What are the initial steps for resuscitating a newborn requiring resuscitation?

Initial Steps for 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 copious and obstructing, drying the infant thoroughly, and providing tactile stimulation through drying—all to be completed within approximately 60 seconds (the "Golden Minute") before reassessing and initiating positive-pressure ventilation if needed. 1, 2

Immediate Assessment at Birth

Before initiating any resuscitation steps, rapidly assess three critical characteristics 3, 1:

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

If the answer to all three questions is "yes," the infant may remain with the mother for routine care including skin-to-skin contact, drying, and covering with dry linen to maintain normal temperature 3, 2. Observation of breathing, activity, and color must be ongoing 3.

If the answer to any of these questions is "no," immediately move the infant to a radiant warmer for the initial stabilization steps 3, 2.

The Initial Stabilization Steps (Within 60 Seconds)

1. Provide Warmth

• Place the infant under a radiant heat source immediately 1, 2
• For preterm infants (<35 weeks), additional measures are critical: preheat the delivery room, cover the baby in plastic wrapping (up to neck level), and consider an exothermic mattress 1, 2
• Target temperature: 36.5-37.5°C 1, 2
• Avoid hyperthermia (>38.0°C) due to potential associated risks 1

2. Position the Airway

• Position the head in a "sniffing" position to open the airway 1, 2
• This neutral head position aligns the posterior pharynx, larynx, and trachea 2

3. Clear Secretions (Only If Necessary)

• Clear secretions only if copious and/or obstructing the airway 3, 1, 2
• Critical pitfall to avoid: Routine endotracheal suctioning should NOT be performed even in non-vigorous infants with meconium-stained amniotic fluid 1
• Aggressive suctioning can cause vagal bradycardia and delay ventilation 1

4. Dry Thoroughly

• Dry the infant completely, which also provides tactile stimulation 1, 2
• Remove wet linen and replace with dry, warm blankets 2

5. Stimulate Breathing

• Provide gentle tactile stimulation through drying and rubbing the back or flicking the soles of the feet 1, 2
• Brief stimulation is appropriate; prolonged stimulation delays necessary interventions 2

Reassessment After Initial Steps

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

• Heart rate (most sensitive indicator of response)
• Respirations (apnea, gasping, or labored/unlabored breathing)

If heart rate is <100 bpm or the infant has apnea/gasping after initial steps, immediately begin positive-pressure ventilation 3, 1.

Oxygen Administration During Initial Steps

For term infants (≥35 weeks):

• Start with 21% oxygen (room air) if respiratory support is needed 3
• Strong recommendation against starting with 100% oxygen 3

For preterm infants (<35 weeks):

• Start with lower oxygen concentration (21-30%) rather than higher concentration (60-100%) 3
• Titrate oxygen concentration using pulse oximetry to match target saturations 3, 1

Critical Timing: The Golden Minute

Approximately 60 seconds are allotted for completing the initial steps, reevaluating, and beginning ventilation if required 3, 1, 2. It is critical to avoid unnecessary delay in initiation of ventilation, as this is the most important step for successful resuscitation 3, 1. The vast majority of newborns requiring resuscitation will respond to effective ventilation alone 3.

Common Pitfalls to Avoid

• Do not delay ventilation to establish IV access or prepare for intubation 1
• Do not perform routine tracheal suctioning for meconium-stained amniotic fluid, even in non-vigorous infants 1
• Do not use prolonged or aggressive stimulation when the infant is not responding—move immediately to positive-pressure ventilation 1, 2
• Do not allow hypothermia, especially in preterm infants, as it increases oxygen consumption and worsens acidosis 1, 2
• Do not start with 100% oxygen for term infants—begin with room air and titrate based on pulse oximetry 3, 1

Monitoring During Initial Steps

Once positive-pressure ventilation or supplementary oxygen is started, assessment should consist of simultaneous evaluation of three vital characteristics 3:

• Heart rate (using 3-lead ECG for rapid, accurate measurement when available) 1
• Respirations
• Oxygen saturation (preductal pulse oximetry) 3, 1

The most sensitive indicator of successful response to each step is an increase in heart rate 3, 1.