What are the steps for a neonatal resuscitation programme?

Neonatal Resuscitation Programme Steps

The neonatal resuscitation programme follows a systematic algorithmic approach beginning with initial assessment and stabilization within the first 60 seconds ("Golden Minute"), followed by sequential escalation through positive pressure ventilation, chest compressions, and medications if needed. 1, 2

Initial Assessment (First 15-30 Seconds)

Immediately assess three critical characteristics simultaneously: 2, 3

• Term gestation status
• Muscle tone quality
• Breathing or crying present

If all three are present, the infant stays with the mother for routine care including skin-to-skin contact and drying. 1, 2 If any are absent, proceed immediately to initial stabilization steps under a radiant warmer. 1

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

Complete these steps rapidly and simultaneously: 1, 2

• Provide warmth by placing the infant under a radiant heat source (maintain temperature 36.5-37.5°C to prevent hypothermia-associated morbidity) 1, 2
• Position the head in a "sniffing" position to open the airway 1, 2
• Clear secretions only if copious and/or obstructing the airway (routine suctioning is not recommended) 1
• Dry the infant thoroughly and remove wet linens 1, 2
• Provide tactile stimulation through drying and gentle stimulation to initiate breathing 1, 2

Critical caveat: For meconium-stained amniotic fluid, do NOT perform routine endotracheal suctioning even in non-vigorous infants—complete the initial steps and begin PPV if heart rate is <100/min or breathing is inadequate. 4

Assessment During Resuscitation

Simultaneously evaluate three parameters: 1, 3

• Heart rate (use 3-lead ECG for rapid, accurate measurement rather than relying solely on auscultation) 4
• Respiratory effort
• Oxygen saturation via pulse oximetry (place probe on right hand/wrist preductally before connecting to instrument) 3

Positive Pressure Ventilation (If Needed After Initial Steps)

Indications for PPV: 3

• Apnea or gasping respirations
• Heart rate <100 bpm despite initial steps
• Persistent labored breathing or cyanosis

PPV technique for term infants: 2

• Start with 21% oxygen (room air), NOT 100% oxygen 2, 3
• Rate: 40-60 breaths per minute 2
• Initial pressure: 20 cm H₂O 2
• Apply approximately 5 cm H₂O PEEP 4
• Use flow-inflating bag, self-inflating bag, or T-piece resuscitator 4

The primary indicator of effective ventilation is a rising heart rate, not chest rise. 2 Titrate oxygen concentration using pulse oximetry to match normal transition values (60% at 1 minute, gradually reaching 90% by 10 minutes). 2, 3

For preterm infants <35 weeks: Initiate resuscitation with low oxygen (21-30%) and titrate to target saturations—do NOT start with high oxygen (≥65%). 4

Chest Compressions (If Heart Rate Remains <60 bpm)

Indications: Heart rate <60 bpm despite adequate ventilation with supplemental oxygen for 30 seconds. 3

Technique: 3

• Use 3:1 compression-to-ventilation ratio
• Compress at least one-third of anterior-posterior chest diameter
• Coordinate compressions with ventilations

Medications and Volume Expansion

Epinephrine: 3

• Indication: Heart rate <60 bpm despite adequate ventilation and chest compressions
• IV route (preferred): 0.01-0.03 mg/kg
• Endotracheal route: 0.05-0.1 mg/kg (higher dose due to unpredictable absorption)

Volume expansion: Consider if evidence of hypovolemia or shock unresponsive to other measures. 3

Airway Management

Endotracheal intubation indications: 2

• PPV is ineffective
• Prolonged ventilation required
• Chest compressions needed
• Suspected diaphragmatic hernia

Confirm tube placement using exhaled CO₂ detection as the primary method—clinical assessment alone is insufficient. 2

Special Considerations

Preterm infants require enhanced temperature management: 1, 2

• Prewarm the delivery room
• Cover the baby in plastic wrapping (up to neck level in resource-limited settings) 4
• Place on exothermic mattress
• Maintain temperature 36.5-37.5°C 1

Delayed cord clamping: Wait at least 60 seconds for infants not requiring immediate resuscitation to improve hemodynamic stability and reduce transfusion needs. 2

Avoid hyperthermia (>38.0°C) due to potential associated risks. 4