before chest compressions.

🔹 7️⃣ Chest Compressions & Drugs

• Begin compressions if HR < 60 after 30 s of effective ventilation.
• 3 compressions: 1 ventilation, ≈ 90 compressions + 30 breaths per min.
• Use two-thumb technique.
• Adrenaline IV/IO: 20 µg/kg (0.2 mL/kg of 1:10,000), repeat every 3–5 min.
• Access: Umbilical vein preferred; IO alternative.

🔹 8️⃣ Post-Resuscitation Care

• Maintain normothermia (36.5–37.5 °C).
• Monitor glucose closely; avoid fluctuations.
• Consider therapeutic hypothermia (33–34 °C) only for suspected moderate/severe HIE with documented criteria.
• Ensure documentation and parental communication are complete and sensitive.

🔹 9️⃣ Stopping or Withholding Resuscitation

• Review if no HR > 10 min post-birth.
• Consider stopping after 20 minutes of no response, once reversible causes excluded.
• Focus on palliative comfort and family support if resuscitation is withdrawn.

Ethical note: RCEM SBA questions often test this threshold of “when to stop” and expect candidates to know the 20-minute rule.

🔹 🔟 High-Yield FRCEM Exam Concepts

1️⃣ Delayed cord clamping ≥ 60 s (beneficial unless immediate resuscitation required).
 2️⃣ No routine suction for meconium.
 3️⃣ Preterm < 32 wks start O₂ 21–30 %.
 4️⃣ Inflation pressures 25–30 cm H₂O.
 5️⃣ Start PPV within 60 s if HR < 100.
 6️⃣ CPAP for spontaneously breathing preterm.
 7️⃣ Adrenaline 20 µg/kg IV/IO (1:10,000).
 8️⃣ Consider stopping after 20 min no response.
 9️⃣ Therapeutic hypothermia only for HIE.
 🔟 Laryngeal mask ≥ 34 wks if mask ventilation fails.

🩺 FRCEM Style Practice Question

A 30-week infant is born by emergency C-section after placental abruption.
 The baby is floppy and apnoeic at birth. Heart rate is 80/min after stimulation.
 What is the most appropriate next step?

A. Start positive-pressure ventilation at 25 cm H₂O with FiO₂ 21–30 % ✅
 B. Immediate tracheal intubation
 C. Dry and wait for cry
 D. Chest compressions
 E. Give adrenaline via umbilical vein

Correct Answer: A — For a preterm (< 32 wks) with HR < 100 and ineffective breathing, initiate PPV at 25 cm H₂O using 21–30 % oxygen.

Practise more with our Neonatal Emergencies demo, realistic questions here:Demo Quiz - Study Zone

🔗 Further Learning & References

• Resuscitation Council UK: Newborn Resuscitation Guideline 2021
  
  
• ILCOR Neonatal Life Support Consensus 2020
  
  
• RCEM Curriculum 2021 – Domain 7: Paediatrics and Perinatal Care
  
  
• RCEMLearning – Newborn Life Support Module
  
  
• FRCEM StudyZone Paediatric Section