Overview
Neonatal Resuscitation
Quick Reference
Critical Alerts
- Most newborns do NOT need resuscitation: 90% transition spontaneously
- Stimulation and airway are first steps: Warmth, dry, stimulate
- Ventilation is the most important intervention: Heart rate almost always improves with effective ventilation
- Room air for term infants initially: Titrate O2 to saturation targets
- Chest compressions only if HR <60 despite effective PPV: 3:1 ratio
- Epinephrine: 0.01-0.03 mg/kg IV/IO (or 0.05-0.1 mg/kg ET): For persistent bradycardia
Initial Assessment
| Question | Action |
|---|---|
| Term gestation? | If preterm, additional warming measures |
| Good muscle tone? | If floppy, stimulate and assess |
| Breathing or crying? | If not, clear airway and stimulate |
| Heart rate? | If <100, begin PPV; if <60 after 30s PPV, compressions |
MR SOPA (PPV Troubleshooting)
| Letter | Intervention |
|---|---|
| M | Mask adjustment (ensure seal) |
| R | Reposition airway (neutral/sniffing position) |
| S | Suction mouth then nose |
| O | Open mouth slightly |
| P | Pressure increase |
| A | Alternate airway (ETT or LMA) |
Heart Rate Thresholds
| Heart Rate | Action |
|---|---|
| >00 bpm | Routine care or supportive |
| 60-100 bpm | Continue PPV; assess effectiveness |
| <60 bpm after 30s PPV | Start chest compressions; consider intubation |
| <60 bpm after CPR | Epinephrine |
Definition
Overview
Neonatal resuscitation is the systematic approach to supporting newborns who fail to transition successfully from fetal to extrauterine life. Approximately 10% of newborns require some assistance at birth (stimulation, airway management), and about 1% require advanced resuscitation (compressions, medications). The Neonatal Resuscitation Program (NRP) provides the standardized approach.
Classification
NRP Pathway:
- Initial steps (warmth, airway, stimulation)
- Positive pressure ventilation (PPV)
- Chest compressions + PPV
- Medications (epinephrine, volume expansion)
Epidemiology
- ~10% of newborns require some resuscitation (drying, stimulation, suctioning)
- ~5% require PPV
- <1% require chest compressions
- ~0.1% require epinephrine
Etiology of Failure to Transition
Causes of Neonatal Compromise:
| Category | Examples |
|---|---|
| Respiratory | Meconium aspiration, RDS, pneumothorax, diaphragmatic hernia |
| Circulatory | PPHN, congenital heart disease, hypovolemia |
| Neurological | Birth asphyxia, drug depression, prematurity |
| Infectious | Sepsis, congenital infection |
| Maternal | Magnesium toxicity, opioids, general anesthesia |
Pathophysiology
Normal Fetal-to-Neonatal Transition
- Lung fluid clearance: First breaths displace fluid
- Pulmonary vasodilation: Oxygen triggers decreased PVR
- Foramen ovale closure: Increased left atrial pressure
- Ductus arteriosus closure: Oxygen and prostaglandin withdrawal
- Systemic vascular resistance increases: Cord clamping
Failed Transition
- Inadequate lung inflation → Hypoxia
- Hypoxia → Pulmonary vasoconstriction → Persistent fetal circulation
- Continued hypoxia → Bradycardia → Cardiac arrest
Why Ventilation Is Key
- Heart rate almost always improves with effective ventilation
- If HR <60 despite effective PPV, compressions are added
- Medications rarely needed if ventilation is effective
Clinical Presentation
Assessment at Birth
Initial Rapid Assessment (within 30 seconds):
| Question | Finding / Action |
|---|---|
| Term gestation? | If preterm, additional warming |
| Breathing/crying? | If not, stimulate and assess |
| Good tone? | If floppy, stimulate |
Apgar Score (Recorded at 1 and 5 minutes):
| Parameter | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (color) | Blue, pale | Acrocyanosis | Pink |
| Pulse (HR) | Absent | <100 | ≥100 |
| Grimace (reflex) | None | Grimace | Cry, cough |
| Activity (tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Weak, irregular | Strong cry |
Note: Apgar score is NOT used to guide resuscitation—it is a summary of status.
