Part 7. Neonatal resuscitation: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Article information

Clin Exp Emerg Med. 2016;3(S):S62-S65
Publication date (electronic) : 2016 July 5
doi :
1Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
2Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
3Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
4Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Korea
5Department of Pediatrics, Kangwon National University College of Medicine, Chuncheon, Korea
6Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea
7Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
8Department of Pediatrics, Ajou University College of Medicine, Suwon, Korea
9Department of Pediatrics, Sungkyungkwan University School of Medicine, Seoul, Korea
10Department of Obstetrics and Gynecology, Yonsei University of College of Medicine, Seoul, Korea
11Department of Nursing, The Catholic University of Korea School of Nursing, Seoul, Korea
12Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
13Department of Obstetrics and Gynecology, The Catholic University of Korea College of Medicine, Seoul, Korea
14Department of Emergency Medicine, Yonsei Universtiy College of Medicine, Seoul, Korea
15Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
Correspondence to: Ai-Rhan Ellen Kim  Division of Neonatology, Department of Pediatrics, Asan Medical Center Children’s Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea  E-mail:
Received 2016 February 16; Revised 2016 March 19; Accepted 2016 March 19.

The following is a summary of the 2015 Korean Neonatal Resuscitation Guidelines. An extensive review of scientific evidence by experts of Neonatal Resuscitation Committee for the 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care including neonatologists, nurse, obstetrician, perinatologist, and anesthesiologist was performed to update the 2011 Korean Neonatal Resuscitation Guidelines.


It has been reported that approximately 85% of term babies will start spontaneous breathing within 10 to 30 seconds after birth, an additional 10% will respond to drying and stimulation for breathing, about 3% will breathe after positive-pressure ventilation (PPV), 2% will need intubation, and 0.1% will require chest compression and/or epinephrine during transition to extrauterine life [1-3].

One of the key factors for neonatal resuscitation is anticipation. Determining who will require resuscitation, what equipment needs to be prepared, whom to join, and how each members should participate in the resuscitation are all important factors in anticipating neonatal deterioration. Beginning resuscitation with antenatal counseling and a team briefing are also important [4,5].

Heart rate and respiration are used to identify the need for neonatal resuscitation and to assess response to resuscitation. Heart rate could be checked by either auscultating along the left side of chest or palpating the umbilical cord base. If the heart rate cannot be determined by auscultation/palpation and the baby is not vigorous, pulse oximetry (could underestimate heart rate) or cardiac monitoring can be used for alternatives measures [6-9]. Oxygen saturation determined by pulse oximetry indicates color, a third vital sign. The most sensitive indicator of a successful resuscitation is an increase in heart rate. The critical factor to achieve successful neonatal resuscitation is an effective ventilation.


Newly born term infants who are breathing or crying and have a good tone immediately after birth should be dried and taken to the mother for routine care, with continuous evaluation (Fig. 1). However, preterm or term infants who are not breathing or crying and have poor tone should be dried and stimulated to initiate breathing, and kept in a position to open the airway effectively. It is recommended that the temperature of newly born, non-asphyxiated infants should be maintained between 36.5°C and 37.5°C after birth through resuscitation or stabilization to admission. It is important to record of the temperature of non-asphyxiated infants, because as it is a strong predictor of mortality and morbidity for all gestations [9]. Hypothermic infants with a temperature less than 36°C on hospital admission could be rewarmed using either the rapid (0.5°C/hr or greater) or the slow (less than 0.5°C/ hr) rewarming method.

Fig. 1.

Neonatal resuscitation algorithm. HR, heart rate; CPAP, continuous positive airway pressure; PPV, positive-pressure ventilation; ECG, electrocardiogram.

