What are the complete steps procedure guidelines for neonatal resuscitation in a newborn with bradycardia and impaired breathing efforts?

Neonatal Resuscitation: Complete Procedural Steps

Initial Assessment Within 60 Seconds ("Golden Minute")

Begin resuscitation immediately if the newborn has bradycardia (<100 bpm) and impaired breathing—complete all initial steps within 60 seconds of birth, then escalate systematically based on heart rate response. 1, 2

The American Academy of Pediatrics recommends rapidly assessing three critical questions at birth: term gestation, good muscle tone, and breathing or crying 1, 2. If any answer is "no," immediately move the infant to a radiant warmer and begin the resuscitation sequence 2.

Step 1: Initial Stabilization (First 30 Seconds)

Execute these steps simultaneously within the first 30 seconds 1, 2:

• Provide warmth by placing infant under radiant heat source; for preterm infants <32 weeks, wrap in plastic up to neck level and maintain room temperature >25°C to achieve core temperature 36.5-37.5°C 2, 3
• Position head in "sniffing" position to open the airway 1, 2
• Clear secretions only if copious and obstructing airway—avoid routine nasopharyngeal suctioning as it causes bradycardia 2
• Dry thoroughly and remove wet linen 1, 2
• Stimulate breathing through drying and gentle tactile stimulation 1, 2

Critical pitfall: Never perform routine endotracheal suctioning for meconium-stained fluid, even in non-vigorous infants—this practice has been abandoned 2, 3.

Step 2: Positive Pressure Ventilation (If HR <100 bpm or Apnea)

Initiate PPV immediately at 60 seconds if the infant is not breathing, gasping, or has heart rate <100 bpm—this is the single most critical intervention in neonatal resuscitation. 1, 2, 3

PPV Technical Parameters

• Oxygen concentration: Start with room air (21%) for term infants; 21-30% for preterm infants <35 weeks 1, 2, 3
• Ventilation rate: 40-60 breaths per minute 1, 2
• Initial pressure: 20 cm H₂O (may need 30-40 cm H₂O in some term infants if no response) 1, 2
• PEEP: Apply 5 cm H₂O 1, 2
• Device: Use face mask with flow-inflating bag, self-inflating bag, or T-piece resuscitator 2, 3

Monitoring During PPV

• Attach pulse oximetry to right hand/wrist (preductal site) before connecting to monitor 2, 3
• Target saturations: 60-65% at 1 minute, gradually reaching 85-95% by 10 minutes 1, 2, 3
• Primary indicator of effective ventilation: Rising heart rate, NOT chest rise 2, 3

Critical pitfall: Never delay PPV beyond 60 seconds to establish IV access or prepare for intubation 1, 2, 3. Never start with 100% oxygen in term infants—this increases mortality 3.

Reassessment at 30 Seconds of PPV

After 30 seconds of adequate ventilation with visible chest rise, reassess heart rate 1, 3:

• If HR >100 bpm: Continue PPV until spontaneous respirations established 3
• If HR 60-100 bpm: Continue effective PPV, ensure adequate chest rise, consider corrective steps (MR SOPA algorithm: Mask adjustment, Reposition airway, Suction mouth/nose, Open mouth, Pressure increase, Alternative airway) 3
• If HR <60 bpm: Proceed immediately to chest compressions 1, 3

Step 3: Chest Compressions (If HR <60 bpm After 30 Seconds of Adequate PPV)

Begin chest compressions only after 30 seconds of effective ventilation with 100% oxygen if heart rate remains <60 bpm—the vast majority of bradycardic newborns respond to ventilation alone. 4, 1, 2, 3

Chest Compression Technique

• Method: Two-thumb encircling hands technique (preferred) 4, 2
• Location: Lower third of sternum 2
• Depth: One-third of anterior-posterior diameter of chest 4, 2
• Ratio: 3:1 compression-to-ventilation ratio (90 compressions:30 breaths = 120 events per minute) 4, 1, 2
• Oxygen: Increase to 100% oxygen when compressions begin 1, 3

Critical pitfall: Never start chest compressions before achieving 30 seconds of effective ventilation with visible chest rise—bradycardia in newborns is almost always due to inadequate lung inflation, not primary cardiac pathology 4, 3.