Physical Examination
Key Findings Requiring Intervention:
| Finding | Significance |
|---|---|
| Apnea or gasping | Need PPV |
| HR <100 | Need PPV |
| HR <60 after PPV | Need compressions |
| Cyanosis (central) | Need oxygen/PPV |
| Floppy tone | Need stimulation and assessment |
| Meconium-stained fluid | Assess vigor; if not vigorous, consider suctioning/intubation |
Red Flags
High-Risk Deliveries (Anticipate Resuscitation)
| Category | Risk Factors |
|---|---|
| Maternal | Preeclampsia, diabetes, infection, hemorrhage, substance use |
| Fetal | Prematurity, IUGR, known anomalies, multiple gestation |
| Intrapartum | Fetal distress, meconium, cord prolapse, prolonged rupture of membranes |
| Delivery | Emergency C-section, forceps/vacuum, shoulder dystocia |
Signs of Severe Compromise
| Finding | Action |
|---|---|
| Persistent HR <60 despite PPV + compressions | Epinephrine |
| Pale, floppy, unresponsive | Consider volume (blood loss) or other causes |
| No improvement with resuscitation | Reassess, consider congenital anomaly or diaphragmatic hernia |
Differential Diagnosis
Causes of Failure to Respond to Resuscitation
| Cause | Features |
|---|---|
| Airway obstruction | Secretions, meconium, choanal atresia |
| Pneumothorax | Asymmetric chest rise, decreased breath sounds |
| Diaphragmatic hernia | Scaphoid abdomen, bowel sounds in chest |
| Severe hypovolemia | Pale, tachycardia, poor perfusion; maternal hemorrhage |
| Congenital heart disease | Persistent cyanosis despite oxygen |
| PPHN | Hypoxia out of proportion to lung disease |
| Drug depression | Maternal opioids, magnesium |
| Sepsis | Risk factors, poor perfusion |
Diagnostic Approach
Monitoring During Resuscitation
| Tool | Purpose |
|---|---|
| Pulse oximetry | Right hand (preductal); target saturation by minute |
| Heart rate (auscultation, ECG, pulse ox) | Most important indicator |
| CO2 detector | Confirm ETT placement |
| Chest X-ray (post-resuscitation) | Assess lungs, ETT position |
Target SpO2 by Minute of Life
| Time | Target SpO2 (Preductal) |
|---|---|
| 1 min | 60-65% |
| 2 min | 65-70% |
| 3 min | 70-75% |
| 4 min | 75-80% |
| 5 min | 80-85% |
| 10 min | 85-95% |
Laboratory (Post-Resuscitation)
- Blood gas (pH, lactate)
- Glucose
- CBC
- Blood cultures (if sepsis suspected)
Treatment
NRP Algorithm Overview
- Initial steps (60 seconds)
- PPV if needed (HR <100 or apnea)
- Reassess HR every 30 seconds
- Chest compressions if HR <60 after effective PPV
- Epinephrine if HR <60 after compressions + PPV
Initial Steps (Within 60 Seconds)
| Step | Details |
|---|---|
| Warmth | Radiant warmer; dry with warm towels; remove wet linens |
| Position | Neutral position ("sniffing") to open airway |
| Clear airway | Suction if needed (mouth then nose); avoid deep suctioning |
| Stimulate | Dry, flick soles, rub back |
| Assess | Breathing? Heart rate? |
For Preterm Infants (<32 weeks):
- Plastic wrap (polyethylene bag) to prevent heat loss
- Increase room temperature
- Consider CPAP
Positive Pressure Ventilation (PPV)
Indication: Apnea, gasping, or HR <100 after initial steps
| Parameter | Value |
|---|---|
| Rate | 40-60 breaths/min |
| Initial PIP | 20-25 cm H2O (may need higher for first breaths) |
| FiO2 | Room air (21%) for term; 21-30% for preterm |
| Assessment of effectiveness | Chest rise, improving HR |
MR SOPA Troubleshooting (If HR not improving):
| Letter | Action |
|---|---|
| M | Mask—adjust for seal |
| R | Reposition—neutral/sniffing position |
| S | Suction—mouth then nose |
| O | Open mouth—slightly during PPV |
| P | Pressure—increase PIP |
| A | Alternate airway—ETT or LMA |
Intubation
Indications:
- Ineffective PPV despite corrective steps
- Prolonged resuscitation
- Diaphragmatic hernia
- Extremely preterm infants
- Meconium aspiration (if needed for tracheal suctioning)
ETT Size by Weight:
| Weight | ETT Size (mm ID) | Depth (cm at lip) |
|---|---|---|
| <1 kg | 2.5 | 6-7 |
| 1-2 kg | 3.0 | 7-8 |
| 2-3 kg | 3.0-3.5 | 8-9 |
| > kg | 3.5-4.0 | 9-10 |
Confirm Placement: CO2 detector (colorimetric), chest rise, bilateral breath sounds
Chest Compressions
Indication: HR <60 bpm after 30 seconds of effective PPV
| Parameter | Details |
|---|---|
| Technique | Two-thumb encircling (preferred) or two-finger |
| Depth | 1/3 AP diameter of chest |
| Rate | 120 events/min (90 compressions + 30 breaths) |
| Ratio | 3:1 (compressions:ventilations) |
Coordinate with PPV: 3 compressions, 1 breath, repeat
Medications
Epinephrine (Adrenaline):
| Route | Dose | Concentration |
|---|---|---|
| IV/IO (preferred) | 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000) | 1:10,000 |
| ETT (if no IV/IO) | 0.05-0.1 mg/kg (0.5-1 mL/kg of 1:10,000) | 1:10,000 |
- Give via UVC if placed (fastest)
- Repeat every 3-5 minutes if HR remains <60
Volume Expansion (If suspected blood loss):
- Normal saline or O-negative blood
- 10 mL/kg IV bolus
Umbilical Venous Catheter (UVC)
Indication: Need for IV access during resuscitation Placement: Insert 2-4 cm into umbilical vein until blood return Use: Epinephrine, volume expansion
Post-Resuscitation Care
| Intervention | Details |
|---|---|
| Temperature | Maintain normothermia (keep warm) |
| Glucose | Monitor and treat hypoglycemia |
| Respiratory support | CPAP, ventilator as needed |
| Blood gas | Assess pH, lactate |
| Therapeutic hypothermia | If HIE suspected (criteria met), transfer to cooling center |
Disposition
NICU Admission
- All infants requiring more than brief PPV
- Prematurity (<35 weeks)
- Prolonged resuscitation or HIE
- Ongoing respiratory support
- Sepsis risk
Normal Newborn Nursery
- Vigorous term infant
- Required only brief stimulation
- Normal vital signs and exam
Transfer for Cooling (Therapeutic Hypothermia)
Criteria for HIE:
- ≥36 weeks GA
- Apgar ≤5 at 10 min OR ongoing resuscitation at 10 min OR pH <7.0 OR base deficit >16
- Moderate-severe encephalopathy
- Initiate passive cooling (skin temp 33-34°C); transfer to cooling center
Patient Education
For Parents (Post-Resuscitation)
- "Your baby needed help breathing at birth, but the team was able to stabilize them."
