NEONATAL RESUSCITATION PROGRAM (NRP) 7th EDITION

MR
SOPA

5 Blocks:
- Initial assessment
(remain with mother vs. moved to
radiant warmer for evaluation)
- Airway (A)
- Breathing (B)
- Circulation (C)
(CPR + coordinated PPV if severe
bradycardia despite assisted ventilation)
- Drug (D)
(Epinephrine)
Clinical findings of abnormal transition from fetal to neonatal respiration
(either interruption in placental function or neonatal respiration)
- Irregular or absent respiratory effort (apnoea) or rapid breathing (tahcypnoea)
- Bradycardia or Tachycardia
- Reduced muscle tone
- Low oxygen saturation
- Low blood pressure
Learning points:
- Unlike adults who experience cardiac arrest due to trauma or heart disease, newborn resuscitation is
usually the result of respiratory failure (before or after birth)
- Most important and effective action in neonatal resuscitation is to ventilate baby’s lungs as prolonged
lack of adequate perfusion and oxygenation will lead to organ damage
- Resuscitation should proceed quickly and efficiently but ensure steps in each block of flow diagram are
completed before moving to the next.
- Teamwork, leadership and communication are critical to successful resuscitation of newborn.

PRE-RESUSCITATION
4 Pre-Birth Questions - What is the expected gestational age? Estimated fetal weight?
- Is the amniotic fluid clear? Or meconium-stained
- How many babies to be expected? Singleton/Twin/Triplet
- Are there any additional risk factors?
Perinatal risk factors

Equipment Check Can I warm the baby, clear the airway, auscultate, ventilate, oxygenate,
intubate and medicate? [WSSSVOIM]
Warm - Preheated warmer with timer
- 2 Warm towels or blankets (1 for cleaning, 1 for cover)
- Temperature sensor + cover for prolonged resuscitation
- Cap, Plastic bag/wrap or food wrap (<32 week POG)
- Thermal mattress (>32 week POG)
Suction - Bulb syringe
- 10F or 12F suction catheter attached to wall suction
(set at 80-100 mmHg)
- Meconium aspirator
Auscultate - Stethoscope
SPO2 - Pulse oximeter with sensor and cover
- Target oxygen saturation table (follow target pre-ductal O2)
 Ventilate - Flowmeter set to 10 L/min
- PPV device (Neopuff or Ambubag)
- Neopuff provides PEEP (5 mmHg) and PIP (20 mmHg)
- Term & preterm-sized masks
- 8F feeding tube and large syringe
Oxygen - Oxygen blender
- Set to 21% for term babies
- Set to 30% for babies <35 weeks POG
Intubation - Laryngoscope
- Size 1: term or bigger baby
- Size 0: preterm or smaller baby
- Size 00: ELBW baby
- ETT
- Size 3.5: >2 kg
- Size 3.0: 1-2 kg
- Size 2.5: <1 kg
- Length: weight + 6
- CO2 detector
- Measuring tape +/- endotracheal tube insertion depth table
- Waterproof tape or tube-securing device
- Laryngeal mask (size 1) and 5-mL syringe
- Orogastric tube 5-6F (in laryngeal mask with insertion port)
- Scissors
- Stylet (optional)
Medication - Epinephrine 1:10,000 (0.1 mg/mL)
- 1 amp (1:1,000) + 10 cc syringe for dilution
- Normal saline/D10 for volume expansion (100-250ml)
- Normal saline for flushes
- Syringes (1/3/5ml or 20-60ml)
- Supplies for placing emergency UVC + medication
- ECG monitor with leads 

Epinephrine Dosage
Venous 0.1-0.3 ml/kg in [1:10,000] + 1.0-3.0 ml of sterile NS flush
ETT 0.5-1.0 ml/kg in [1:10,000] + 0.5-1.0 ml NS
.

