What is the initial step in Neonatal Resuscitation Program (NRP) for a newborn requiring resuscitation?

NRP Resuscitation Protocol

Initial Step in Neonatal Resuscitation

The initial step in neonatal resuscitation is to rapidly assess three critical questions—term gestation, good muscle tone, and breathing or crying—and if any answer is "no," immediately provide warmth by placing the infant under a radiant heat source, position the head in a "sniffing" position, clear secretions only if obstructing the airway, dry thoroughly, and provide tactile stimulation, all within the "Golden Minute" (60 seconds from birth). 1, 2, 3

The Three-Question Assessment

Before initiating any resuscitation steps, rapidly determine: 1, 2

• 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, 2 If any answer is "no," proceed immediately to the initial resuscitation steps. 2, 3

The Initial Steps (Within 60 Seconds)

Complete these steps rapidly and simultaneously: 1, 3

• Provide warmth: Place the infant under a radiant heat source immediately 3
• Position the airway: Place the head in a "sniffing" position to open the airway 1, 3
• Clear secretions: Suction only if copious secretions are obstructing the airway—routine suctioning is not indicated 3
• Dry thoroughly: Use warm towels to dry the infant completely, which also provides tactile stimulation 1, 3
• Provide tactile stimulation: Drying and gentle rubbing of the back or soles of feet stimulates breathing 2, 3

Critical Timing: The Golden Minute

Approximately 60 seconds from birth is allotted to complete the initial steps and determine heart rate. 1, 3 After these initial steps, immediately reassess the infant's heart rate and breathing. 3

When to Escalate to Positive Pressure Ventilation

Initiate PPV immediately if: 1, 2

• The infant is apneic or gasping, OR
• Heart rate is <100 beats per minute despite completing initial steps

Do not delay PPV beyond 60 seconds to establish IV access or prepare for intubation—ventilation is the cornerstone of neonatal resuscitation because bradycardia results from inadequate lung inflation and hypoxemia, not primary cardiac pathology. 1, 2

PPV Parameters

When PPV is required: 1, 2

• Initial oxygen concentration: 21% (room air) for term/late-preterm infants; 21-30% for preterm infants <35 weeks 1, 2
• Ventilation rate: 40-60 breaths per minute 1
• Initial pressure: 20 cm H₂O (though 30-40 cm H₂O may be necessary in some term infants) 1, 2
• PEEP: Approximately 5 cm H₂O 1, 2

The primary indicator of effective ventilation is a rising heart rate, not chest rise. 2 Reassess heart rate after 30 seconds of adequate ventilation. 1, 2

Further Escalation Algorithm

After 30 seconds of adequate PPV: 1, 2

• If heart rate >100 bpm: Continue PPV until spontaneous respirations and heart rate remain stable 2
• If heart rate 60-100 bpm: Continue PPV and ensure adequate technique 2
• If heart rate <60 bpm despite adequate PPV with 100% oxygen: Begin chest compressions using two-thumb encircling technique with 3:1 compression-to-ventilation ratio 1, 2

Do not start chest compressions until after 30 seconds of adequate ventilation—the vast majority of bradycardic newborns respond to effective ventilation alone. 2

Special Considerations for Preterm Infants

Preterm infants require enhanced temperature management: 2, 3

• Prewarm the delivery room 3
• Cover the infant in plastic wrapping up to neck level 2
• Place on an exothermic mattress if available 3
• Maintain temperature between 36.5-37.5°C and avoid hyperthermia >38.0°C 2, 3

Critical Pitfalls to Avoid

Never: 1, 2

• Delay PPV beyond 60 seconds for any reason 1
• Start with 100% oxygen in term infants—begin with room air and titrate based on pulse oximetry 1, 2
• Perform routine endotracheal suctioning for meconium-stained amniotic fluid 1, 2
• Start chest compressions before 30 seconds of adequate ventilation 1, 2
• Rely solely on chest rise as an indicator of effective ventilation—use heart rate response 2
• Neglect temperature management, especially in preterm infants 1

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. 1, 2 However, clamp the cord immediately in infants not breathing or crying so resuscitation can commence promptly. 1

Assessment Tools

Use 3-lead ECG for rapid, accurate heart rate measurement rather than relying solely on auscultation during resuscitation. 2 Apply pulse oximetry to guide oxygen titration, targeting preductal saturations of 60% at 1 minute, gradually reaching 90% by 10 minutes. 2