After the aforementioned “initial care,” physicians should determine the heart rate. If the newborn infant’s heart rate is lower than 100 beats/min or gasping or apnea is observed, physicians should provide an effective ventilation with a face mask or endotracheal intubation (recommending intubation prior to beginning chest compression). If the newly born infant has a heart rate greater than or equal to 100 beats/min and shows labored breathing or persistent cyanosis, continuous positive airway pressure will be required [10-12]. Only approximately 60 seconds after birth is allotted to initiate ventilation after determination of heart rate. When PPV begins, consider using electrocardiogram monitoring for accurate assessment of the heart rate. After 30 seconds of PPV that initiates chest movement, the heart rate is reassessed. If the heart rate is lower than 60 beats/min, corrective steps should be taken to ensure adequate ventilation [13]. Alternative airways such as endotracheal intubation (if face mask was used) or laryngeal mask (if intubation is unsuccessful or not possible for late preterm infants of more than 34 weeks gestation or in case of term infants) can be used to secure airway [14]. If the infant’s heart rate is not recovered, perform chest compression with 100% oxygen. Compression point (lower 1/3 of the sternum) and compression-to-ventilation ratio (3:1) remains unchanged. Superimposed thumbs may be a better technique for cardiac compression in newborns and can be continued from the head of the bed while accessing the umbilical line. Reassessment of heart rate is performed after 60 seconds of chest compression, at which time medications should be administered. Medication is rarely indicated during neonatal resuscitation because bradycardia during newborn resuscitation is usually due to inadequate lung inflation or hypoxemia, and initiating ventilation is the most critical and important step to resolution. Epinephrine remains a major medication. The recommended fluid for acute hypovolemia is normal saline or type-0-negative blood via an umbilical venous catheter or via an intraosseous needle, if required, in term and preterm newborns.

A newly born infant with meconium-stained amniotic fluid does not need a routine intubation for tracheal suctioning even when non-vigorous. Instead, adequate oxygenation and ventilation should be considered first [15-19].

A few changes have been made with regard to resuscitation of preterm infants. With regard to cord clamping, delaying umbilical cord clamping for more than 30 seconds is suggested for preterm infants not requiring resuscitation. For preterm infants requiring resuscitation, there is insufficient evidence supporting a delayed cord clamping at birth. Routine use of umbilical cord milking for infants of gestational age 28 weeks or less is not recommended; however, it may be considered on individual basis or in research settings [4,9,20].

Maintenance of the room temperature to approximately 23°C to 25°C in preparation for the birth of preterm infants and using radiant warmer, plastic wrap, warm blankets, hat, thermal mattress, warm humidified gases are recommended for preterm infants of less than 32 weeks of gestation to reduce hypothermia [21,22]. It is recommended that hyperthermia (38°C) should be avoided. Regarding the use of oxygen, resuscitation of newborns of 35- week gestation or greater should begin with 21% oxygen. Resuscitation of newborns of less than 35 weeks of gestation should begin with 21% to 30% oxygen [23-25]. Free-flow oxygen administration may be initiated using an oxygen blender at 30%, and titrate oxygen to achieve preductal oxygen saturation targets for healthy term infants after vaginal delivery [26]. When PPV is required for resuscitating preterm infants, it is preferable to use positive end expiratory pressure devices to inflate lungs at 5 cm H2O between the positive pressures [27]. The routine use of initial sustained inflation longer than 5 seconds for preterm infants without spontaneous respiration is not recommended [9].


Once newborns who required resuscitation are stabilized, they should be hospitalized where close monitoring is possible. Infants of more than 36 weeks of gestation with evolving moderate-to-severe hypoxic ischemic encephalopathy should be considered for therapeutic hypothermia at an institution where multidisciplinary care and well-defined protocols can be applied (i.e., cooling within 6 hours, temperature control at 33°C to 34°C for 72 hours, and rewarming over, at least, 4 hours) [5].


Evidence for delivery prognostic score for preterm infants of less than 25 weeks of gestation is insufficient to support its use. It may be reasonable to stop resuscitation for newborns with an Apgar score of 0 after 10 minutes of optimal resuscitation; however, the decision to stop resuscitation should be individualized [28]. If spontaneous respiration is not seen or Apgar scores of 1 to 3 at 20 minutes of age in newborns with greater than 34 weeks of gestation, it may be reasonable to stop resuscitation in settings with limited resources [9]. In all cases, risk and benefits of attempting resuscitation and life-sustaining treatment should be discussed with parents, and decision should be made in the best interest of the infant.


