What are the initial steps for newborn resuscitation?

Newborn Resuscitation: Initial Steps and Algorithm

The initial steps of newborn resuscitation must be completed within the "Golden Minute" (approximately 60 seconds from birth) and include: providing warmth under a radiant heat source, positioning the head in a "sniffing" position, clearing secretions only if copious or obstructing, drying thoroughly, and providing tactile stimulation—with positive pressure ventilation (PPV) initiated immediately if the infant is not breathing or has a heart rate <100/min. 1, 2, 3

Immediate Assessment at Birth

Rapidly assess three critical questions to determine if resuscitation is needed 1, 2:

• Term gestation?
• Good muscle tone?
• Breathing or crying?

If all three answers are "yes": The infant stays with mother for routine care including skin-to-skin contact, drying, and covering with dry linen 1, 3. Continue ongoing observation of breathing, activity, and color 1.

If any answer is "no": Move immediately to radiant warmer for resuscitation 1, 2.

The Initial Steps (First 60 Seconds)

Complete these steps rapidly and simultaneously 1, 2, 3:

1. Provide warmth: Place under radiant heat source immediately 1, 3

   • For preterm infants <32 weeks: Use plastic wrap (up to neck), thermal mattress, prewarm delivery room to 23-25°C, and consider warmed humidified gases 1, 2
   • Target temperature: 36.5-37.5°C; avoid hyperthermia >38°C 1, 2, 4

2. Position airway: Place head in "sniffing" position (slight neck extension) 1, 3

3. Clear secretions: Only if copious and/or obstructing the airway—routine suctioning is not recommended 1, 3

   • Critical update on meconium: Do NOT perform routine endotracheal suctioning even in non-vigorous infants with meconium-stained fluid; instead complete initial steps and begin PPV if needed 1, 2

4. Dry thoroughly: Use warm towels, remove wet linen 1, 3

5. Stimulate breathing: Drying and gentle tactile stimulation (flick soles, rub back) 1, 3

Reassessment and Decision Point (at 60 seconds)

Simultaneously assess two vital characteristics 1, 2:

• Respirations: Apnea, gasping, or labored/unlabored breathing
• Heart rate: <100/min or ≥100/min

The most sensitive indicator of successful resuscitation is an increase in heart rate 1, 2.

Heart Rate Assessment Methods

• Primary method: Auscultate precordial pulse with stethoscope 1
• Alternative: Palpate umbilical pulse (more accurate than other sites) 1
• Optimal method: Apply 3-lead ECG for rapid, accurate continuous measurement—superior to pulse oximetry which takes 1-2 minutes to apply and may not function with poor perfusion 1, 2, 5
  • ECG provides reliable heart rate signal in median 16 seconds vs. 199 seconds for pulse oximetry 5

Initiating Positive Pressure Ventilation

Begin PPV immediately if: 1, 2

• Apnea or gasping respirations, OR
• Heart rate <100/min despite initial steps

PPV Technical Details

Oxygen concentration: 1, 2

• Term/late-preterm infants (≥35 weeks): Start with 21% oxygen (room air)—do NOT start with 100% oxygen 1, 2
• Preterm infants (<35 weeks): Start with 21-30% oxygen, then titrate to target saturations 1, 2

Ventilation parameters: 1, 2

• Rate: 40-60 breaths per minute
• Initial pressure: 20 cm H₂O (may need 30-40 cm H₂O in some term infants)
• PEEP: Apply approximately 5 cm H₂O 1, 2

Devices: Flow-inflating bag, self-inflating bag, or T-piece resuscitator are all acceptable 1, 6

Target oxygen saturations (preductal): 2

• 1 minute: 60%
• 5 minutes: 80%
• 10 minutes: 90%

Escalation Algorithm After 30 Seconds of PPV

Reassess heart rate after 30 seconds of adequate ventilation: 2

• Heart rate >100/min: Continue PPV until spontaneous respirations established 2
• Heart rate 60-100/min: Continue effective PPV, ensure adequate chest rise, consider increasing pressure or checking mask seal 2
• Heart rate <60/min despite adequate PPV with 100% oxygen: Begin chest compressions using two-thumb encircling technique with 3:1 compression-to-ventilation ratio 2

Critical Pitfalls to Avoid

• Do not delay PPV beyond 60 seconds to establish IV access or prepare for intubation 2
• Do not start with 100% oxygen in term infants—begin with room air and titrate 1, 2
• Do not perform routine endotracheal suctioning for meconium—this practice is no longer recommended 1, 2
• Do not start chest compressions until after 30 seconds of adequate ventilation, as the vast majority of bradycardic newborns respond to effective ventilation alone 2
• Do not rely solely on chest rise as indicator of effective ventilation—rising heart rate is the primary indicator 2
• Do not neglect temperature management in preterm infants—hypothermia worsens outcomes 1, 4

Special Considerations for Delayed Cord Clamping

For infants who are breathing and crying at birth, delay cord clamping for at least 60 seconds to improve hemodynamic stability and reduce transfusion needs 2. However, infants not breathing or crying should have the cord clamped immediately so resuscitation can commence promptly 1.