Next Step in Neonatal Resuscitation
Give positive-pressure ventilation immediately (Option B). This 30-week preterm infant with apnea, cyanosis, and heart rate of 70 bpm requires immediate PPV as the single most critical intervention—bradycardia in newborns results from inadequate lung inflation, and effective ventilation is the cornerstone of successful resuscitation. 1, 2, 3
Why Positive-Pressure Ventilation is the Priority
The neonatal resuscitation algorithm is clear and sequential: after initial steps (warming, positioning, drying, stimulation), any infant with apnea, gasping, or heart rate <100 bpm requires immediate PPV. 1, 2 This baby meets all three criteria for PPV:
- Not breathing (apnea)
- Heart rate <100 bpm (70 bpm)
- Cyanosis indicating inadequate oxygenation
Effective ventilation is the most critical intervention for successful delivery room resuscitation—approximately 60 seconds ("the Golden Minute") are allotted for completing initial steps and beginning ventilation if required. 1, 3
Specific PPV Parameters for This Preterm Infant
Initial ventilation settings should be:
- Oxygen concentration: Start with 21-30% oxygen (NOT 100%) for this 30-week preterm infant, then titrate based on pulse oximetry 1, 2, 4
- Ventilation rate: 40-60 breaths per minute 2, 4
- Initial pressure: 20-25 cm H₂O 2, 4
- PEEP: Approximately 5 cm H₂O when using devices capable of delivering it 2, 4
Apply pulse oximetry to the right hand/wrist to guide oxygen titration toward target saturations (60-65% at 1 minute, progressing to 85-95% by 10 minutes). 2, 4
Why Other Options Are Incorrect
Option D (stimulation) is already completed: The initial steps of drying and tactile stimulation should have been performed in the first 30 seconds. 1 Since this baby remains apneic with bradycardia, further stimulation wastes critical time—progression to PPV is mandatory. 1, 2
Option C (chest compressions) is premature: Chest compressions are indicated only if heart rate remains <60 bpm after 30 seconds of adequate PPV with supplemental oxygen. 1, 2 You must establish effective ventilation first, as bradycardia is nearly always due to inadequate lung inflation. 1, 3
Option E (intubation) is not the immediate next step: While intubation may become necessary if bag-mask PPV is ineffective, the algorithm calls for initiating PPV first (typically with bag-mask), then considering intubation if ventilation is inadequate or prolonged. 1
Option A (umbilical catheter) comes later: Vascular access is needed only if the infant fails to respond to adequate ventilation and chest compressions, requiring medications like epinephrine. 1 This is several steps down the algorithm.
Critical Pitfalls to Avoid
Do not start with 100% oxygen: For preterm infants <35 weeks gestation, starting with 21-30% oxygen is reasonable, and 100% oxygen should be avoided initially as it causes harm without demonstrated benefit. 1, 2, 4
Do not delay PPV: The most common error is inadequate or delayed ventilation. 3 Heart rate is the most sensitive indicator of successful resuscitation, and it will not improve without effective lung inflation. 1
Do not skip assessment of ventilation effectiveness: After initiating PPV, immediately assess for chest rise, breath sounds, and heart rate response—if heart rate does not improve within 30 seconds, ensure adequate ventilation before progressing to chest compressions. 1
Monitor for preterm-specific complications: This 30-week infant has immature lungs vulnerable to injury from excessive pressure, immature brain vessels prone to hemorrhage, and increased risk of hypothermia—maintain thermal neutrality throughout resuscitation. 1
Algorithm Progression if PPV Fails
If heart rate remains <60 bpm after 30 seconds of adequate PPV:
- Increase oxygen to 100% 2, 4
- Consider intubation to ensure effective ventilation 1
- Begin chest compressions at 3:1 ratio with continued PPV 1, 2
If heart rate remains <60 bpm despite effective ventilation and chest compressions: