Latest Neonatal Resuscitation Program (NRP) Guidelines
Initial Assessment and the "Golden Minute"
Complete the initial steps within approximately 60 seconds from birth, and initiate positive pressure ventilation (PPV) within 60 seconds if the infant remains apneic or has a heart rate <100 bpm. 1, 2
- Rapidly assess three critical characteristics at birth: term gestation, good muscle tone, and breathing or crying 3, 2
- If all three are present, the infant may remain with the mother for routine care including skin-to-skin contact and drying 1, 3
- If any characteristic is absent, proceed immediately to the radiant warmer for initial steps 2
The initial steps include: providing warmth under a radiant heat source, positioning the head in a "sniffing" position, clearing secretions only if necessary (not routinely), drying thoroughly, and providing gentle tactile stimulation 3, 2
Umbilical Cord Management
Delay cord clamping for ≥30-60 seconds in infants who do not require immediate resuscitation. 1, 2
- For term and late preterm infants ≥34 weeks not requiring resuscitation: delay clamping for ≥30 seconds 1
- For nonvigorous term/late preterm infants (35-42 weeks): intact cord milking may be reasonable compared with early clamping 1
- For preterm infants <34 weeks not requiring resuscitation: delay clamping ≥30 seconds 1
- For infants 28-34 weeks when delayed clamping cannot be performed: intact cord milking may be reasonable 1
- Do NOT perform intact cord milking for extremely preterm infants <28 weeks 1
Positive Pressure Ventilation (PPV)
Initiate PPV immediately if the infant is apneic, gasping, or has a heart rate <100 bpm after initial steps. 3, 2
Initial Oxygen Concentration
- Term and late preterm infants ≥35 weeks: start with 21% oxygen (room air) 1, 3, 4
- Preterm infants <35 weeks: start with low oxygen (21-30%) 1, 3, 4
- Titrate oxygen based on pulse oximetry to match target preductal saturations: 60-65% at 1 minute, gradually reaching 85-95% by 10 minutes 3
- Do NOT start with 100% oxygen in term infants—it is associated with excess mortality 4
Ventilation Parameters
- Rate: 40-60 breaths per minute 1, 2
- Initial pressure: 20 cm H₂O (though 30-40 cm H₂O may be necessary in some term infants) 3, 2
- PEEP: approximately 5 cm H₂O for preterm newborns 1, 2
Device Selection
- Prefer T-piece resuscitators over self-inflating bags for delivering PPV 1
- A self-inflating bag must be available as backup in case of gas source failure 1
- Flow-inflating bags are also acceptable 3
Airway Interface
- Consider supraglottic airways (laryngeal masks) as the primary interface for PPV instead of face masks for infants ≥34 weeks gestation 1
- Face masks remain acceptable for all gestational ages 3
Heart Rate Assessment
The primary indicator of effective ventilation is a rising heart rate, not chest rise. 3
- Consider 3-lead ECG for rapid and accurate heart rate measurement during resuscitation 1, 3
- ECG provides faster and more accurate assessment than auscultation or palpation 1
Escalation: When PPV is Ineffective
If heart rate remains <100 bpm after initiating PPV, implement the MR SOPA corrective steps before escalating further. 3
MR SOPA Algorithm
- Mask adjustment (ensure proper seal)
- Reposition airway (sniffing position)
- Suction mouth and nose if needed
- Open mouth (slightly open)
- Pressure increase (incrementally up to 30-40 cm H₂O if needed)
- Alternative airway (endotracheal intubation or laryngeal mask) 3
Reassess heart rate after 30 seconds of adequate ventilation with visible chest rise. 3, 2
Chest Compressions
Begin chest compressions if heart rate remains <60 bpm after 30 seconds of adequate PPV with 100% oxygen. 3, 2
- Use the 2-thumb encircling hands technique 1, 5
- Compression-to-ventilation ratio: 3:1 (90 compressions and 30 breaths achieving ~120 events/minute) 1, 5
- Depth: one-third the anterior-posterior diameter of the chest 5
- Do NOT start chest compressions until after 30 seconds of adequate ventilation—the vast majority of bradycardic newborns will respond to effective ventilation alone 3
Medications and Vascular Access
If heart rate remains <60 bpm despite adequate ventilation and chest compressions, administer epinephrine. 5, 6
- Dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) 5
- Preferred route: intravenous (umbilical venous catheter) 5, 7
- Intraosseous access can serve as an alternative if umbilical or other direct venous access is not readily available 5
Meconium-Stained Amniotic Fluid
Do NOT perform routine intubation for tracheal suction in nonvigorous infants born through meconium-stained amniotic fluid. 1, 3, 7
- Instead, complete the initial steps and begin PPV if heart rate is <100 bpm or breathing is inadequate 3
- This represents a major change from older guidelines that recommended routine suctioning 5, 7
Temperature Management
Maintain temperature between 36.5-37.5°C for all newborns, especially preterm infants. 1, 3
- For preterm infants <28 weeks: use plastic wrapping up to neck level without drying first 1, 3
- Prewarm the delivery room 3
- Avoid hyperthermia (>38.0°C) due to potential associated risks 3
Endotracheal Intubation Indications
Intubation is indicated when: 3
- PPV via face mask or laryngeal mask is ineffective
- Prolonged ventilation is required
- Chest compressions are needed
- Suspected diaphragmatic hernia is present
Use exhaled CO₂ detection as the primary confirmation method for tube placement—clinical assessment alone is insufficient. 3, 7
Critical Pitfalls to Avoid
- Do NOT delay PPV beyond 60 seconds to establish IV access or prepare for intubation 3, 2
- Do NOT start with 100% oxygen in term infants 3, 2, 4
- Do NOT perform routine endotracheal suctioning for meconium 1, 3, 7
- Do NOT start chest compressions until after 30 seconds of adequate ventilation 3, 2
- Do NOT rely solely on chest rise as an indicator of effective ventilation—watch the heart rate 3, 2
- Do NOT neglect temperature management in preterm infants 2