Preterm Infants Born Before 28 Weeks Gestation - Management of

Publication: 30/11/2007  --
Last review: 21/02/2017  
Next review: 01/02/2020  
Clinical Guideline
ID: 1178 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Preterm Infants Born before 28 Weeks Gestation

Summary of Guideline
Delivery and Stabilisation
The Golden Hour

Summary of Guideline

This guideline covers the key aspects to be considered prior to the delivery of an infant at less than 28 weeks gestation. It also covers delivery room care and the golden hour on the neonatal unit for these infants.


The CESDI Project 27/28 report on infants born between 27 and 28 weeks highlighted differences in early care between babies surviving and not surviving the first 28 days of life1,2. There were increased incidences of deficiencies in the latter group. The report made recommendations for stabilisation and early care for these infants.

10 principal steps of management for extremely preterm infants have been identified as:

  1. Antenatal counselling
  2. Trained stabilisation team
  3. Preparation for stabilisation
  4. Prophylactic surfactant
  5. Avoidance of initial lung damage at stabilisation
  6. Thermal control
  7. Avoidance of hyperoxia
  8. Control of pCO2
  9. Structured approach to problematic respiratory distress syndrome
  10. Minimal handling

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1 Counselling

  • All parents expected to deliver babies before 28 weeks should be seen routinely by a neonatal doctor and offered written information - BLISS, Tommys book, Leeds centre for newborn care information. Network leaflet for babies 23-25 weeks.
  • Counselling should be undertaken by an experienced registrar or consultant. More junior colleagues should be encouraged to attend for training. For parents expected to deliver before 24 weeks, counselling should ideally be carried out by a consultant or an experienced neonatal registrar.
  • Check with obstetric team that they have considered antenatal steroids and intrapartum magnesium (both proven to improve outcome <30 weeks).

2 Resuscitation at the borderline of viability

3 Stabilisation team

  • A team of tier 1 and tier 2 medical / ANNP staff and senior neonatal nursing staff should ensure each are aware of an impending delivery

4a Equipment – Neonatal Unit

  • Surfactant: A person should be designated to collect one vial of surfactant from the neonatal unit when called to the delivery. This will be administered as per guidelines: Administration of Surfactant in Neonates
  • Incubator Aim: To create an optimum environment for minimal handling, good skin care and reduced trans-epidermal fluid loss. Use a “Giraffe” incubator but where not available a standard incubator is acceptable. Set up, warm and humidify to 80%, to be increased once admission procedures finished.
  • Neopuff: Set up with air/O2 mix and set to inflation pressures of 20/4
  • Ventilator: The initial mode of ventilation will normally be “PC-AC with VG” for all babies. Set up Draeger VN 5000 with VG at 5ml/kg, rate 40/min and I time 0.4, PIP max at 25, PEEP at 4
  • Monitors: All with appropriate attachments including invasive arterial monitoring and possibly end tidal CO2.
  • UAC/UVC trolley: Ensure this is set up on NNU and ready for immediate insertion of lines

4b. Equipment – Delivery Suite

  • Resuscitaire: Set up an air/oxygen mix resuscitaire. Start with 30% inspired oxygen. Ensure cylinders are full of gas for transfer.
  • Set inspiratory pressure to 20cm H2O and PEEP is set to 5-6cm H2O
  • Check plastic bags and hats of varying sizes
  • For deliveries below 26 weeks – put heated pad in place ready to activate as delivery imminent
  • Set heater to manual and maximise output
  • Prepare additional towels to warm ready for transportation to the neonatal unit

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Delivery and stabilisation

1 Staffing 

  • Team of Tier 1 and Tier 2 ANNP / medical staff and senior nurse to attend all deliveries. Where staffing allows, the nurse who will be caring for the baby should attend the delivery.
  • Deliveries ≤ 25 weeks require highly experienced staff. The consultant should be made aware of an impending delivery.
  • Consideration should be made as to whether the consultant attends the delivery to support the registrar during stabilisation and to assist with communication between medical teams and parents.

