What is the initial stepwise approach for neonatal resuscitation protocol?

Neonatal Resuscitation Protocol: Initial Stepwise Approach

Immediate Assessment (First 10-15 Seconds)

Begin by simultaneously assessing three critical characteristics: term gestation, good muscle tone, and breathing or crying. 1 If all three are present, the infant may remain with the mother for routine care including skin-to-skin contact and drying. 1

The Initial Steps (Within 60 Seconds - "The Golden Minute")

If the infant requires intervention, immediately perform these five initial steps: 2, 1

• Provide warmth by placing the infant under a radiant heat source (maintain temperature 36.5-37.5°C) 1
• Position the head in a "sniffing" position to open the airway 2
• Clear secretions only if copious and obstructing the airway (routine suctioning is no longer recommended) 1
• Dry thoroughly and remove wet linen 2, 1
• Stimulate breathing through drying and gentle tactile stimulation 2

Critical Temperature Considerations

For very low-birth-weight infants (<1500g), additional warming techniques are mandatory: 2

• Prewarm delivery room to 26°C
• Cover infant in food-grade plastic wrapping (except face)
• Use exothermic mattress
• Maintain radiant heat throughout resuscitation

Avoid hyperthermia, as temperatures >37.5°C are associated with increased perinatal respiratory depression, seizures, and mortality. 2

Heart Rate-Based Algorithm (After Initial Steps)

Heart Rate ≥100 bpm and Breathing Adequately

• Continue observation and routine care 1
• Apply pulse oximetry to right hand/wrist for preductal monitoring 1

Heart Rate <100 bpm OR Apnea/Gasping

Immediately initiate positive-pressure ventilation (PPV) within 60 seconds of birth. 2, 1

PPV Parameters:

• Start with room air (21% oxygen) for term infants - this is strongly recommended over 100% oxygen, which increases mortality 2
• Rate: 40-60 breaths per minute 2
• Initial pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants) 2
• Use PEEP (positive end-expiratory pressure) if equipment available 2
• Primary indicator of effective ventilation is rising heart rate - not chest rise 2

Oxygen Titration Strategy:

• Use pulse oximetry to guide oxygen concentration 2
• Target preductal oxygen saturations matching healthy term newborns (60% at 1 minute, gradually reaching 90% by 10 minutes) 2
• If heart rate remains <60 bpm after 90 seconds of PPV with lower oxygen concentration, increase to 100% oxygen 2

Heart Rate <60 bpm Despite Adequate PPV for 30 Seconds

Initiate chest compressions coordinated with ventilation. 3, 4

Chest Compression Technique:

• Use 2-thumb encircling-hands method (preferred over 2-finger technique) 3
• Depth: one-third anterior-posterior chest diameter 3
• Ratio: 3 compressions to 1 ventilation (3:1) 3, 4
• Rate: 90 compressions + 30 breaths = 120 events per minute 4
• Increase oxygen to 100% during chest compressions 2

Heart Rate <60 bpm After 30 Seconds of Coordinated Compressions and Ventilation

Administer epinephrine. 3, 4, 5

Epinephrine Dosing:

• IV/umbilical venous route (preferred): 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) 3, 4
• Endotracheal route (while obtaining IV access): 0.05-0.1 mg/kg (higher dose) 3, 5
• High-dose IV epinephrine is NOT recommended 4
• Repeat every 3-5 minutes if needed 4

Volume Expansion (if hypovolemia suspected):

• Use isotonic crystalloid (normal saline or Ringer's lactate) or O-negative blood 3
• Dose: 10 mL/kg IV over 5-10 minutes 3
• Albumin is no longer first-line for volume expansion 3

Airway Management Specifics

Endotracheal Intubation Indications:

• PPV ineffective by bag-mask 2
• Prolonged ventilation required 2
• Chest compressions needed 2
• Suspected diaphragmatic hernia 2

Confirmation of Tube Placement:

Use exhaled CO₂ detection as primary confirmation method (requires adequate cardiac output). 2, 3, 4 Clinical assessment alone is insufficient.

Alternative Airway:

Laryngeal mask airway is acceptable if bag-mask ventilation fails and intubation attempts unsuccessful (for infants >34 weeks gestation and >2000g). 3, 4

Special Considerations

Meconium-Stained Amniotic Fluid:

Routine intrapartum suctioning is no longer recommended. 3, 4 Only suction if secretions are obstructing the airway and preventing effective ventilation. 1

Preterm Infants:

• May initiate resuscitation with blended oxygen (30-40%) rather than room air 2
• Titrate to target saturations using pulse oximetry 2
• Enhanced temperature management is critical 2, 1

Delayed Cord Clamping:

Delay cord clamping at least 60 seconds for infants not requiring immediate resuscitation. 2 This improves hemodynamic stability and reduces need for transfusion.

When to Consider Stopping Resuscitation

If heart rate remains absent after 10 minutes of continuous adequate resuscitation, discontinuation may be justified - survival with intact neurologic function is extremely rare beyond this point. 3, 4 This decision should involve discussion with parents when possible.

Critical Pitfalls to Avoid

• Do not delay PPV beyond 60 seconds - ventilation is the cornerstone of neonatal resuscitation 2, 1
• Do not start with 100% oxygen in term infants - room air improves survival 2
• Do not rely on chest rise alone - heart rate response is the primary indicator of effective ventilation 2
• Do not use high-dose IV epinephrine - standard dosing is more effective and safer 4
• Do not forget temperature management - hypothermia independently predicts mortality 2, 1