What is the protocol for the Neonatal Resuscitation Programme (NRP) in newborns?

Neonatal Resuscitation Programme Protocol

Initial Assessment at Birth

The Neonatal Resuscitation Program follows a systematic algorithm where approximately 90% of newborns transition successfully without intervention, but skilled personnel must be prepared for every delivery to rapidly identify and resuscitate the 10% who require assistance. 1

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

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

If all three answers are "yes," the infant remains with the mother for routine care (skin-to-skin contact, drying, covering with dry linen to maintain temperature) 1. If any answer is "no," immediately move the infant to a radiant warmer for resuscitation 1.

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

Complete the initial stabilization steps within approximately 60 seconds from birth, as this timeframe is critical for initiating ventilation if needed—the single most important intervention in neonatal resuscitation. 1, 2

The initial steps include 1, 2, 3:

• Provide warmth under a radiant heat source
• Position the airway in "sniffing" position
• Clear secretions only if copious and obstructing the airway
• Dry thoroughly and remove wet linen
• Stimulate breathing through drying and gentle tactile stimulation

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

• Respirations (apnea, gasping, labored, or unlabored breathing)
• Heart rate (above or below 100/min)

Ventilation Protocol (The Most Critical Step)

If the infant is apneic, gasping, or has a heart rate below 100/min after initial steps, immediately begin positive-pressure ventilation (PPV)—this is the cornerstone of neonatal resuscitation because newborn bradycardia results from inadequate lung inflation and hypoxemia, not primary cardiac pathology. 1, 3

PPV Parameters:

Initial oxygen concentration 2, 4:

• Term infants (≥35 weeks): Start with 21% oxygen (room air)
• Preterm infants (<35 weeks): Start with 21-30% oxygen

Ventilation settings 2, 4:

• Rate: 40-60 breaths per minute
• Initial pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants)
• PEEP: Approximately 5 cm H₂O

Device options 2, 4:

• T-piece resuscitator (preferred)
• Flow-inflating bag
• Self-inflating bag (must be available as backup)

Heart Rate Monitoring:

Consider using 3-lead ECG for rapid and accurate heart rate assessment rather than relying solely on auscultation, which is known to be inaccurate during resuscitation. 1, 4

Use pulse oximetry to guide oxygen titration, targeting preductal saturations that match healthy term newborns 2, 3:

• 60-65% at 1 minute
• Gradually reaching 85-95% by 10 minutes

Reassessment and Escalation (30-Second Intervals)

After 30 seconds of adequate PPV, reassess heart rate—the most sensitive indicator of successful resuscitation is an increasing heart rate, not chest rise. 1, 3

Decision Algorithm:

If heart rate >100/min: Continue PPV until spontaneous respirations established 3

If heart rate 60-100/min: Continue effective PPV and reassess every 30 seconds 3

If heart rate <60/min despite 30 seconds of adequate ventilation:

Critical Pitfall: Do not start chest compressions until you have confirmed 30 seconds of effective ventilation with visible chest rise—the vast majority of bradycardic newborns respond to effective ventilation alone 3, 4.

If ventilation appears ineffective, immediately implement the MR SOPA algorithm before proceeding to compressions 3:

• Mask adjustment (ensure proper seal)
• Reposition airway (sniffing position)
• Suction mouth and nose if needed
• Open mouth (jaw thrust)
• Pressure increase (up to 30-40 cm H₂O)
• Alternative airway (endotracheal intubation or laryngeal mask for infants ≥34 weeks/≥2000g)

Chest Compressions Protocol

If heart rate remains <60/min after 30 seconds of effective PPV with 100% oxygen and visible chest rise, begin chest compressions using the two-thumb encircling hands technique. 2, 3, 4

Compression technique 2, 4:

• Method: Two-thumb encircling hands (superior to two-finger technique)
• Depth: One-third of anterior-posterior diameter of chest
• Ratio: 3:1 compression-to-ventilation (90 compressions and 30 breaths = ~120 events/minute)
• Oxygen: Increase to 100% during compressions

Coordinate compressions with ventilation—deliver 3 compressions followed by 1 ventilation, ensuring the ventilation is delivered during the brief pause after the third compression. 2, 4

Medications and Advanced Resuscitation

If heart rate remains <60/min after 60 seconds of chest compressions coordinated with PPV using 100% oxygen, administer epinephrine. 1

The sequence progresses to 1:

• C. Chest compressions (as above)
• D. Epinephrine and/or volume expansion

Special Considerations

Umbilical Cord Management:

For infants who are breathing and crying, perform delayed cord clamping for at least 30-60 seconds, as this improves hemodynamic stability and reduces transfusion needs. 2, 4

For infants not breathing or crying, clamp the cord immediately (unless part of a research protocol) so resuscitation can commence promptly. 1

For preterm infants 28-34 weeks when delayed clamping cannot be performed, intact cord milking may be reasonable, but do not perform cord milking in extremely preterm infants <28 weeks 4.

Temperature Management:

Maintain temperature between 36.5-37.5°C throughout resuscitation—hypothermia is a predictor of mortality and must be avoided. 1, 4

For preterm infants <28 weeks, place in plastic wrapping up to neck level without drying first 4.

Avoid hyperthermia (>38.0°C) due to associated risks. 3

Meconium-Stained Amniotic Fluid:

Do not perform routine endotracheal intubation for tracheal suctioning, even in nonvigorous infants born through meconium-stained amniotic fluid—instead, proceed directly with initial steps and PPV if indicated. 3, 4

Critical Pitfalls to Avoid

• Never delay ventilation to establish IV access or prepare for intubation—ventilation is the priority 3
• Never start with 100% oxygen for term infants—begin with room air and titrate based on pulse oximetry 3
• Never start chest compressions before ensuring 30 seconds of effective ventilation with visible chest rise 3, 4
• Never rely solely on auscultation for heart rate assessment—it is inaccurate during resuscitation 1

Preparation and Team Readiness

Every birth must be attended by at least one person skilled in the initial steps of newborn resuscitation, with immediate access to full resuscitation equipment and a system to rapidly assemble additional personnel based on perinatal risk assessment. 1, 5, 6