What are the steps in newborn resuscitation?

Steps in Newborn Resuscitation

Newborn resuscitation follows a sequential algorithm of four key steps: initial stabilization, ventilation/oxygenation, chest compressions, and medication administration if needed, with assessment and progression based on heart rate and respiratory effort.

Initial Assessment

Upon delivery, rapidly assess the newborn by answering three questions:

• Term gestation?
• Good muscle tone?
• Breathing or crying?

If all answers are "yes," provide routine care:

• Dry the infant
• Place skin-to-skin with mother
• Cover with dry linen to maintain temperature
• Continue observation of breathing, activity, and color

If any answer is "no," move to the resuscitation algorithm.

Resuscitation Algorithm

1. Initial Stabilization (First 60 Seconds - "The Golden Minute")

• Place infant under radiant warmer
• Position head in "sniffing" position to open airway
• Clear secretions only if copious or obstructing airway
• Dry thoroughly
• Provide tactile stimulation
• Maintain normal temperature (36.5-37.5°C) 1

For preterm infants (<35 weeks):

• Consider additional warming techniques:
  • Preheat delivery room to 26°C
  • Use plastic wrapping/bags
  • Use exothermic mattress 1

2. Ventilation and Oxygenation

If heart rate <100/min, gasping, or apneic:

• Begin positive pressure ventilation (PPV)
• Use appropriate device (flow-inflating bag, self-inflating bag, or T-piece resuscitator) 1
• Apply pulse oximeter to right hand/wrist (preductal)
• Consider ECG monitoring for rapid and accurate heart rate assessment 1

Oxygen titration targets (preductal SpO₂):

• 1 min: 60-65%
• 2 min: 65-70%
• 3 min: 70-75%
• 4 min: 75-80%
• 5 min: 80-85%
• 10 min: 85-95% 1

For preterm infants (<35 weeks):

• Initiate resuscitation with low oxygen (21-30%)
• Titrate to achieve target SpO₂ 1
• Avoid high oxygen (>65%) 1
• Consider PEEP of approximately 5 cm H₂O 1

3. Chest Compressions

If heart rate remains <60/min after 30 seconds of effective ventilation:

• Begin chest compressions at lower third of sternum
• Use two-thumb technique (preferred)
• Compression depth: one-third AP diameter of chest
• Compression-to-ventilation ratio: 3:1 (90 compressions and 30 breaths per minute) 1
• Continue until heart rate is ≥60/min

4. Medication Administration

If heart rate remains <60/min despite effective ventilation and chest compressions:

• Establish vascular access (umbilical venous catheter preferred)
• Administer epinephrine:
  • Concentration: 1:10,000 (0.1 mg/mL)
  • Dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg)
  • Route: IV preferred; may give via endotracheal tube at higher dose while establishing IV access 1, 2
• Consider volume expansion (10 mL/kg) for suspected blood loss or signs of shock 1

Special Considerations

Meconium-Stained Amniotic Fluid

• If the infant is vigorous (good tone, breathing, heart rate >100/min), provide routine care
• If the infant has poor muscle tone and inadequate breathing:
  • Complete initial steps under radiant warmer
  • Begin PPV if not breathing or heart rate <100/min
  • Routine intubation for tracheal suction is not recommended 1

Monitoring During Resuscitation

• Heart rate assessment is the most sensitive indicator of successful response to interventions 1, 3
• ECG provides faster and more reliable heart rate detection than pulse oximetry (16 seconds vs. 199 seconds to achieve reliable signal) 4
• Continuous assessment should include heart rate, respirations, and oxygen saturation 1, 5

Common Pitfalls and Caveats

1. Delayed Ventilation: Avoid unnecessary delay in initiating ventilation beyond the "Golden Minute" as this is the most important step for successful resuscitation 1

2. Ineffective Ventilation: Ensure proper mask seal and appropriate pressure; observe for chest movement and improvement in heart rate 1

3. Temperature Management: Hypothermia increases morbidity and mortality; hyperthermia (>38°C) should also be avoided 1

4. Excessive Oxygen: Avoid initiating resuscitation with high oxygen in preterm infants as it may increase oxidative stress 1

5. Inaccurate Heart Rate Assessment: Clinical assessment alone may be unreliable; consider ECG monitoring for accurate heart rate determination 3, 4

6. Delayed Recognition of Need for Advanced Resuscitation: Continuously reassess the infant's response to interventions and escalate care promptly if needed 1, 6