Reassessment During Compressions

Reassess heart rate every 60 seconds during coordinated chest compressions and ventilation 4:

• If HR >60 bpm: Discontinue compressions, continue PPV 3
• If HR remains <60 bpm: Continue compressions and prepare for medication administration 4, 3

Step 4: Medications (If HR <60 bpm Despite Adequate Ventilation and Compressions)

Administer epinephrine 0.01-0.03 mg/kg IV if heart rate remains <60 bpm after adequate ventilation with 100% oxygen and chest compressions—IV route is strongly preferred over endotracheal administration. 4, 2, 3

Epinephrine Administration

• IV dose (preferred): 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) 4, 2
• Endotracheal dose (if IV not yet available): 0.05-0.1 mg/kg—less effective and requires higher doses 2
• Route priority: Establish umbilical venous catheter as soon as possible; IV route is far superior to endotracheal 4, 2

Critical evidence: Animal studies show endotracheal epinephrine at currently recommended doses is ineffective; higher IV doses (>0.03 mg/kg) cause exaggerated hypertension and worse neurological outcomes 4.

Volume Expansion (If Blood Loss Suspected)

• Indication: Pale skin, poor perfusion, weak pulse, and inadequate response to other measures 4
• Fluid: Isotonic crystalloid (normal saline or Ringer's lactate) or O-negative blood 4, 5
• Dose: 10 mL/kg IV over 5-10 minutes, may repeat 4
• Caution: Avoid rapid infusions in premature infants—associated with intraventricular hemorrhage 4

Medications NOT Recommended in Delivery Room

• Naloxone: Not recommended as part of initial resuscitation—restore heart rate and oxygenation by supporting ventilation 4
• Sodium bicarbonate: Not recommended during acute resuscitation in delivery room 2
• Glucose: Administer IV glucose infusion as soon as practical after resuscitation to avoid hypoglycemia, but not during active resuscitation 4

Step 5: Advanced Airway Management

Consider endotracheal intubation if mask ventilation is ineffective after corrective steps, prolonged ventilation is required, chest compressions are needed, or suspected diaphragmatic hernia. 3

Intubation Confirmation

• Primary method: Exhaled CO₂ detection—clinical assessment alone is insufficient 3, 5
• Secondary assessment: Rising heart rate, bilateral breath sounds, chest rise 3
• Continuous monitoring: Verify tube placement when inserted, during transport, and whenever patient is moved 3

Alternative Airway

• Laryngeal mask airway: Effective alternative for infants ≥34 weeks gestation or ≥2000g if bag-mask ventilation fails and intubation attempts unsuccessful 3, 5

Special Considerations

Delayed Cord Clamping

The American College of Obstetricians and Gynecologists recommends delaying cord clamping for at least 60 seconds in infants who are breathing and crying at birth, but clamping immediately in infants not breathing or crying so resuscitation can commence promptly 1, 3.

Heart Rate Assessment

Use 3-lead ECG for rapid, accurate heart rate measurement rather than relying solely on auscultation 3. If ECG unavailable, use stethoscope—umbilical cord palpation is unreliable (undetectable in 20% of healthy newborns), and brachial/femoral pulses are even less reliable (undetectable in 45-60%) 6.

Temperature Management

• Target range: 36.5-37.5°C throughout resuscitation 2, 3
• Avoid hypothermia: Increases mortality and morbidity 2, 3
• Avoid hyperthermia: Temperature >38°C associated with adverse outcomes 2, 3

Meconium-Stained Amniotic Fluid

Do not perform routine endotracheal suctioning, even in non-vigorous infants—complete initial steps and begin PPV if heart rate <100 bpm or breathing inadequate 3, 5.

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 decisions beyond 10 minutes 2, 5. Intact survival has been reported following prolonged resuscitation despite absence of spontaneous circulation after 2 doses of epinephrine 7.

Post-Resuscitation Care

Once adequate ventilation and circulation are established, transfer infant to environment where close monitoring and anticipatory care can be provided—babies requiring resuscitation are at risk for deterioration after vital signs normalize 4.