Delayed cord clamping

- Delayed at least 30-60 seconds for most vigorous term and preterm newborns with baby placed skin-
to-skin on mother’s chest or abdomen or held securely in warm blanket (plastric wrap for very preterm)
- Time of birth (when the last fetal part emerges from mother’s body) till cord is clamped
- Selection criteria: placental circulation is still intact
- Exclusion criteria:
- Placental circulation not intact (abruptio placenta, PP, vasa previa, cord avulsion)
- Fetal IUGR, abnormal UA doppler, abnormal placentation, impaired utero-placental perfusion
- Multiple gestations
Advantage Disadvantage
- Reduced mortality (fewer brain - Delayed resuscitation for compromised newborns
haemorrhages) - Increased risk of polycythaemia & jaundice
- Higher blood pressure and volume (less
transfusion required)
- Reduced chance of develop IDA
- Improve neurodevelopmental outcomes
RESUSCITATION
Initial - Appears to be term? (If <37, bring to radiant warmer first)
Assessment - Good muscle tone?
(3 Questions) - Normal: active with flexed extremities
- Abnormal: flaccid with extended extremities
- Strong cry or breathing effort (Abnormal: weak or no cry, gasping)
If all YES, baby can remain with mother with initial steps performed on bedside.
If any answer is no, baby should be brought to radiant warmer + start timer
Warmth Vigorous, term newborn
- Direct skin-to-skin contact and cover with warm towel or blanket
Non-vigorous, preterm newborn
- Under pre-warm radiant warmer with uncovered exposure
- Put on temperature sensor to skin under auto mode (avoid hypothermia or
overheating), maintain body temp btw 36.5-37.5’C
Position Vigorous, term newborn
- Direct skin-to-skin contact
Non-vigorous, preterm newborn
- Sniffing position (supine, head and neck neutral or slightly extended) to allow
unrestricted air entry
- Apply shoulder roll when correcting position in those with large occiput from
molding, oedema or prematurity
Suction Vigorous, term newborn
- Direct wiping for URT secretions with cloths
- Gentle suction with bulb syringe for those with meconium-stained fluid, secretions
obstructing baby’s breathing or having difficulty clearing secretions
Non-vigorous, preterm newborn
- Suction with bulb syringe if baby not breathing, gasping, poor tone, difficulty
clearing secretions, meconium-stained fluid or anticipate to start PPV
- If copious secretions, turn head to the side to collect secretion in the cheek
- Suction ‘mouth before nose’ to prevent aspiration
- Avoid vigorous suction to prevent posterior pharynx stimulation for vasovagal
response leading to bradycardia or apnoea (suction catheter set at 80-100
mmHg when tubing is occluded)
Dry Vigorous, term newborn
- Dry with cloth + continue monitoring of breathing, tone, activity, colour, temp
Non-vigorous, preterm newborn
- Place on warm towel or blanket, gently dry any fluid. Drying not necessary for
very preterm babies <32 POG as they should be covered with plastic wrap
Stimulate Non-vigorous, preterm newborn
- Tactile stimulation by gentle rubbing in newborn’s back and flick the toes.
- Never shake a baby
Evaluate - Breathing: look for apnoea, gasping and put on SPO2 monitor over right wrist
- Heart rate (HR at least 100 bpm)
- Stethoscope (best method, count for 6 seconds x 10)
- Umbilical cord pulsation at the base (may underestimate true HR)
- Pulse oximetry (may not function if HR is low or poor perfusion)
- ECG monitor (beware of pulseless elecrical activity)
If apnoea, gasping or bradycardia (HR<100bpm), start PPV.
If persistent central cyanosis, confirm with SPO 2, consider giving supplemental O2 (with free-flow oxygen
tubing close to mouth and nose) or PPV (all not held tightly against face).
If laboured breathing with hypoxia but still breathing and not bradycardia, start trial of CPAP then CPAP.
*Avoid routine endotracheal intubation and suction immediately after birth to reduced MAS.
Positive-Pressure
Ventilation (PPV)

Ventilation is the
single most
important and
effective step in
NRP.

- 3 types of devices: (all require manometer to measure pressure)

