A
Let's do this properly, the way it plays out in an NLS practical assessment. I'll run it as an interactive scenario — I give you the situation, you tell me what you'd do at each decision point, and I'll tell you whether that's right before moving on. That's much better prep than me just reciting the algorithm at you.
A quick note before we start: this follows the standard Resuscitation Council UK NLS algorithm structure. Guidelines get periodically updated (ILCOR review cycles), so for your actual course always defer to the current edition of the NLS manual/algorithm your provider gives you — this is for practising the process and decision-making, not a substitute for the current official algorithm.
Scenario: "The one that doesn't go to plan"
You're the NLS-trained practitioner called to a delivery. Handover from the midwife:
"37+2 weeks, category 1 section for suspected placental abruption. Baby about to be delivered now. No time for full handover."
Baby is delivered and handed to you at 0 minutes. Floppy, blue, not crying.
What are your first actions in the first 30 seconds?
Tell me what you'd do (call it out like you would in the exam — actions, not just thoughts), and I'll respond as the scenario would.
Good — solid sequence, and mostly right. A few refinements an examiner would want to hear explicitly:
What you got right:
- Dry, remove wet towel, keep warm ✓
- Neutral position (airway alignment) ✓
- 5 inflation breaths as the next step for an apnoeic/floppy baby ✓
- Reassess after — correct instinct ✓
What's missing/needs to be explicit:
- Start the clock — you need to call this out loud ("starting the clock, time zero") because everything after is time-stamped against it.
- Call for help early — if you're not already flanked by a team, this baby's presentation (floppy, blue, not crying, post-abruption) should trigger a call for a second pair of hands/senior neonatal help now, not later.
- Before jumping straight to inflation breaths, you should verbalise your initial assessment: tone, breathing effort, heart rate (auscultate or feel cord). You clearly know it's apnoeic (that's why you're giving inflation breaths), but in the exam you say what you saw, not just what you did.
- Inflation breaths are given via face mask, 2 rescuer ideally, 5 breaths, 3 seconds each, air (or 21–30% oxygen if <32/40 — this baby's 37+2 so air is fine), and — critically — you need to be watching for chest movement.
Continuing the scenario:
You give 5 inflation breaths. You are not confident you saw chest movement.
Heart rate on reassessment: 60 bpm, baby still floppy, no respiratory effort.
What do you do now?
A
Exactly right — and this is the single most commonly missed step in NLS exams, so well done catching it. No chest movement after inflation breaths = airway problem, not a heart problem. You don't jump to compressions yet. The algorithm wants:
- Reposition the airway (re-check neutral position, consider jaw thrust)
- Consider 2-person technique — one holds the mask/seal + jaw thrust, one squeezes the bag
- Check for an obstruction — look in the mouth, consider suction if secretions/meconium visible
- Repeat inflation breaths (5 breaths) and this time confirm chest wall movement
You called all of that out correctly, plus the reassessment. Good.
Continuing:
Second set of inflation breaths given, 2-person technique. This time you do see chest movement — good bilateral rise.
Reassess at this point:
- Heart rate: 50 bpm
- No spontaneous respiratory effort
- Still floppy, colour poor
What's your next step?
A
Yes — that's the right call. Chest is now aerating (you confirmed movement), HR is <60 despite adequate inflation, so compressions are indicated. You've got the key pieces:
- 3:1 ratio, compressions to breaths (90 compressions : 30 breaths per minute) ✓
- Continue ventilation — compressions never happen alone in NLS ✓
- Escalating for help / prepping for UVC access — good forward thinking, shows you're anticipating drugs may be needed ✓
- Reassess HR after 30 seconds ✓
Two things an examiner would want added, said out loud:
- Increase oxygen concentration — once compressions start, you step up to higher oxygen (guided by sats/pulse oximetry, moving toward 100% if needed), rather than staying on air.
- Technique — two-thumb encircling technique, lower third of sternum, depth ~1/3 AP diameter of chest. Worth stating even briefly, examiners like to hear it.
Continuing the scenario:
30 seconds of 3:1 compressions + ventilation. Team member has now got a saturation probe on and ECG leads attached (faster/more reliable than auscultation here).
