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NRP Guide — Neonatal Resuscitation Program

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Full Algorithm at a Glance

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STEP 1 — Before the Baby is Delivered: Pre-Delivery Preparation

A. Antenatal Counseling

• Review maternal history and identify risk factors that predict a need for resuscitation
• Key questions to ask (NRP Pre-Delivery History — Box 159.3):
  1. What is the estimated gestational age?
  2. Is this a multiple gestation?
  3. Is meconium present in the amniotic fluid?
  4. Is there a history of vaginal bleeding?
  5. Were medications given or drugs taken by the mother?
  6. Was there documented maternal fever?
  7. Did the mother have routine prenatal care? Any abnormalities on prenatal ultrasound?

B. Team Briefing

• Designate roles before delivery — at least one qualified provider whose sole responsibility is the neonate must attend every delivery
• High-risk deliveries require a provider capable of full resuscitation including intubation
• Communicate the plan, assign tasks (airway, compressions, medications, documentation)
• NRP emphasizes simulation-based teamwork: implementation of TeamSTEPPS principles improves communication and reduces medication errors

C. Equipment & Room Temperature Check

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STEP 2 — At Birth: The 3 Rapid Assessment Questions

1. Term gestation? 2. Good muscle tone? 3. Breathing or crying?

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STEP 3 — Initial Steps (All answers NOT fully "Yes" → 60-second clock starts)

1. Warm and maintain normal temperature (36.5–37.5°C)
   • Dry immediately; replace wet blankets with dry/warm ones
   • Leave baby uncovered to facilitate radiant warming and team access
2. Position the airway
   • Supine, neck in slight extension (not hyperextended)
   • Place a rolled towel (~1 inch) under the shoulders (not under neck) to align posterior pharynx, larynx, and trachea
3. Clear secretions if needed (only if obvious obstruction, poor tone, or meconium with bradycardia)
   • Suction mouth first, then nose (to prevent aspiration if baby gasps after nasal suction)
   • Use ≤100 mmHg suction; avoid deep/vigorous suctioning — causes vagal bradycardia and apnea
4. Dry
5. Stimulate (rub back, flick soles of feet)

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STEP 4 — After Initial Steps: Apneic / Gasping / HR <100 bpm?

• Rate: 40–60 breaths/min ("breathe-two-three, breathe-two-three")
• Initial pressures: Up to 40 cmH₂O for first breaths; thereafter ≤30 cmH₂O
• Starting O₂: Term infants — begin with 21% O₂ (room air); preterm <35 weeks — begin with 21–30% O₂
• SpO₂ monitoring: Attach pulse oximeter to the right hand or wrist (preductal) — see targeted SpO₂ table below
• Consider ECG/cardiac monitor for continuous heart rate assessment

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STEP 5 — PPV Done, but Still Apneic/Gasping and HR <100 bpm?

→ Ventilation Corrective Steps (MR. SOPA)

• ETT depth ("tip to lip") = 6 cm + weight in kg
• Confirm placement with capnography (CO₂ detector)
• Exclude right mainstem intubation by bilateral auscultation

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STEP 6 — HR <60 bpm After Adequate PPV?

→ Chest Compressions + Escalation

1. Intubate if not already done (ETT preferred for coordinated compressions)
2. Chest compressions:
   • Technique: 2-thumb encircling technique (preferred) or 2-finger technique
   • Depth: ⅓ of AP chest diameter
   • Rate: 3 compressions : 1 breath at 90 compressions + 30 breaths/min (120 events/min)
   • Coordinate PPV with compressions — do not deliver simultaneously
3. Switch to 100% O₂ during compressions
4. Attach cardiac monitor (ECG) if not already done — ECG gives faster and more accurate HR than pulse oximetry in this phase
5. Consider umbilical vein catheterization (UVC) for emergency vascular access
   • Insert 3.5F or 5F umbilical catheter just below skin level with free backflow — do not advance into liver (risk of hypertonic solution injury)

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STEP 7 — HR Still <60 bpm After Compressions + PPV?

→ Medications + Rule Out Reversible Causes

A. Epinephrine (FIRST LINE)

• Dose: 0.01–0.03 mg/kg IV (0.1–0.3 mL/kg of 1:10,000 solution)
• Route: IV (umbilical vein catheter preferred) → if no IV access yet: endotracheal route (1 mL saline flush) — note ETT absorption is unreliable, higher doses may be needed
• Repeat: Every 3–5 minutes if HR remains <60 bpm

B. Consider & Treat Reversible Causes

Nearly ⅔ of premature infants requiring resuscitation are hypovolemic at birth — always consider this.

• Naloxone 0.1 mg/kg IV (or 0.2 mg/kg IM): only if respiratory depression from maternal opioids in last 4 hours — do NOT give if mother is a chronic opioid user (precipitates withdrawal)
• Sodium bicarbonate 2 mEq/kg (0.5 mEq/mL, 4.2% solution): only for documented severe metabolic acidosis with adequate ventilation, or prolonged resuscitation >5 min; infuse slowly ≤1 mEq/kg/min

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STEP 8 — Baby Survives: Post-Resuscitation Care

Immediate stabilization:

• Continue monitoring: oxygenation, ventilation, perfusion, temperature, blood glucose
• Check blood glucose — up to 10% of neonates have hypoglycemia (glucose <35 mg/dL), especially those delivered by C-section

NICU Admission:

• Any neonate requiring: umbilical line, intubation, medications, or extensive resuscitation → transfer to NICU with personnel skilled in neonatal resuscitation
• If feasible and safe, allow parents to see, touch, and hold the baby before transport

Therapeutic Hypothermia (if HIE suspected):

• Indicated for moderate to severe hypoxic-ischemic encephalopathy (HIE)
• Target temp: 33.5–34.5°C for 72 hours, initiated within 6 hours of birth, then gradual rewarming over ≥4 hours
• Signs of evolving brain injury: abnormal consciousness, seizures, hypotonia, hyporeflexia
• Monitor for complications: thrombocytopenia, hypotension

Common post-resuscitation complications to watch for:

Team Debriefing:

• Conduct a structured debrief with the full team after every resuscitation
• Review: what went well, what could improve, communication breakdowns, medication errors
• NRP emphasizes debriefing as a core component of the curriculum — simulation-based training with debriefing has been shown to improve provider confidence, technical skills, and patient outcomes

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Quick Summary Flow

PRE-DELIVERY
Antenatal counseling → Team briefing → Equipment/room check
           ↓
          BIRTH
  Term? Tone? Breathing/crying?
     ↓ ALL YES → Routine care with mother
     ↓ ANY NO ↓
  Warm · Position · Suction (if needed) · Dry · Stimulate (≤1 min)
           ↓
   Apneic/gasping or HR <100?
     ↓ YES
     PPV + SpO₂ monitor ± ECG
           ↓
   HR still <100 or no chest rise?
     ↓ YES
     MR.SOPA corrective steps → Intubate if needed
           ↓
   HR <60?
     ↓ YES
     Intubate + Chest compressions (3:1) + 100% O₂ + ECG + UVC
           ↓
   HR still <60?
     ↓ YES
     IV Epinephrine (repeat q3-5 min) + Rule out hypovolemia/pneumothorax
           ↓
   HR ≥60 / improving
     ↓
   Post-resuscitation care → NICU → Team debrief

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