2 Cord Gases

  • Obstetric policy is to collect cord gases routinely at delivery. Staff should remind the obstetric/midwifery team to do so.

3 Thermoregulation
Maintaining good thermoregulation is a critical part of resuscitation. There is evidence to suggest hypothermia may be associated with a poorer outcome. The following are essential:

  • Maximum heat output from resuscitaire overhead heater.
  • Delivery into a plastic bag without drying ensuring a snug seal around the baby’s neck to prevent draught and evaporative loss6
  • Allow exposure to radiant heater - do not cover baby with towels until ready to leave delivery suite.
  • Place a hat on baby’s head.
  • Use a transwarmer mattress if less than 26+0 weeks
  • Monitor temperature on the resuscitaire with reusable probes
  • Check and document temperature before leaving delivery suite

See guideline: Thermoregulation in the Newborn

4 Delivery of PEEP
Many infants can be managed simply with face mask PEEP for transfer to the NNU prior to starting CPAP. If an infant is ≥ 27+0 weeks, has had steroids and is in good condition at birth this approach is better for the infant.

  • Facial peep can be given at pressure of 5cm H20 with a well-fitting face mask.

5 Intubation

  • Only infants less than 27 weeks should be routinely intubated on delivery suite.
  • Intubation should be carried out by a competent operator as soon as possible after delivery. This is not a situation for an SHO trying a first ever intubation.
  • The position of the ETT should be checked using a NeoStat CO2 detector. Gently ventilate, looking for equal chest movement together with equal bilateral air entry and an improvement in heart rate.

6 Pressure

  • Gentle ventilation is essential as most babies will be easily transitioned with minimal effort.
  • Starting inflation pressures = 20cm H2O with PEEP 4 cm H2O.
  • Maximum of 2 seconds per breath and return to short ventilation breaths as soon as a stable heart rate is achieved. Observe for heart rate, chest movement and colour. A stable heart rate over 100 beats per minute is the most reliable indicator of effective ventilation.

If no response in heart rate occurs

  • Check ETT is correctly sited and chest movement is achieved.
  • Increase ventilation pressures to 25/4.
  • Increase inspired oxygen

Once a good response has been obtained

  • Reduce ventilation pressures to 20/4
  • Reduce inspired oxygen

7 Oxygen Vs. Air
There is evidence supporting the detrimental effect of resuscitation in
100% O2.9. Resuscitation of infants <28 weeks should start in 30% FiO2.

  • Aiming to maintain saturations between 88-92% by 10 minutes.
  • Monitor saturations on right arm.
  • Oxygen saturations will gradually rise over the first few minutes of life.

2 minutes


3 minutes


4 minutes


5 minutes


10 minutes


8 Surfactant

All ventilated babies < 27 weeks should receive surfactant in delivery suite.

9 Drugs for Resuscitation
The predominant reason heart rate remains low after birth is inadequate ventilation.

  • Only use drugs as a last resort after adequate ventilation is achieved.
  • Consider pneumothorax as a cause of poor ventilation.

In infants between 26-28 weeks gestation the use of drugs is appropriate if:

  • Heart rate remains below 60 despite at least 30 seconds of adequate ventilation and a further 30 seconds of coordinated ventilation and chest compressions.
  • Prepare for insertion of an umbilical venous catheter and if necessary administer the first dose of adrenaline via the ETT.

Below 26 weeks:

  • Drugs for resuscitation would not normally be appropriate for these babies and this should be included in pre-delivery discussions.