- Self-inflating bag (fill spontaneously with gas after being squeezed/released,
cannot administer CPAP or free-flow O2 unless via open reservoir ‘tail’)
- Flow-inflating bag (only fills when gas from compressed source flows into it and
outlet is sealed)
- T-piece resuscitator (directs compressed gas to baby when an opening on the
top of device is occluded)
- Should be started within 1 min of birth
- Indications:
- Apnoeic (not breathing) *watch for chest movement
- Gasping
- Bradycardia (HR<100) *Heart rate monitoring
- SPO2 drops below target range despite free-flow O2 or CPAP *Pulse oximetry
Clear airway Suction mouth then nose to be certain that secretions will
not obstruct PPV (if not done already)
Position yourself Person positioning the airway and hold the mask is
positioned at the baby’s head
Position baby Place baby’s head and neck in neutral or slightlyl extended
(sniffing position) to ensure both chin and nose are directed
upwards. Ensure proper positioning for effective mask
ventilation. Lift the shoulders if baby’s occiput is prominent
with rolled towel or small blanket.
Mask Round vs anatomically shaped. Both should rest on chin,
cover mouth and nose but not eyes to create airtight seal.
Single-hand technique: Hold the mask on the face with
thumb & index finger encircling the rim whilst place other 3
fingers under bony angle of jaw, gently lift the jaw upward
towards the mask.
Two-hand technique with jaw thrust: if difficult to maintain a
good seal and correct head position with 1 hand
Oxygen 21% (≥35 POG) or 21-30% (<35 POG) for initial resuscitation.
Set flowmeter to 10L/min. Target PIP: 20-25 cmH2O. Target
PEEP: 5cm H2O (avoid to high to prevent pneumothorax)
Breath Give at rate of 40-60 breath/min.
Rhythm: ‘Breath, 2, 3. Breath, 2, 3.’ (Breath when squeeze
the bag or occlude T-piece cap and release while saying 2,3)
- Important indicator of successful PPV: Rising heart rate
- 1st assessment (within first 15 seconds of PPV)
- 2nd assessment (after another 15 seconds of PPV)
If HR increasing, continue PPV.
If HR not increasing, assess chest movement. If ‘chest is moving’, continue PPV, reassess after 15s.
If ‘chest is not moving’, perform ventilation corrective steps (MR SOPA). Continue PPV and reassess
after 30s of PPV that moves the chest.
Ventilation - Probable reasons for ineffective mask ventilation:
Corrective Steps - Leakage around the mask
- Airway obstruction
- Insufficient ventilating pressure

Is the chest moving?

Bilateral breath
sound?

- Consider insert orogastric tube if newborn need CPAP or PPV with mask longer
than few minutes. Leave it uncapped to act as a vent for stomach to avoid
interfering with ventilation.
- CO2 detector is helpful to assess efficacy of ventilation. Detector turning yellow
during each exhalation indicates effective ventilation. If remain blue/purple after
MR SOPA and HR not improved means poor ventilation or low cardiac output.
Alternative - Types:
Airways - Endotracheal tubes (infraglottic)
- Laryngeal masks (supraglottic)
- Maximise efficacy of positive-pressure breath if CPR is necessary
- Reliable airway access in suspected CDH, surfactant administration, direct
tracheal suction if airway is obstructed by thick secretions
A) Endotracheal tubes
- Preparation for intubation with ongoing PPV + SPO2 monitor:
- Laryngoscope + blades (straight Miller is preferred than curved Macintosh)
- ETT (uncuffed 2.5/3.0/3.5mm) + Stylet (optional)
- Suction setup + Waterproof adhesive tape + Scissor + Measuring tape
 - CO2 detector, Meconium aspirator, Stethoscope (with neonatal head)
- Indications:
- If CPR is necessary
- Stabilisation of newborn with CDH
- Surfactant administration
- Direct tracheal suction if airway is obstructed by thick secretions
- Ensuring correct placement:
- Check tip-to-lip insertion depth
*Estimated depth: NTL (nasal septum to tragus length) + 1 cm

