What is the initial step in neonatal resuscitation protocol?

Initial Steps in Neonatal Resuscitation Protocol

The initial step in neonatal resuscitation is to provide warmth, position the head in a "sniffing" position to open the airway, clear secretions only if copious and/or obstructing the airway, dry the infant, and stimulate breathing. 1

Assessment Before Resuscitation

Before initiating resuscitation, rapidly assess the following three questions:

• Term gestation? 1
• Good tone? 1
• Breathing or crying? 1

If the answer to all three questions is "yes," the infant may stay with the mother for routine care (drying, skin-to-skin contact, and covering with dry linen to maintain normal temperature). 1

If the answer to any of these questions is "no," the infant should be moved to a radiant warmer to receive the initial stabilization steps. 1

Initial Stabilization Steps (Step A)

The initial steps of neonatal resuscitation include:

• Provide warmth by placing the baby under a radiant heat source 1
• Position the head in a "sniffing" position to open the airway 1
• Clear the airway if necessary (only if secretions are copious and/or obstructing the airway) 1
• Dry the baby thoroughly 1
• Provide tactile stimulation to initiate breathing 1

The Resuscitation Sequence

After the initial steps, the neonatal resuscitation protocol follows this sequence:

1. Initial steps in stabilization (warm and maintain normal temperature, position, clear secretions only if needed, dry, stimulate) 1
2. Ventilate and oxygenate (if needed) 1
3. Initiate chest compressions (if needed) 1
4. Administer epinephrine and/or volume expansion (if needed) 1

Critical Timing Considerations

• The "Golden Minute" - approximately 60 seconds are allotted for completing the initial steps, reevaluating, and beginning ventilation if required 1
• Avoid unnecessary delay in initiating ventilation, as this is the most important step for successful resuscitation 1

Assessment During Resuscitation

Once resuscitation begins, assessment should include simultaneous evaluation of:

• Heart rate (most sensitive indicator of successful response) 1, 2
• Respirations 1
• Oxygen saturation (via pulse oximetry) 1, 3

Common Pitfalls and Caveats

• Delayed ventilation: Failure to initiate ventilation within the Golden Minute can significantly increase the risk of hypoxic injury 2, 4
• Inaccurate heart rate assessment: Heart rate should be assessed using a stethoscope for accuracy; palpation of pulses can be unreliable 5, 2
• Temperature management: Hypothermia is associated with serious morbidities, especially in preterm infants. Maintain temperature between 36.5°C and 37.5°C 1
• Excessive suctioning: Routine suctioning is not recommended and can cause vagal stimulation leading to bradycardia 1, 4
• Inadequate team preparation: Every birth should be attended by at least one person capable of performing initial steps and positive-pressure ventilation 1, 4

Special Considerations for Preterm Infants

Preterm infants require additional warming techniques:

• Prewarming the delivery room 1
• Covering the baby in plastic wrapping 1
• Placing the baby on an exothermic mattress 1
• Placing the baby under radiant heat 1

By following this systematic approach to neonatal resuscitation, focusing first on the initial stabilization steps, providers can optimize outcomes for newborns requiring assistance at birth.