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The Golden Hour

1 Transport to the Neonatal Unit

  • All infants should be transported on a mobile resuscitaire.
  • All babies receiving surfactant in delivery suite should be transported to the Neonatal unit intubated.8
  • Ensure ETT is properly fixed with good adherence of the harness to the baby’s face.
  • Switch the resuscitaire heat output manually to maximum and for growth retarded babies > 26 weeks consider the additional use of a heated mattress.
  • Check temperature before leaving delivery suite.
  • Cover baby with dry warm towels just after the radiant heater is disconnected for journey to Neonatal Unit and do not delay transfer once the heater is switched off.
  • Ensure saturation monitor is recording a stable heart rate and oxygen saturation levels of > 60% before departure.

2 Admission to the NNU

  • Preterm babies do not tolerate handling well and become hypothermic quickly.
  • All admissions procedures should be completed as quickly as possible, ideally within one hour of birth. Non-essential procedures should not take precedence over those that require a baby to be handled.
  • On admission weigh baby with plastic bag, hat and ETT in place and then place directly in a humidified incubator / Giraffe.

3 Thermoregulation

  • Leave plastic bag in place until normothermia is reached inside humidified system and all lines are inserted, x-rayed and secured.
  • The hat should be left on until plastic bag can be removed.

4 Ventilation

  • Tidal Ventilation – Drager PC-AC + VG. Initially set up inspiratory time (Ti) to 0.4 secs. Set tidal volume (Vt) to 5 mls/kg, set maximum PIP (Pmax) to 25, PEEP to 5cm H2O and rate to 40/min.
  • Set FiO2 to provide O2 saturations of 91-94% (alarm limits 90 and 95%).
  • Direct observation and manipulation of ventilation in the first 30 minutes is fundamental to stabilisation at a time of changing lung compliance.
  • If infant is well enough for CPAP this should be started using a PEEP of 6cm H2O.
  • Infants should not be started on High Flow
  • Aim to maintain normocarbia (arterial PCO2 5 - 8 kPa with pH > 7.25) and in particular avoid hypocarbia (PaCO2 < 4.5 kPa) due to the potential risk of periventricular leukomalacia.
  • Arterial pO2 should be maintained at 6 -10 kPa with O2 saturations of 88 – 92%.8

5 Examination
Immediately after transfer to incubator:

  • Reassess ABC, chest movement, coordination with ventilator.


  • All babies require an examination including head circumference. Document this on Badger and NIPE.
  • Examination and auscultation can be carried out through the bag but if access to the baby is required e.g. for a UVC, make a small hole in bag and reseal as soon as possible.5

Initial observations

  • HR, O2 saturation target 91-94%, temperature (axillary). ECG leads may lead to skin damage and should be used with caution below 26 weeks. If not used, monitor heart rate from an O2 saturation probe.

6 Insertion of umbilical lines
These should ideally be completed within the first hour after birth.

See guideline Neonatal Procedures.


  • It is not always necessary to site a peripheral IV line in babies who are ≤28 weeks. An umbilical artery catheter and double lumen umbilical venous catheter should be sited as soon as possible by an experienced operator if required.
  • Babies may need a peripheral cannula sited for the administration of fluids if umbilical lines are going to take a while to prevent hypoglycemia.

Training opportunities

  • These are essential, but inexperienced operators should be directly assisted by an experienced operator. Avoid prolonged attempts of insertion of lines.

Timing of line insertion

  • Umbilical lines should be inserted promptly and should not interfere with stabilisation of the baby or good thermoregulation. A nominated member of staff should maintain close observation of ventilation and the baby’s clinical state whilst lines are inserted.

Initial Blood sampling

  • Take blood from the umbilical lines as inserted for FBC, blood group, CRP and blood cultures. Ensure that the group and save sample is labelled as “preterm baby; may need repeat transfusions - paedipack please
  • Electrolytes should be checked around 8 -12 hours after admission.
  • Check position of umbilical catheters immediately with an x-ray. Ensure an NGT is sited before this x-ray.

