OLS 27

 A

NLS deep dive

Your summary gives the sequence. The detail below is drawn from the UK Resuscitation Council NLS algorithm as I know it, not from the video itself, so check the numbers against the current guidelines and your local protocol before relying on them.

1. Pre-delivery briefing

• The four questions: gestation, clear or meconium-stained liquor, number of babies, and additional risk factors. Cord clamping plans are also agreed at this point.
• Team prep: assign a team leader, airway and compressions roles, and a timekeeper, and check equipment (a working ventilation device, suction, a heat source, an ECG monitor and a saturation probe).
• Environment: a warm room (ideally 23-25°C or higher for very preterm babies), a radiant heater on, and pre-warmed towels.

2. Initial assessment

• Cord clamping: delay for at least 60 seconds if the baby is stable. If resuscitation is needed, resuscitate with the cord intact where possible.
• Start the clock at delivery.
• Assess tone, breathing and heart rate. Heart rate is the key indicator, best checked with a stethoscope or ECG rather than by palpating the cord.
• Keep the baby warm: dry them, remove wet towels and cover the head. Babies under 32 weeks go into a plastic bag or wrap without drying, wearing a hat. The target temperature is 36.5-37.5°C.
• Airway: keep the head in a neutral position, since the newborn's large occiput easily causes flexion. A folded towel under the shoulders can help.

3. Inflation breaths

• Trigger: the baby is apnoeic or gasping, or has a heart rate below 100.
• Technique: give five breaths of about 2-3 seconds each, using air for term babies and 21-30% oxygen for preterm babies.
• What success looks like: the first sign is a rising heart rate, and visible chest movement usually follows.
• Reassess heart rate and chest movement after the fifth breath.

4. If the chest isn't moving

This is the common failure point, so work through the airway checklist (the "airway ladder"):

• Recheck head position and jaw support.
• Move to a two-person technique, with one person holding the mask and jaw thrust while the other delivers breaths.
• Try longer inflation times.
• Consider an oropharyngeal airway or LMA if there is no response.
• Suction only under direct vision if you can see an obstruction.
• Repeat the inflation breaths once the airway is corrected.

5. Ventilation breaths

• Once the chest is moving and the heart rate is rising, give about 30-40 breaths per minute (roughly 15 over 30 seconds), with one second per breath.
• Continue until the baby is breathing effectively and the heart rate is above 100.

6. Chest compressions

• Trigger: the heart rate stays below 60 despite effective, chest-moving ventilation.
• Ratio: 3:1, which gives about 90 compressions and 30 breaths per minute.
• Technique: use the two-thumb encircling method on the lower third of the sternum, compressing to about one third of the chest's depth.
• Oxygen: increase to 100% and call for senior help.
• Reassess the heart rate after 30 seconds, and use an ECG for accuracy.

7. Drugs and fluids

• Adrenaline: give it if the heart rate remains below 60 after 30 seconds of effective compressions. The dose is 10-30 micrograms/kg (0.1-0.3 mL/kg of 1:10,000), given via UVC or IO, and can be repeated every 3-5 minutes.
• Consider: 10 mL/kg of 0.9% saline if hypovolaemia is suspected, 2.5 mL/kg of 10% glucose if hypoglycaemia is possible, and bicarbonate in prolonged arrest.
• Difficult access: if there is no IV access, go straight to IO rather than persisting with UVC attempts.

8. Post-resuscitation

• Parents: counsel them promptly and honestly.
• Care after resuscitation: check blood glucose, monitor temperature, and consider therapeutic hypothermia for suspected hypoxic-ischaemic injury.
• Team: hold a debrief covering what went well and what could be improved, and document everything with timings.
• Stopping resuscitation: discuss with senior staff and the parents if there is no heart rate after about 20 minutes of good-quality resuscitation.

Key exam points

• Airway and effective ventilation matter more than anything else.
• The first indicator of successful lung inflation is heart rate.
• Ventilate first, then start compressions only after effective ventilation has been confirmed.
• Preterm babies need warmth, wrap and low-oxygen strategies.

I can turn this into flashcards or a practice quiz if that would help.