What are the steps for resuscitating a newborn patient according to the Neonatal Resuscitation Program (NRP) guidelines?

Neonatal Resuscitation According to NRP Guidelines

Follow the structured NRP algorithm starting with rapid assessment of three questions at birth, proceeding through the "Golden Minute" of initial steps, then escalating to positive-pressure ventilation, chest compressions, and medications based on heart rate response. 1

Initial Assessment at Birth

Upon delivery, rapidly assess three critical questions to determine if resuscitation is needed: 1

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

If the answer to all three questions is "yes," the infant can remain with the mother for routine care including delayed cord clamping (at least 60 seconds) and skin-to-skin contact. 1, 2

If the answer to any question is "no," immediately clamp the cord and move to the radiant warmer to begin resuscitation. 1

The Golden Minute: Initial Steps (0-60 Seconds)

Complete these initial steps within approximately 60 seconds: 1

• Provide warmth by placing under a radiant heat source 2
• Position the head in a "sniffing" position to open the airway 2
• Clear secretions only if visibly obstructing the airway (routine suctioning is not recommended and can cause bradycardia) 3
• Dry thoroughly and remove wet linens 2
• Stimulate breathing through drying and gentle tactile stimulation 2

After completing initial steps, simultaneously assess two vital characteristics: 1

• Respirations: apnea, gasping, or labored/unlabored breathing
• Heart rate: Use precordial auscultation as primary method (most accurate), with ECG monitoring recommended for rapid, accurate measurement 1, 2

Escalation Based on Heart Rate Response

Heart Rate ≥100/min and Breathing Adequately

• Continue routine care and monitoring 1
• Use pulse oximetry to guide oxygen supplementation, targeting preductal saturations: 60-65% at 1 minute, gradually reaching 85-95% by 10 minutes 2, 3

Heart Rate <100/min OR Labored Breathing/Apnea/Gasping

Initiate positive-pressure ventilation (PPV) immediately: 1, 2

• Start with room air (21% oxygen) for term infants 2
• Use 21-30% oxygen for preterm infants <35 weeks 2
• Rate: 40-60 breaths per minute 2
• Initial pressure: 20 cm H₂O (may need 30-40 cm H₂O in some term infants) 2
• Apply PEEP: approximately 5 cm H₂O 2
• Delivery methods: Face mask with self-inflating bag, flow-inflating bag, or T-piece resuscitator 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. 2

Heart Rate Remains <60/min After 30 Seconds of Adequate PPV

Before starting chest compressions, ensure ventilation is optimal: 1

• Verify mask seal and head position
• Consider increasing pressure
• Consider endotracheal intubation or laryngeal mask airway 1
• Increase oxygen to 100% 1

If heart rate remains <60/min despite adequate ventilation with 100% oxygen, begin chest compressions: 1, 2

• Location: Lower third of sternum 1
• Depth: Approximately one-third of anterior-posterior diameter of chest 1
• Technique: Two-thumb encircling hands technique (preferred method) 1
• Ratio: 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute = 120 events/minute) 1
• Coordinate compressions and ventilations to avoid simultaneous delivery 1
• Ensure full chest recoil between compressions without lifting thumbs from chest 1

Reassess heart rate after 60 seconds of coordinated chest compressions and ventilation. 1

Heart Rate Remains <60/min After 60 Seconds of Chest Compressions and PPV

Establish vascular access (umbilical venous catheter preferred) and administer epinephrine: 1

• IV/IO dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) 4
• Endotracheal dose (while obtaining IV access): up to 0.1 mg/kg, though IV route is strongly preferred 4
• Flush with 3 mL normal saline after IV epinephrine 5
• May repeat every 3-5 minutes if heart rate remains <60/min 1

Consider volume expansion if suspected blood loss: 6

• 10 mL/kg isotonic crystalloid or blood over 5-10 minutes 6
• Avoid rapid infusions in preterm infants (risk of intraventricular hemorrhage) 6

Special Considerations

Endotracheal Intubation Indications 1, 2

• Bag-mask ventilation is ineffective or prolonged
• Chest compressions are being performed
• Special circumstances (e.g., congenital diaphragmatic hernia)
• Confirm placement with exhaled CO₂ detection (most reliable method) 1

Preterm Infants 2

• Consider CPAP as initial respiratory support for spontaneously breathing preterm infants with respiratory distress 1
• Enhanced temperature management: plastic wrapping up to neck, maintain 36.5-37.5°C 2
• Start with lower oxygen concentrations (21-30%) 2

Meconium-Stained Amniotic Fluid 2

• Do NOT perform routine endotracheal suctioning, even in non-vigorous infants 2
• Complete initial steps and begin PPV if heart rate <100/min or inadequate breathing 2

Critical Pitfalls to Avoid

• Do not delay ventilation to establish IV access or prepare for intubation 2
• Do not start chest compressions before 30 seconds of adequate ventilation 2
• Do not perform routine suctioning (causes bradycardia and delays resuscitation) 3
• Avoid both hyperoxemia and hypoxemia by using pulse oximetry to guide oxygen titration 3
• Do not use high-dose epinephrine routinely 4

When to Consider Discontinuing Resuscitation

If there has been no detectable heart rate for 10 minutes despite continuous and adequate resuscitative efforts, it is appropriate to consider discontinuing resuscitation, though many factors contribute to this decision. 1, 4

Post-Resuscitation Care

Newborns requiring resuscitation need close surveillance: 6

• Continuous heart rate monitoring (target >100/min) 6
• Maintain preductal oxygen saturation ≥95% 6
• Maintain temperature 36.5-37.5°C, avoid hyperthermia >38°C 6
• Administer IV glucose as soon as possible to avoid hypoglycemia 6
• Consider therapeutic hypothermia (32-34°C for 12-24 hours) for term/near-term infants with moderate-to-severe hypoxic-ischemic encephalopathy 6, 4