Neonatal resuscitation

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Neonatal Resuscitation

Approximately 10% of newborns require some assistance at birth, and fewer than 1% need advanced resuscitative measures. The vast majority respond to the initial steps alone.

Pre-Birth Preparation

Before every delivery, a team briefing and equipment check should be completed. Key equipment includes:

Radiant warmer, warm blankets, plastic wrap (for preterm)
Bulb syringe, suction catheter (sizes 5, 8, 10 Fr) at ~100 mmHg
Self-inflating bag (450/750 mL) + age-appropriate masks
Laryngoscope with straight blades (00, 0, 1)
ETT sizes 2.5-4.0 mm (uncuffed), stylets, CO2 detector
Umbilical catheters (3.5 and 5 Fr) for vascular access

Key maternal history questions: gestational age, multiple gestation, meconium presence, medications/drugs, maternal fever, prenatal anomalies.

The NRP Algorithm (Step by Step)

AHA Neonatal Resuscitation Algorithm - ROSEN's Emergency Medicine

Step 1 - Initial Assessment (within 60 seconds - "The Golden Minute")

Ask three questions simultaneously:

Term gestation?
Good tone?
Breathing or crying?

If all three are YES → infant stays with mother for routine care (warm, dry, position airway, observe).

If ANY is NO → proceed to resuscitation steps.

Step 2 - Initial Steps (Warm, Dry, Stimulate)

Place under radiant warmer
Position airway (slight neck extension, "sniffing" position)
Clear secretions only if obstructed (mouth first, then nose)
Dry and stimulate (rub the back, flick soles of feet)
Delayed cord clamping 1-3 minutes for vigorous term infants

Suction precautions: Overly vigorous/deep suctioning causes vagal stimulation, bradycardia, and apnea. Use only if obstruction is present, and keep suction <100 mmHg.

Step 3 - Re-assess: Labored Breathing or Persistent Cyanosis (HR >100)?

Position and clear airway
Monitor SpO2 (on right hand/wrist - preductal)
Supplemental O2 as needed to reach targeted saturations
Consider CPAP

Targeted Preductal SpO2 After Birth:

Time	Target SpO2
1 min	60-65%
2 min	65-70%
3 min	70-75%
4 min	75-80%
5 min	80-85%
10 min	85-95%

Oxygen Note: Resuscitation with 100% O2 is no longer recommended. Start with room air (21%) for term infants and 21-30% FiO2 for preterm (<35 weeks). Titrate upward to achieve target SpO2. 100% O2 is reserved for HR <60 bpm after 90 seconds. Hyperoxia causes oxidative stress and cardiac/renal/neurologic injury. - ROSEN's Emergency Medicine

Step 4 - Apnea, Gasping, or HR <100 bpm → Positive Pressure Ventilation (PPV)

Rate: 40-60 breaths/min
Pressure: 30 cm H2O (term); 20-25 cm H2O (preterm)
Best indicators of effectiveness: chest rise and increasing HR (usually within 5-10 breaths)
Apply SpO2 monitor and consider ECG monitor (3-lead ECG is more accurate than pulse oximetry or umbilical palpation for HR)

APGAR Score (assessed at 1, 5, and 10 minutes):

Parameter	0	1	2
Heart rate	Absent	<100/min	≥100/min
Respiratory effort	Absent	Weak/irregular	Strong, crying
Muscle tone	Limp	Some flexion	Active motion
Reflex irritability	None	Grimace	Cry/cough/sneeze
Color	Blue/pale all over	Blue extremities	Completely pink

The 1-minute score guides need for resuscitation; the 5-minute score assesses efficacy.

If PPV is not working - use MR SOPA:

Mask - adjust seal
Reposition the head
Suction mouth then nose
Open mouth with jaw thrust
Pressure - increase (max 40 cm H2O)
Airway - definitive (intubate)

Step 5 - HR Still <100 After PPV → Check Ventilation, Consider Intubation

Check chest movement and take ventilation corrective steps. If still no improvement, intubate or place LMA.