Blood pressure monitoring

  • Start BP monitoring via umbilical artery catheter as soon after insertion of lines as possible.
  • See guideline for Hypotension in the newborn: Hypotension in Newborn Infants

7 Fluids and drugs

  • Maintenance fluids at 80mls/kg/day Babiven (day 1 TPN).
  • Check blood sugar with the first blood gas and if serum glucose less than 2.0mmol/l treat with 2.0 mls/kg 10% dextrose as soon as IV access is available.
  • Avoid prolonged hypoglycaemia. If umbilical line insertion is difficult it may be necessary to site a peripheral cannula.
  • Umbilical artery catheter infusion of 0.9% heparin saline (1U/ml) at 0.5 – 1ml/hr.
  • Give antibiotics if risk factors for infection or significant RDS.
  • Give vitamin K 400mcg/kg by IM injection, if not given in delivery suite. See Vitamin K Prophylaxis guideline.
  • All babies less than 28 weeks must have Cx powder prescribed to their cord, groin and axillae. See guideline Cord Care in Newborns.
  • All babies <28 weeks and with central lines (incl. umbilical lines) should be prescribed nystatin for fungal prophylaxis. See Candidia Infection in Neonates guidelines.

8 Documentation

  • Complete purple admission form, Badger admission and early progress on Badger and print out for clinical notes. Remember perinatal history is important.
  • Document findings of initial x-ray in relation to lung fields and position of ETT, lines and NGT. Document your clinical examination.
  • Ensure any fetal medicine letters or other antenatal communications are transferred to baby notes.

9 Communication with parents

  • Do not wait for parents to visit baby. Once admission is complete and baby stabilised, visit parents on delivery suite to inform them of baby’s progress. Take photo on first visit and document on yellow parental communication sheet including time of visit.
  • Parents must be seen by a senior clinician within the first 24 hours and this must be recorded on Badger.

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Record: 1178

This guideline is aimed at all staff involved in admissions of extremely preterm infants. It should ensure optimum standards of early care for all extremely preterm infants and improve communication between members of the obstetric, neonatal teams and parents.

To provide evidence-based recommendations for the management of infants who are born at <28 weeks gestation. This guideline is to be read in conjunction with the following guidelines:

Clinical condition:

Delivery, transition and golden hour of extremely preterm infants

Target patient group: Preterm infants, less than 28 weeks
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

1. CESDI Project 27/28. An enquiry into quality of care and its effect on the survival of babies born at 27-28 weeks.

2. Acolet D, et al on behalf of the Confidential Enquiry Into Maternal and Child Health. Project 27/28: Inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland. Pediatrics 2005 Dec 116 (6): 1457 – 65

3. Critical Care and decisions in fetal and neonatal medicine:ethical issues. Nuffield Council on bioethics. 2006.

4. Costeloe K et al. The EPIcure study: Outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 2000; 106:659-671.

5. Vohra S et al. Effect of polyethylene occlusive wrapping on heat loss in very low birth weight infants at delivery: a randomised trial. J Pediatrics1999;134:547-551

6. Lyon A, Stenson B. Cold comfort for babies. ADC F&N 2004 89:93

7. CL Smith et al. Changes in body temperature after birth in preterm infants stabilised in polythene bags. ADC F&N 2005:90:F444

8. RCPCH Guidelines for good practice. Management of neonatal respiratory distress syndrome. Dec 2000.

9. International Liason Committee on Resuscitation (ILCOR) Consensus on Science With Treatment Recommendations for Pediatric and Neonatal Patients: Neonatal resuscitation. Pediatrics 2006;117:978-988.

10.BAPM Statement on current evidence for early care of the newborn (2005)

11. The Management of Babies born Extremely Preterm at less than 26 weeks of gestation. BAPM A Framework for Clinical Practice at the time of Birth Arch Dis Child - FNN, Oct 2008 10.1136/adc.2008.143321

12. European Consensus Guideline on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants - 2016 update. Neonatology 2017;111:107–125

13. 2015 Resuscitation Guidelines, Resuscitation Council UK.

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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