Management of Preterm infants <32 weeks in the Delivery Room   
Date of Initial Publication: January 12, 2021   
Revision Date: 
Contact Author: Jennifer Cohen 
Contributing Authors: El Noh, Melissa Schmatz, Stephanie Ardell, Jennifer Hesler, John Chuo, Sarvin Ghavam, Kristen Nelson

Consensus statement and clinical recommendations  

• These recommendations refer specifically to the immediate resuscitation period after delivery, in the first 10 minutes of life
• These recommendations apply to infants <32 weeks
• ECG monitoring as soon after birth as possible is recommended
• T piece resuscitator for initial resuscitation is recommended over other ventilation devices

Oxygen Saturation Targeting

(Follow NRP standards for oxygen saturation targeting goals 7th Ed)

1. Pulse oximeter is placed on a preductal location on the right upper extremity, usually wrist or palm, as soon as possible.
2. Oxygen concentration is started at 21-30%. The oxygen concentration should be adjusted to achieve the targeted SpO2 levels, monitored by the pulse oximeter.
3. If chest compressions are initiated, oxygen concentration is increased to 100% and weaned rapidly when the heart rate recovers and compressions are no longer needed.
4. Oxygen concentrations are adjusted to maintain saturations that match recommended range for each minute after birth. 

Respiratory support  

1. Non-invasive respiratory support is the first line therapy for all spontaneously breathing infants <32 weeks.
2. HR assessment is critical and ECG monitoring is recommended.
3. Immediately initiate CPAP 5cm H2O and titrate (max 8-10cm H2O) to reduce work of breathing and O2 requirement 2
4. If PPV is required, gentle ventilation is provided with initial PIP 20cm H2O, with increase to 25-30cm H2O as needed.
5. Avoid using RAM cannula for initial resuscitation; nasal CPAP or facial CPAP is rec 

Intubation and surfactant administration 

1. Intubation criteria:  

   a. Persistent apnea at 5 minutes of life  

   b. Bradycardia <100 despite optimal CPAP/PPV support  

   c. Note: FiO2 requirement in the DR/OR should NOT be a primary indicator for intubation/surfactant administration  

2. Check ET tube placement with auscultation, colorimetric CO2 detector, and/or chest xray
3. Surfactant administration per institutional guidelines/practices Note: ETT should not be suctioned for 2 hours following surfactant administration unless signs of significant airway obstruction 

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The Neonatology Consensus Statements (“Statements”) are based on a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These Statements are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.  

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