Reassessment:
- Heart rate: 45 bpm (ECG confirmed)
- Sats: 40%
- Still no spontaneous effort, still floppy
This baby is not responding to effective ventilation + compressions.
What now?
A
Good instincts, and importantly you've connected the dots that this is a placental abruption — that's your clue toward hypovolaemia, so thinking about volume replacement is exactly the kind of scenario-awareness examiners are looking for. A few corrections and refinements:
Right:
- UVC access as the drug route ✓
- Adrenaline ✓
- Volume replacement (saline, or ideally emergency O-negative blood if abruption/blood loss suspected — you're right to think volume here) ✓
- Continue compressions + ventilation throughout, don't stop for access ✓
- Reassess after 30s / recheck HR ✓
Corrections:
- Adrenaline dose: IV/UVC route is 10 micrograms/kg (0.1 mL/kg of 1:10,000), repeated every 3–5 minutes if no response. Say the dose out loud in the exam — they will ask.
- Dextrose — not yet. This is a common exam trap. Dextrose is for post-resuscitation care (preventing hypoglycaemia once the baby is responding), not part of the acute drug-giving cycle during ongoing CPR. Calling for it now would likely lose you a mark for prioritisation. Park it mentally for later.
- Volume dose, if you get there: 10 mL/kg, given over 5–10 minutes (faster if actively exsanguinating).
- Also worth voicing: check/secure the airway — has this baby been intubated yet, or are you still on mask ventilation? At this stage of a prolonged resuscitation with drugs going in, examiners usually expect you to be moving toward a secured airway (ETT) if not already done, partly because effective ventilation is still the number one priority even while giving drugs.
Continuing:
Adrenaline given via UVC (correct dose), volume bolus of 10 mL/kg started. Compressions and ventilation continue throughout, uninterrupted.
30 seconds later, reassessment:
- Heart rate: 110 bpm and rising
- Some spontaneous gasping respiratory effort beginning
- Sats improving on the monitor
- Colour improving
What do you do now?
A
Correct on the big one — HR >100 means stop compressions, that's the threshold, and you got it right without hesitation. Good.
Right:
- Stop compressions once HR >100 ✓
- Continue ventilation (baby's only gasping, not yet establishing adequate own effort) ✓
- Keep warm ✓
- Continue monitoring SpO2/ECG ✓
- Reassess ✓
What you'd want to add now — this is the "post-resuscitation care" phase, and examiners specifically probe this because candidates often just stop thinking once HR recovers:
- Titrate oxygen down — don't leave the baby on high FiO2; wean guided by pre-ductal sats targets (following the standard post-birth sats-by-minute reference, but don't overshoot to hyperoxia either).
- Blood glucose check — this is where dextrose thinking comes back in, now it's actually indicated if hypoglycaemic, not before.
- Consider the abruption context — this baby was hypovolaemic/shocked. Think: full set of bloods, Hb/FBC, clotting, blood gas (lactate will tell you how much of a struggle that was), group & save/crossmatch given likely more blood needed.
- Temperature — recheck, this baby's had a prolonged resus, hypothermia risk is real.
- Consider therapeutic hypothermia pathway — significant HIE risk after a resus like this (prolonged bradycardia, needed adrenaline + volume); this baby needs cooling-pathway assessment per unit protocol, and early NICU/tertiary discussion.
- Debrief and documentation — timings, drugs given, doses, response — while it's fresh, plus a structured team debrief (this is often explicitly marked in NLS OSCE stations).
- Communicate with parents — often forgotten under exam pressure but genuinely expected.
That's a full high-acuity NLS scenario run start to finish — and you handled the resuscitation sequence itself very well: airway-first troubleshooting, correct escalation to compressions, correct drug route/thinking, correct stop-criteria. The main things examiners tend to dock marks for (and where you needed prompting) were explicit verbalisation (doses, technique, calling the clock), and not jumping ahead (dextrose too early) or stopping too soon (forgetting post-resus care).
Want to run a second scenario — maybe one with a different failure branch, like a meconium-stained baby who won't aerate despite good technique (airway obstruction path), or a preterm <28 weeker where the whole approach shifts (polythene bag, different O2 strategy, gentler handling)?
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