Revised Instructions For Infant And Newborn CPR

*To take the corresponding CDE quiz, visit the College of Emergency Dispatch.*

As an Emergency Medical Dispatcher (EMD), it is not often that you have an unexpected baby birth on the line. After holding your own breath through Protocol F: Childbirth – Delivery instructions, hearing that infant cry on the line is a joy to be celebrated. In fact, many comm. centers recognize these special deliveries with stork pins and even pink- or blue-frosted sheet cakes. Similar accolades are given for CPR saves—the ability to sustain life in a patient that had no heartbeat is indescribable—but the combination of both is rare, indeed. 

Out of the 378 agencies that provide call data to the International Academies of Emergency Dispatch^® (IAED^™), a total of 1,806,283 CPR calls were recorded between January 2020 and March of 2026. Of these calls, nearly 2% (36,104) utilized Protocol A for infants, and only 0.45% (8,062) utilized Protocol N for newborn/neonates. 

These statistics can help us understand the patient circumstances that are most likely to result in unexpected delivery and newborn life support, as unplanned out-of-hospital birth (UOHB) is associated with poorer outcomes for babies. According to an Australian study, these births (most often attended by emergency ambulance) may be increasing internationally.¹ 

Research shows that mothers giving birth in the out-of-hospital setting are more likely to have already given birth two or more times. Generally, they experience faster labors compared to first-time mothers, they have increased rates of perinatal complication, and their labor and birth is more likely to occur outside of typical hours.² 

In fact, a British study in 2018 revealed that babies are most likely to be born at 4 a.m., with the more than 70% of spontaneous births occurring between the hours of 1 a.m. and 7 a.m.³—which is fair warning for our night-shift EMDs! 

Out-of-hospital newborn care 

For babies born unexpectedly outside of hospitals, the immediate care of the infant is critical—especially for babies born prematurely (< 37 weeks) or at a low birth weight (< 5.5 lbs or 2500 g) or who undergo complicated labor, experience reduced oxygen supply during birth, or are affected by infection or maternal illness. 

In an out-of-hospital environment, the most common concern (and most simply and effectively preventable) is hypothermia, defined as a temperature below 97.7°F (36.5°C). For newly born infants, temperature is not secondary or comfort care—it is core care, as neonatal hypothermia can lead to hypoxia (low oxygen), hypoglycemia (low blood sugar), and acidosis (high blood acidity). 

“Alongside breathing and heart rate, temperature is a critical vital sign,” said Bethan Jones, Welsh Ambulance Services University NHS Trust and Chair of the IAED High Risk Obstetrics Council. “Newborns lose heat rapidly, especially immediately after birth, and hypothermia can significantly worsen breathing difficulties and recovery. Even mild drops in temperature increase oxygen consumption and metabolic stress, making resuscitation more difficult.” 

Fortunately, the vast majority of newborns do not require resuscitation. International evidence shows that around 10% of newborns require some assistance at birth—usually simple measures such as drying, stimulation, warmth, and airway support. 

For that reason, Protocol F recently changed to instruct the caller to place the infant on top of the mother for shared warmth, which supports breathing, circulation, and overall physiological stability. 

“Keeping baby warm is lifesaving intervention in itself, and newborn resuscitation is often not about restarting breathing but helping with the transition from a fluid-filled intrauterine environment to air breathing, in most cases,” Jones said. “These infants are born wanting to survive—and doing all these little things dramatically changes the journey ahead for baby and mom.” 

When assistance is necessary 

But what happens directly after the baby is delivered when no infant cry follows? There are several key signs that a newborn may need immediate assistance, according to Jones, including not breathing or not crying, poor muscle tone or minimal movement, a low heart rate, and pale or blue coloring. 

Approximately 5% to 10% of newborn infants need help to begin breathing at birth, and approximately 1% need advanced resuscitative measures to restore cardiorespiratory function.⁴ 

Addressing these scenarios, the Medical Priority Dispatch System^™ (MPDS^®) directs the EMD to begin instructions on Protocol N: Airway/Arrest/Choking (Unconscious) – Newborn/Neonate < 1 day. This provides a unique pathway specifically for newborn/neonates— recently redefined from “< 30 days” to “< 24 hours” old. This distinction reflects the significant physiological differences between a newly born infant still transitioning after birth and an infant who has already established independent respiration. 