Further refinement in the current instructor program is needed to prepare instructors to train providers. It is suggested that neonatal resuscitation training for neonatal resuscitation providers be conducted as frequently as 6 months or more [29,30], however, the best interval for renewal is to be determined.


1. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation 2012;83:869–73.
2. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med 1995;149:20–5.
3. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006;118:1028–34.
4. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 11. Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122(16 Suppl 2):S516–38.
5. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 11. Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e260–87.
6. Dawson JA, Saraswat A, Simionato L, et al. Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants. Acta Paediatr 2013;102:955–60.
7. Kamlin CO, Dawson JA, O’Donnell CP, et al. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr 2008;152:756–60.
8. van Vonderen JJ, Hooper SB, Kroese JK, et al. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr 2015;166:49–53.
9. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7. Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2015;132(16 Suppl 1):S204–41.
10. Morley CJ, Davis PG, Doyle LW, et al. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008;358:700–8.
11. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Finer NN, Carlo WA, et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010;362:1970–9.
12. Dunn MS, Kaempf J, de Klerk A, et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011;128:e1069–76.
13. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S909–19.
14. Esmail N, Saleh M, Ali A. Laryngeal mask airway versus endotracheal intubation for Apgar score improvement in neonatal resuscitation. Egypt J Anesth 2002;18:115–21.
15. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. J Pediatr 2015;166:1208–13.
16. Davis RO, Philips JB 3rd, Harris BA Jr, Wilson ER, Huddleston JF. Fatal meconium aspiration syndrome occurring despite airway management considered appropriate. Am J Obstet Gynecol 1985;151:731–6.
17. Dooley SL, Pesavento DJ, Depp R, Socol ML, Tamura RK, Wiringa KS. Meconium below the vocal cords at delivery: correlation with intrapartum events. Am J Obstet Gynecol 1985;153:767–70.
18. Rossi EM, Philipson EH, Williams TG, Kalhan SC. Meconium aspiration syndrome: intrapartum and neonatal attributes. Am J Obstet Gynecol 1989;161:1106–10.
19. Yoder BA. Meconium-stained amniotic fluid and respiratory complications: impact of selective tracheal suction. Obstet Gynecol 1994;83:77–84.
20. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7. Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e169–201.
21. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and efficacy of Trans-warmer mattress for preterm neonates: results of a randomized controlled trial. J Perinatol 2011;31:780–4.
22. te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidified and heated air during stabilization at birth improves temperature in preterm infants. Pediatrics 2010;125:e1427–32.
23. Armanian AM, Badiee Z. Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen. J Res Pharm Pract 2012;1:25–9.
24. Kapadia VS, Chalak LF, Sparks JE, Allen JR, Savani RC, Wyckoff MH. Resuscitation of preterm neonates with limited versus high oxygen strategy. Pediatrics 2013;132:e1488–96.
25. Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterm infants with different inspired oxygen fractions. J Pediatr 2014;164:1322–6.
26. Mariani G, Dik PB, Ezquer A, et al. Pre-ductal and post-ductal O2 saturation in healthy term neonates after birth. J Pediatr 2007;150:418–21.
27. Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for newborn ventilation in the delivery room. J Pediatr 2014;165:234–9.
28. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospitalbased cohort. Am J Obstet Gynecol 2007;196:463.
29. Ernst KD, Cline WL, Dannaway DC, et al. Weekly and consecutive day neonatal intubation training: comparable on a pediatrics clerkship. Acad Med 2014;89:505–10.
30. Mosley CM, Shaw BN. A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course. Arch Dis Child 2013;98:582–6.

Article information Continued

Fig. 1.

Neonatal resuscitation algorithm. HR, heart rate; CPAP, continuous positive airway pressure; PPV, positive-pressure ventilation; ECG, electrocardiogram.