Intubation indications:

Ineffective or prolonged bag-mask ventilation
Tracheal suctioning for non-vigorous infant with meconium
Chest compressions
Extremely low birth weight or anatomic anomalies (e.g., diaphragmatic hernia)

ETT size by weight/gestational age:

Gestational Age	Weight	ETT Size
<28 weeks	<1000 g	2.5 mm
28-34 weeks	1000-2000 g	3.0 mm
34-38 weeks	2000-3000 g	3.5 mm
>38 weeks	>3000 g	3.5-4.0 mm

ETT confirmation: expired CO2 via capnography (gold standard: plain radiograph).

Post-intubation deterioration - DOPE mnemonic:

Dislodged tube
Obstructed tube
Pneumothorax
Equipment failure

Step 6 - HR <60 bpm Despite Adequate Ventilation → Chest Compressions

Begin compressions if HR <60 after 30 seconds of adequate ventilation
Ratio: 3:1 compressions to ventilations (90 compressions + 30 breaths = 120 events/min)
Technique: Thumb-encircling method (preferred) - both thumbs on lower 1/3 of sternum, fingers encircling the chest
Depth: ~1/3 of AP chest diameter
Escalate FiO2 to 100%
Establish emergency umbilical vein catheter (UVC)
ECG monitor essential

If cardiac arrest is known to be of primary cardiac etiology, a 15:2 ratio (as in pediatric CPR) may be more appropriate. - ROSEN's Emergency Medicine

Step 7 - HR Still <60 After Compressions → Epinephrine ± Volume Expansion

Epinephrine:

Route	Concentration	Dose
IV/IO (preferred)	1:10,000	0.01-0.03 mg/kg
Endotracheal (less reliable)	1:10,000	0.05-0.1 mg/kg (higher dose)

Give IV/IO rapidly; repeat every 3-5 minutes if HR remains <60
Endotracheal route has unreliable absorption and is a last resort

Volume expansion (if suspected blood loss/hypovolemia):

Normal saline, lactated Ringer's, or PRBCs
10 mL/kg IV over 5-10 minutes

If HR persistently <60: consider pneumothorax, hypovolemia.

Special Situations

Meconium-Stained Amniotic Fluid

Current NRP guidelines no longer recommend routine intubation and tracheal suctioning for all meconium-stained deliveries. Tracheal suctioning via ETT is only indicated if:

Meconium is present AND
Infant has poor tone, poor respiratory effort, or HR <100 bpm after 1 minute of appropriate PPV

Vigorous infants with meconium-stained fluid should be treated like any other newborn. - ROSEN's Emergency Medicine

Preterm Infants

Initiate resuscitation with 21-30% FiO2 (not room air alone, not 100% O2)
Use plastic wrap/bag to prevent hypothermia (do not dry first for <32 weeks)
Lower ventilation pressures (20-25 cm H2O)
Higher risk of respiratory distress syndrome - early surfactant considerations

Threshold of Viability

Infants born at 22-25 weeks pose ethical challenges. Decisions about resuscitation should incorporate gestational age, birth weight, parental wishes, and institutional capability.

Discontinuing Resuscitation

If no cardiac activity for >10 minutes despite adequate resuscitative efforts, discontinuing resuscitation is reasonable
Decisions should be individualized, with input from the team and family - Tintinalli's Emergency Medicine

Post-Resuscitation Complications

Common complications to monitor for after resuscitation:

Hypoglycemia (check glucose early)
Transient tachypnea of the newborn
Meconium aspiration syndrome
Pneumothorax
Electrolyte disturbances
Severe hyperbilirubinemia
Sepsis
Intraventricular hemorrhage (in preterm)

For infants who required chest compressions/CPR at birth, therapeutic hypothermia should be considered if they meet criteria for hypoxic-ischemic encephalopathy (HIE).

2025 AHA/AAP Guideline Update

The 2025 AHA/American Academy of Pediatrics guidelines (PMID: 41122887, Circulation, October 2025) represent the most current update, superseding the 2020 guidelines. Key changes from earlier versions include refinements in oxygen management, ECG monitoring recommendations, and approaches to threshold-of-viability resuscitation.

Sources:

ROSEN's Emergency Medicine, Ch. 159
Tintinalli's Emergency Medicine, Ch. 108
Barash Clinical Anesthesia, 9e, Ch. 41
Morgan & Mikhail's Clinical Anesthesiology, 7e
AHA/AAP 2025 Neonatal Resuscitation Guidelines [PMID: 41122887]

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