These instructions prioritize airway and breathing over chest compressions. Recently they were updated to instruct the caller to deliver five inflation breaths (to help clear fluid and inflate the lungs), then approximately 30 seconds of ventilatory breaths to support effective respiration. The objective is for the newborn to begin breathing on their own. Unlike adult cardiac arrest, newborn resuscitation is primarily focused on supporting the transition to effective breathing and circulation after birth. 

“Inflation and ventilation form the cornerstone of newborn resuscitation,” Jones said. “Most newborn compromise is due to lack of oxygen rather than heart disease. Effective inflation and ventilation usually leads to a rapid improvement in heart rate.” 

For this reason, chest compressions should only be considered after adequate ventilation has been attempted. This approach is particularly important when providing instructions in a nonvisual, telephone-assisted environment. 

Out-of-hospital newborn care is different when the birth happened in the back of a car, a home bathroom, or other uncontrolled environment. Protocol instructions must focus on simple, high-impact actions that support breathing, drying the baby and keeping them warm, and continuous reassurance. This is especially necessary in circumstances where there is no clinical equipment, no visual feedback (for the EMD), typically no medical training for the caller, and extremely high emotional stress. 

“There is no woman who expects their baby’s birth to go that way,” Jones said. “EMDs are the calming voice because that woman and her support are going to need compassion and clarity, telling them what to do and why.” 

When resuscitation is necessary 

The focus on ventilations is not as effective in an infant who has already transitioned to breathing independently (> 24 hours). For (older) infants who have stopped breathing, the EMD turns to Protocol A: Airway/Arrest/Choking (Unconscious) – Infant 1 day – < 1 Yr, which instructs the caller to do both ventilations and compressions from the beginning. 

However, instead of using two-finger compressions as instructed in Protocol N, older infants should receive compressions from “the heel of one hand.” This reflects 2025 guidelines from the American Heart Association, and other international guidelines based on evidence reviewed by the International Liaison on Resuscitation (ILCOR), which allows for this variation to be used when a trained two-hand encircling technique with thumb compressions is not feasible, such as in a non-visual environment. 

Teaching the latter technique over the phone is problematic, as is performing timely ventilations when only one rescuer is present. The evidence presented also showed that adequate compression depth was not being achieved with the former two-finger technique, so the recommended depth of compressions was also increased from 0.5” to 1.5” to encourage deeper, more effective compressions. 

Compressions positioning has also changed to instruct the caller to place the infant on a firm, flat surface (not on the ground), which is more physically sustainable and effective. 

Conclusion 

As protocols evolve, embedding simple, safe, and effective instructions is a fundamental priority to ensure we give babies the best possible start to life from the very first moment a call is answered. 

The EMD’s role is the hardest job in every service, but they are the first critical part of the patient’s journey, ensuring everything that follows happens safely. 

As evidence and practice continue to evolve, these protocol updates aim to provide EMDs with practical, evidence-based tools to support newborns and infants during some of the most time-critical moments in emergency care. 

Sources 

1. Bradfield, M., Goodwin, L., Tinnion, R., Hedge, S., Kerslake, D., Madar, J., Murcott, L., Tyler, W., Yates, J., Powell, A., Hall, L. “Evaluation of a new out-of-hospital newborn life support (OH-NLS) course in the UK South West region: a mixed-methods survey study.” British Paramedic Journal. 2024; Dec 1. vol. 9(3) 44–52 doi.org/10.29045/14784726.2024.12.9.3.44 (accessed April 22, 2026). 

2. See note 1. 

3. Roxby, P. “Babies most likely to be born at 4am, study finds.” BBC News. 2018; June 14. bbc.com/news/health-44483080 (accessed April 22, 2026). 

4. Lee, H. C., Strand, M. L., Finan, E., Illuzzi, J., Kamath-Rayne, B. D., Kapadia, V., Mahgoub, M., Niermeyer, S., Schexnayder, S. M., Schmölzer, G. M., Weglarz, J., Williams, A. L., Weiner, G.M., Wyckoff, M., Yamada, N. K., Szyld, E. “Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation. American Heart Association. 2025: Oct 22. ahajournals.org/doi/10.1161/CIR.0000000000001367 (accessed April 22, 2026).