What are the steps for neonatal resuscitation in a newborn requiring resuscitation?

Neonatal Resuscitation Steps

Complete the initial steps within the "Golden Minute" (60 seconds from birth): provide warmth, position the airway, clear secretions if needed, dry thoroughly, and stimulate breathing—then immediately begin positive pressure ventilation if the infant is apneic, gasping, or has heart rate <100 bpm. 1, 2, 3

Initial Assessment (First 10-15 Seconds)

Rapidly assess three critical questions to determine resuscitation needs 1, 2:

• Term gestation?
• Good muscle tone?
• 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 1, 2, 3. If any answer is "no," proceed immediately to initial resuscitation steps 1, 3.

Initial Resuscitation Steps (Within 60 Seconds)

Place the infant under a radiant warmer and perform the following simultaneously 1, 3:

• Provide warmth by placing under radiant heat source 3
• Position head in "sniffing" position to open airway 1, 3
• Clear secretions only if copious or obstructing the airway (routine suctioning not indicated) 3
• Dry thoroughly with warm towels 1, 3
• Provide tactile stimulation through drying and gentle rubbing of back/soles 1, 3

Critical pitfall: Do NOT perform routine endotracheal suctioning for meconium-stained amniotic fluid, even in non-vigorous infants—this practice is no longer recommended 4, 2.

Reassessment at 30-60 Seconds

Evaluate heart rate and respirations simultaneously 4, 2:

• Heart rate >100 bpm AND regular breathing: Continue observation 1
• Heart rate <100 bpm OR apnea/gasping: Immediately initiate positive pressure ventilation 1, 2
• Labored breathing or persistent cyanosis: Consider CPAP 4

Use pulse oximetry to guide oxygen therapy, targeting preductal saturations: 60-65% at 1 minute, gradually reaching 85-95% by 10 minutes 2. Auscultation of the precordium remains the primary method for assessing heart rate, though 3-lead ECG provides more rapid and accurate measurement 4, 2.

Positive Pressure Ventilation (If HR <100 or Apnea)

Begin PPV immediately if indicated 1, 2:

• Initial oxygen concentration: 21% (room air) for term infants; 21-30% for preterm infants 1, 2
• Ventilation rate: 40-60 breaths per minute 1, 2
• Initial pressure: 20 cm H₂O (may need 30-40 cm H₂O in some term infants) 2
• PEEP: Approximately 5 cm H₂O 1, 2
• Device options: Flow-inflating bag, self-inflating bag, or T-piece resuscitator 2

The primary indicator of effective ventilation is a rising heart rate, NOT chest rise 2. Titrate oxygen concentration based on pulse oximetry readings 1, 2.

Critical pitfall: Do NOT delay PPV beyond 60 seconds to establish IV access or prepare for intubation 1, 2.

Reassessment After 30 Seconds of Adequate PPV

After 30 seconds of effective ventilation with visible chest rise, reassess heart rate 2:

• HR >100 bpm: Continue PPV until HR stable and spontaneous respirations established 2
• HR 60-100 bpm: Continue PPV, ensure adequate ventilation using MR SOPA algorithm (Mask adjustment, Reposition airway, Suction mouth/nose, Open mouth, Pressure increase, Alternative airway) 2
• HR <60 bpm: Increase oxygen to 100% and begin chest compressions 1, 2

Critical pitfall: Do NOT start chest compressions until after 30 seconds of adequate ventilation with visible chest rise, as the vast majority of bradycardic newborns respond to effective ventilation alone 2.

Chest Compressions (If HR <60 After Adequate PPV)

If heart rate remains <60 bpm despite 30 seconds of adequate ventilation with 100% oxygen 1, 2:

• Technique: Two-thumb encircling hands method 1, 2, 5
• Depth: One-third of anterior-posterior diameter of chest 5
• Ratio: 3:1 compression-to-ventilation ratio (3 compressions followed by 1 ventilation) 4, 1
• Coordinate compressions with PPV 4

Exception: Consider higher compression-to-ventilation ratio if arrest is known to be of cardiac etiology 4.

Medications and Vascular Access (If HR <60 Despite Compressions)

If heart rate remains <60 bpm after adequate ventilation and chest compressions 4, 1:

• Epinephrine: 0.01-0.03 mg/kg IV (0.1-0.3 mL/kg of 1:10,000 solution) 5
• Route: Umbilical venous catheter preferred; intraosseous access is alternative if umbilical access unavailable 5
• Volume expansion: Consider isotonic crystalloid or O-negative red blood cells if hypovolemia suspected 5

Special Considerations

Delayed cord clamping: Delay cord clamping for at least 60 seconds in infants who are breathing and crying; clamp immediately in infants requiring resuscitation 4, 1, 2.

Preterm infants: Require enhanced temperature management including plastic wrapping (up to neck), prewarmed delivery room, and exothermic mattress to maintain temperature 36.5-37.5°C 2, 3. Avoid hyperthermia >38.0°C 2.

Therapeutic hypothermia: Consider for term/near-term infants with evolving moderate to severe hypoxic-ischemic encephalopathy, coordinated through regional perinatal system 4.

Discontinuation of Resuscitation

It is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, though many factors contribute to the decision to continue beyond this timeframe 4.