What is the protocol for newborn resuscitation?

Newborn Resuscitation Protocol

Begin resuscitation within the "Golden Minute" (60 seconds from birth) by providing warmth, positioning the head in a "sniffing" position, clearing secretions if needed, drying thoroughly, and providing tactile stimulation—then immediately initiate positive pressure ventilation if the infant is apneic, gasping, or has a heart rate <100 bpm. 1

Initial Assessment (First 15-30 Seconds)

Rapidly assess three critical questions to determine resuscitation needs: 1

• Is the infant term gestation?
• Does the infant have good muscle tone?
• Is the infant breathing or crying?

If all three answers are "yes," the infant stays with the mother for routine care including skin-to-skin contact, drying, and covering with dry linen, with ongoing observation. 1 If any answer is "no," proceed immediately with resuscitation steps. 1

The Golden Minute: Initial Steps

Complete these steps within approximately 60 seconds from birth: 1

• Provide warmth by placing under a radiant heat source (critical for preterm infants <1500g who require additional measures like plastic wrapping and prewarming the delivery room to 26°C) 2
• Position the head in a "sniffing" position to open the airway 2, 1
• Clear secretions with bulb syringe or suction catheter only if necessary 2
• Dry thoroughly and provide tactile stimulation 2, 1
• Remove wet linen and cover with dry, warm blankets 2

Critical pitfall: Do not perform routine endotracheal suctioning for meconium—this practice is no longer recommended. 1

Ventilation Strategy (If Needed After Initial Steps)

Initiate positive pressure ventilation immediately if: 1

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

Ventilation Parameters

Use these specific settings: 1

• Rate: 40-60 breaths per minute
• Initial pressure: 20 cm H₂O
• PEEP: Approximately 5 cm H₂O 2

Initial Oxygen Concentration

For term and late-preterm infants (≥35 weeks): Start with 21% oxygen (room air). 2 Do not use 100% oxygen to initiate resuscitation—this is associated with excess mortality. 2

For preterm infants (<35 weeks): Start with 21-30% oxygen. 2 Initiating resuscitation with high oxygen (≥65%) is not recommended. 2

Oxygen Titration

Apply pulse oximetry probe to the right hand/wrist (preductal) before connecting to the instrument for faster readings. 3 Titrate oxygen to match normal transition values—healthy term infants start at 60% saturation and take approximately 10 minutes to reach 90%. 3, 4

Critical pitfall: Do not delay PPV beyond 60 seconds to establish IV access or prepare for intubation. 1 Ventilation is the cornerstone of neonatal resuscitation, and most infants respond to respiratory support alone. 2

Reassessment at 30 Seconds

After 30 seconds of adequate ventilation, reassess heart rate: 1

• If heart rate ≥100 bpm and spontaneous breathing: Continue supportive care and monitoring
• If heart rate 60-99 bpm: Continue PPV, ensure adequate ventilation technique, consider increasing oxygen
• If heart rate <60 bpm despite adequate PPV: Escalate to chest compressions

Critical pitfall: Do not start chest compressions until after 30 seconds of adequate ventilation. 1 Do not rely solely on chest rise as an indicator of effective ventilation—the best indication is a prompt increase in heart rate. 5

Chest Compressions (If Heart Rate <60 bpm)

Begin chest compressions if heart rate remains <60 bpm despite 30 seconds of adequate PPV with 100% oxygen: 1, 3

• Technique: Two-thumb encircling technique (preferred method) 2
• Ratio: 3:1 compression-to-ventilation ratio 2, 3
• Depth: At least one-third of the anterior-posterior chest diameter 3
• Coordination: Synchronize compressions with ventilations 3

The 3:1 ratio is specifically recommended for neonatal resuscitation because newborns require adequate lung aeration first—the fluid-filled lungs must be cleared and functional residual capacity established before circulation can be effective. 2

Medications (Rarely Needed)

Epinephrine

Administer if heart rate remains <60 bpm despite adequate ventilation and chest compressions: 3

• IV route (preferred): 0.01-0.03 mg/kg 3
• Endotracheal route: 0.05-0.1 mg/kg 3

Volume Expansion

Consider if there is evidence of hypovolemia or shock unresponsive to other measures. 3

Ventilation Devices

PPV can be delivered effectively with: 2

• Flow-inflating bag
• Self-inflating bag (only device usable without compressed gas source)
• T-piece resuscitator

Important distinction: Self-inflating bags cannot deliver continuous positive airway pressure (CPAP) and may not achieve PEEP reliably even with a PEEP valve, unlike flow-inflating bags or T-piece resuscitators. 2

Delayed Cord Clamping

Delay cord clamping for at least 60 seconds in infants who are breathing and crying at birth to improve hemodynamic stability and reduce transfusion needs. 1 However, clamp the cord immediately in infants not breathing or crying so resuscitation can commence promptly. 1

Temperature Management

For very low birth weight infants (<1500g): 2

• Prewarm delivery room to 26°C
• Cover in plastic wrapping (food or medical grade, heat-resistant)
• Place on exothermic mattress
• Place under radiant heat
• Monitor temperature closely to avoid hyperthermia

Hypothermia increases oxygen consumption and worsens outcomes. 3 All resuscitation procedures, including intubation and chest compressions, can be performed with these temperature-controlling interventions in place. 2

Post-Resuscitation Care

For infants with evolving moderate to severe hypoxic-ischemic encephalopathy, initiate therapeutic hypothermia within 6 hours of birth and transfer to a neonatal intensive care facility with multidisciplinary capabilities. 3