Initial Steps in Neonatal Resuscitation
The initial steps in neonatal resuscitation are to provide warmth by placing the baby under a radiant heat source, positioning the head in a "sniffing" position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing. 1, 2
Assessment Before Resuscitation
- Assess the infant's term gestation, tone, and breathing or crying status to determine the need for intervention 2
- If the infant is term, has good tone, and is breathing or crying, they may stay with the mother for routine care 2
- For infants requiring resuscitation, the initial assessment should be completed within the "Golden Minute" - approximately 60 seconds allotted for completing initial steps, reevaluating, and beginning ventilation if required 1, 2
Step 1: Provide Warmth
- Place the baby under a radiant heat source to prevent hypothermia 1, 2
- For very low-birth-weight preterm babies (<1500g), additional warming techniques are recommended:
- Maintain temperature between 36.5°C and 37.5°C to prevent hypothermia and associated morbidities 2, 3
- Avoid hyperthermia (temperature >38.0°C) due to associated risks 1, 3
Step 2: Position the Head
- Position the head in a "sniffing" position to open the airway 1, 2, 3
- This position aligns the posterior pharynx, larynx, and trachea for optimal air entry 2
Step 3: Clear the Airway
- Clear the airway if necessary with a bulb syringe or suction catheter 1, 2
- Suction should be performed only if secretions are copious and/or obstructing the airway 2
- For meconium-stained amniotic fluid:
Step 4: Dry the Baby
- Thoroughly dry the baby to prevent heat loss 1, 2
- Replace wet linens with dry ones 2
- For preterm infants, plastic wrapping without drying may be used to prevent heat loss 1, 2
Step 5: Stimulate Breathing
- Provide tactile stimulation to initiate breathing 1, 2, 3
- Methods include rubbing the back, trunk, or extremities 2
- Avoid aggressive stimulation methods 2
Assessment During Resuscitation
- Simultaneously assess three vital characteristics: 1, 2
- Heart rate (whether greater than or less than 100 beats per minute)
- Respirations (apnea, gasping, or labored or unlabored breathing)
- Oxygenation status (optimally determined by pulse oximeter)
- Heart rate assessment should be done by intermittently auscultating the precordial pulse 1
- A 3-lead ECG may be reasonable for rapid and accurate measurement of heart rate 1
- The most sensitive indicator of a successful response to each step is an increase in heart rate 1
Progression Beyond Initial Steps
- If the infant is not breathing adequately or heart rate is less than 100/min after the initial steps, proceed to positive pressure ventilation (PPV) 1, 2
- The decision to progress beyond initial steps is determined by simultaneous assessment of respirations and heart rate 1
Special Considerations for Preterm Infants
- Preterm infants have special considerations: 1
- Immature lungs that may be more difficult to ventilate
- Vulnerability to injury by positive-pressure ventilation
- Immature blood vessels in the brain prone to hemorrhage
- Thin skin and large surface area contributing to rapid heat loss
- Increased susceptibility to infection
- Increased risk of hypovolemic shock related to small blood volume
- Resuscitation of preterm newborns <35 weeks gestation should be initiated with low oxygen (21% to 30%) 1
Common Pitfalls and Caveats
- Failing to complete the initial steps within the "Golden Minute" 1, 2
- Inadequate temperature management, especially in preterm infants 1, 2
- Unnecessary or aggressive suctioning that can cause bradycardia 3
- Delayed recognition of the need to progress beyond initial steps 1, 2
- Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended 1