- "We are monitoring your baby closely in the NICU."
- "We will explain everything that happened and answer your questions."
Documentation
- Time of birth
- Apgar scores (1, 5, 10 min)
- Interventions provided (stimulation, PPV, intubation, compressions, medications)
- Heart rate response at each step
- Cord gas if available
Special Populations
Preterm Infants (<32 Weeks)
- Higher risk of hypothermia: Use plastic wrap, warm room
- May need CPAP rather than PPV for mild RDS
- Lower FiO2 target (start 21-30%)
- Avoid excessive tidal volumes (lung injury)
- Consider surfactant if intubated for RDS
Meconium-Stained Amniotic Fluid
Current NRP Guidance:
- If vigorous (good tone, crying, HR >100): Routine care
- If NOT vigorous (depressed): Clear airway, proceed with PPV; consider intubation for tracheal suctioning if obstruction suspected
Suspected Blood Loss
- Pale, poor perfusion, maternal hemorrhage
- Early volume expansion: NS or O-negative blood 10 mL/kg
- May need more aggressive resuscitation
Drug-Exposed Infant (Maternal Opioids)
- Often depressed at birth
- Naloxone NOT recommended routinely (risk of seizures in dependent infants)
- Provide PPV; supportive care
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Apgar documentation at 1 & 5 min | 100% | Standard |
| HR assessed within 60 seconds | 100% | Key metric |
| PPV started if HR <100 after initial steps | 100% | Guideline adherence |
| SpO2 monitored during resuscitation | 100% | Avoid hyperoxia |
| Post-resuscitation glucose check | 100% | Prevent hypoglycemia |
Documentation Requirements
- Gestational age
- Risk factors
- Apgar scores
- Interventions and timing
- HR response at each step
- Oxygen use and SpO2
- Team members present
Key Clinical Pearls
Assessment Pearls
- Most newborns need only warmth, drying, stimulation: Avoid over-intervention
- HR is the most important indicator: Drives all decisions
- Ventilation fixes most problems: Effective PPV improves HR in almost all cases
- Chest rise confirms effective ventilation: If no chest rise, troubleshoot (MR SOPA)
- Avoid routine deep suctioning: Can cause vagal bradycardia
Treatment Pearls
- Room air for term infants: Titrate O2 to saturation targets
- Compressions are rare: Only if HR <60 after effective PPV
- 3:1 ratio for compressions: Different from pediatric/adult (15:2)
- Epinephrine via UVC is fastest: IV/IO preferred over ET
- Don't give naloxone routinely: Risk of seizures in opioid-dependent infant
- Meconium: Suction if obstructed, not routinely: Vigorous = routine care
Disposition Pearls
- NICU for any significant resuscitation: Beyond brief stimulation
- Therapeutic hypothermia for HIE: Start passive cooling early, transfer
- Communicate with parents: Explain what happened and what to expect
References
- Weiner GM, Zaichkin J, eds. Textbook of Neonatal Resuscitation (NRP). 8th ed. American Academy of Pediatrics; 2021.
- Wyckoff MH, et al. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 5: Neonatal Resuscitation. Circulation. 2020;142(16_suppl_2):S524-S550.
- Perlman JM, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation. Circulation. 2015;132(16 Suppl 1):S204-S241.
- Wyllie J, et al. European Resuscitation Council Guidelines 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation. 2015;95:249-263.
- Saugstad OD, et al. Oxygenation of the newborn: A molecular approach. Neonatology. 2012;101(4):315-325.
- Aziz K, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation. Pediatrics. 2021;147(Suppl 1):e2020038505E.
- American Heart Association. Highlights of the 2020 AHA Guidelines for CPR and ECC. 2020.
- UpToDate. Neonatal resuscitation in the delivery room. 2024.