What are the initial steps in neonatal resuscitation?

Initial Steps in Neonatal Resuscitation

The initial steps in neonatal resuscitation consist of providing warmth under a radiant heat source, positioning the head in a "sniffing" position to open the airway, clearing secretions only if they are copious or obstructing, drying the infant thoroughly, and providing tactile stimulation to initiate breathing—all to be completed within approximately 60 seconds (the "Golden Minute"). 1, 2

Pre-Resuscitation Assessment

Before initiating any intervention, rapidly assess three critical characteristics simultaneously 1, 2:

• Term gestation (≥37 weeks)
• Good muscle tone
• Breathing or crying

If all three are present, the infant may remain with the mother for routine care including skin-to-skin contact and drying 1, 2. If any characteristic is absent, proceed immediately to the initial steps.

The Initial Steps (Complete Within 60 Seconds)

1. Provide Warmth

• Place the infant immediately under a radiant heat source 3, 2
• For preterm infants <32 weeks, use additional measures: prewarm the delivery room to 23-25°C, cover the infant (except the face) in food-grade plastic wrap up to the neck level without drying first, consider an exothermic mattress, and maintain temperature between 36.5-37.5°C 3, 1, 2
• Critical pitfall: Avoid hyperthermia >38°C, which is associated with potential harm 3, 1

2. Position the Airway

• Place the head in a "sniffing" position—slight extension of the neck with the head in a neutral position 3, 2
• Avoid hyperextension or flexion, both of which can obstruct the airway 2
• A shoulder roll may help achieve proper positioning 3

3. Clear Secretions (Only If Necessary)

• Suction only if secretions are copious or clearly obstructing the airway 3, 2
• Use a bulb syringe or suction catheter 3
• Critical pitfall: Avoid routine suctioning, as unnecessary nasopharyngeal suctioning can induce bradycardia and worsen pulmonary compliance 3

4. Dry Thoroughly

• Dry the infant vigorously with warm towels, then remove wet linens 3, 2
• Exception: For preterm infants <32 weeks requiring plastic wrap, do not dry before wrapping 3, 1

5. Stimulate Breathing

• Drying and gentle tactile stimulation (rubbing the back, flicking the soles of the feet) are usually sufficient 2
• If no response after brief stimulation, do not continue—proceed immediately to positive-pressure ventilation 3

Special Consideration: Meconium-Stained Amniotic Fluid

Do not perform routine endotracheal suctioning, even in non-vigorous infants born through meconium-stained amniotic fluid. 3, 1 Instead:

• Complete the initial steps as outlined above 1
• Begin positive-pressure ventilation if heart rate is <100/min or breathing is inadequate 1
• Suction only if the airway appears obstructed and ventilation cannot be achieved 3

This represents a major shift from historical practice, as randomized trials demonstrated no benefit from routine tracheal suctioning 3.

Assessment After Initial Steps

After completing the initial steps (within 60 seconds), simultaneously assess two vital characteristics 3:

Heart Rate (Primary Indicator)

• Auscultate the precordial pulse—this remains the gold standard 3
• Palpation of the umbilical pulse is acceptable but tends to underestimate heart rate 3
• Consider 3-lead ECG for rapid, accurate measurement during ongoing resuscitation 1

Respirations

• Assess for apnea, gasping, or labored versus unlabored breathing 3

Decision Point:

• If heart rate <100/min, gasping, or apnea: Begin positive-pressure ventilation immediately 3
• If heart rate ≥100/min and breathing adequately: Continue observation and consider supplemental oxygen only if needed based on pulse oximetry 3

Ongoing Monitoring

Once positive-pressure ventilation or supplemental oxygen is initiated, assess three characteristics simultaneously 3, 2:

• Heart rate (most sensitive indicator of successful resuscitation)
• Respirations
• Oxygen saturation via pulse oximetry (preductal—right hand or wrist) 3, 1

Target oxygen saturations match healthy term newborns: 60% at 1 minute, gradually reaching 90% by 10 minutes 1.

Critical Timing Concept: The Golden Minute

Approximately 60 seconds are allotted for completing the initial steps, reassessing the infant, and beginning ventilation if required. 3, 2 This emphasizes the urgency of neonatal resuscitation—delays in establishing effective ventilation are the most common cause of unsuccessful resuscitation 4.

Common Pitfalls to Avoid

• Do not delay warming measures: Hypothermia increases oxygen consumption, worsens acidosis, and increases mortality in a dose-dependent manner below 36.5°C 3, 5
• Do not suction routinely: This can induce bradycardia and delay ventilation 3
• Do not continue prolonged tactile stimulation: If the infant does not respond to brief stimulation, begin positive-pressure ventilation immediately 3
• Do not forget delayed cord clamping: For infants not requiring immediate resuscitation, delay cord clamping for at least 60 seconds to improve hemodynamic stability 3, 1