- Prompt increase in HR and increasing SPO2

- Symmetrical chest movement, equal breath sound over both axilla
- Little or no air leak from mouth during PPV
- Water vapour inside the ETT
- Yellowing of CO2 detector (within 8-10 breaths) or ETCO2 from capnometer
- CXR (above carina, about T3 and T4)
- Sudden deterioration after intubation, consider DOPE:
- Displaced endotracheal tube (advanced too far)
- Obstructed endotracheal tube (blood, meconium, thick secretions)
- Pneumothorax
- Equipment failure (disconnected PPV, leakage)
- Intubation first before CPR (ensure maximum ventilation efficacy, most will
improve during first 30s following intubation and CPR may not be necessary)
B) Laryngeal mask
- Advantages: Not require a tight seal against face, bypasses tongue, not require
visualisation for cord for placement (situation for ‘can’t ventilate, can’t intubate’)
- Indications:
- Craniofacial anomalies (unable to achieve good seal with face mask or difficult to
visualise with laryngoscope)
- Small mandible or large tonge (face-mask ventilation & intubation are
unsuccessful eg. Rbin sequence, Trisomy 21)
- Ineffective PPV + face mask and intubation is unfeasible or unsuccessful
- Caveat: cannot be used in very small newborns (>2kg)
If HR<60 bpm despite 30s of PPV (preferably via alternative airway), increase FiO2 to 100% & start CPR.
If HR>100 bpm, breathing spontaneously but laboured breathing/low SPO 2, consider CPAP.
If HR>100, breathing spontaneously after PPV, gradual discontinue PPV followed by giving free-flow O2
CPR - Indicated when HR<60 bpm after ≥30s of PPV evidenced by chest movement with
ventilation
- Do not begin CPR unless chest movement is achieved with ventilation attempt and
focus on ventilation corrective steps
- Compressor stand at the side of warmer whilst another member stand at the head
of bed to provide coordinated ventilation via ETT
- If UVC is needed, compressor stand at the head of bed (mechanical advntage
results in less fatique), another member with PPV moves to the side.
- Thumbs are placed on the lower third of sternum below imaginary line connecting
baby’s nipples, hand encircling chest, place your fingers under the baby’s back to
provide support. Compress 1/3 of AP diameter of chest. Allow full recoil but do
not lift thumbs completely off the chest between compressions.
- Compression rate: 90 compression/min with 30 ventilation/min
(3 rapid compressions + 1 ventilation with PIP every 2 seconds)
‘One and Two and Three and Breathe and; One and Two and Three and Breathe’
- Increase O2 concentration to 100% when CPR is started.
- Wait 1 minute after started coordinated CPR and ventilation before pause briefly
to reassess HR. ECG monitor is preferred method (beware of PEA) to assess HR, but
can also use stetheoscope (prolonged interruption in compression) or pulse
oximeter (inaccurate in poor perfusion).
If HR ≥60 bpm, stop CPR. Once stopped, give PPV at faster rate of 40-60 breath/min.
If HR still <60 bpm, reassess quality of ventilation and CPR:
- Is chest moving with each breath? Bilaterally audible?
- Is 100% O2 given via PPV?
- Is CPR depth adequate? (1/3 of AP diameter of chest)
- Is compression rate correct? Are CPR and ventilation well-coordinated?
If reassessed but HR <60 bpm, epinephrine is indicated with emergency vascular assess (UVC or IO)
Medication - Indications:
(Epinephrine) HR <60 bpm after at least 30s of PPV that inflates the lungs + another 1 min of
CPR coordinated with PPC using 100% O2
- Cannot be given if no established effective ventilation
- 1:10,000 preparation (0.1 mg/ml) *1g of Epinephrine in 10,000ml of fluid
- 2 routes:
- Central IV/IO (rapidly reach central circulation, effective,+ flush 0.5-1ml NS,
dosage: 0.1-0.3 ml/kg) *estimate baby weight after birth
- Endotracheal (absorption is unreliable but can buy some time before IV/IO is
established, dosage: 0.5-1.0 ml/kg)
- Assess HR 1min after giving Epinephrine, continue PPV with 100% O2 and CPR. HR
should increase to 60 bpm or higher within 1 min of IV/IO route
If HR <60 bpm after 1st dose of IV/IO Epinephrine, repeat dose every 3-5 minutes.
If lower dosage was started, consider increase subsequent doses but not exceed maximum dosage.
If unsatisfactory after repeated IV/IO Epinephrine, consider hypovolemia, tension pneumothorax.
Hypovolemia - Possible conditions:
- Fetal-maternal haemorrhage, bleeding vasa previa, extensive PV bleed
- Fetal trauma, umbilical cord prolapse, blood loss from umbilical cord
- Signs: Pale, prolonged CRT, weak pulses
- Mx: Give volume expander if resuscitation failed + sign of shock/acute blood loss
*Not routinely given as volume loading to injured heart can worsen cardiac output
- Crystalloids (0.9% NS over 10ml/kg)
- RBC (Packed cell over 10ml/kg in severe fetal anaemia)
If there is a confirmed absence of HR (Apgar 0) after 10 min of resuscitation, it is reasonable to stop
resuscitative efforts. Yet the decision to continue or discontinue should be individualized.
 POST-RESUSCITATION CARE

REFERENCE:
Textbook of Neonatal Resuscitation (NRP), 7th Ed
By American Academy of Pediatrics and American Heart Association
Edited by Gary M. Weiner and Jeanette Zaichkin
Book | Published in 2016
ISBN (paper): 978-1-61002-024-4
ISBN (electronic): 978-1-61002-025-1

THIS NOTES SERVE AS A RECAP ON NRP 7TH EDITION AND SHALL NEVER BE USED FOR ANY
COMMERCIAL PURPOSES.