Neonatal Resuscitation (NRP)

Overview

The majority of newborns do not require additional intervention at birth; about one in ten needs help to start breathing, and about one percent require advanced resuscitation involving chest compressions or medication. In the first seconds, the team asks three questions together:

Is the baby term? Is the tone good?

Is the baby breathing or crying? If the answer to any of these questions is no, the golden minute begins, and the baby is successively warmed, dried, stimulated, the airway is opened while keeping the head neutral or slightly extended, and secretions are cleared if necessary.

After this, breathing and heart rate are assessed together; if apnea or gasping is observed, or if the heart rate is below 100 beats per minute, positive pressure ventilation is started immediately. Reliable monitoring of heart rate is a critical step because auscultation often underestimates the heart rate; therefore, three-lead ECG monitoring is preferred whenever possible, and pulse oximetry is placed on the right hand (pre-ductal position) to monitor saturation.

The Apgar score is not used to decide when to start resuscitation or which intervention to apply; since resuscitation will already have started before the first-minute Apgar score is assigned, the scoring is only used to document the condition and response to intervention. At five minutes, infants with an Apgar score of 0-3 and a cord or arterial blood gas pH of 7.0 or below have a significantly increased risk of hypoxic-ischemic encephalopathy; these threshold values are part of the criteria used to evaluate eligibility for therapeutic hypothermia.

The timing of umbilical cord clamping has also become part of resuscitation: in preterm infants (<37 weeks gestation) and term/late-preterm infants who do not need additional resuscitation, delaying clamping for at least 60 seconds is now the preferred strategy; in infants who are not vigorous (pale, low tone), early clamping is recommended; however, in extremely preterm infants under 28 weeks, clamping is not recommended because it increases the risk of severe intraventricular hemorrhage.

Key considerations

• Primary or secondary apnea develops due to perinatal asphyxia and is the most common cause of a non-responsive newborn at birth; its distinguishing feature is that it usually resolves with tactile stimulation and effective ventilation.
• Preterm lung immaturity and surfactant deficiency occur along with low gestational age and manifest with signs of respiratory distress such as grunting, retractions, and nasal flaring.
• Congenital diaphragmatic hernia presents with a scaphoid (sunken) abdomen, absent breath sounds on that side, and paradoxical worsening with mask ventilation; in these babies, early intubation is preferred because mask ventilation may inflate the stomach and compress the thorax.
• Pneumothorax appears with sudden deterioration despite ventilation, asymmetric chest movement, and decreased breath sounds on the affected side; emergency needle decompression may be required in tension pneumothorax.
• Congenital heart disease and persistent pulmonary hypertension progress with refractory hypoxemia and bradycardia despite oxygen; in this case, increasing oxygen to reach saturation targets has a limited response.
• Choanal atresia or upper airway obstruction should be considered in a baby who turns pink when crying and cyanotic when calm; improvement with oral airway or positional change supports the diagnosis.
• Respiratory depression due to opioids administered to the mother or general anesthetic agents is considered in a baby whose tone is relatively preserved but respiratory effort is weak; treatment is effective ventilation, not naloxone, because naloxone can trigger seizures in the newborn and is not part of routine initial resuscitation.
• Severe anemia or acute blood loss (placenta previa, vasa previa rupture, feto-maternal transfusion) manifests with pallor, weak pulse, and poor response to resuscitation; volume replacement may be necessary in these babies.
• Neuromuscular disease or congenital myopathy should be considered in babies with markedly reduced tone and weak respiratory effort from birth, in whom spontaneous breathing returns late or not at all despite ventilation.

Why it matters

The main problem in neonatal asphyxia is almost always inadequate ventilation; therefore, the American Heart Association (AHA) 2020 Section 5 and the Neonatal Resuscitation Program (NRP) 8 edition structure the algorithm around early and effective positive pressure ventilation and consider a heart rate dropping below 100 beats per minute as the threshold to start ventilation. If the heart rate remains below 60 beats per minute despite adequate ventilation, this indicates that circulation is also inadequate and chest compressions are added; the selected compression-ventilation ratio of 3 compressions to 1 breath (90 compressions and 30 breaths per minute, approximately 120 total events) aims to maintain oxygenation until circulation is established in the neonate, and this ratio is the same in both the AHA 2020 and European Resuscitation Council (ERC) 2021 guidelines.

Adrenaline is only administered if the heart rate remains below 60 beats per minute despite adequate ventilation and compressions; intravenous administration via the umbilical vein is preferred because absorption through the endotracheal route is variable and unpredictable. Preductal saturation targets gradually increase according to the minute after birth; low saturation in the first minutes is a physiological sign of transition and attempting to force it to normal, especially in preterms, increases the risk of oxidative damage through unnecessary high oxygen exposure.

In umbilical cord management, the 2023 ILCOR-focused update has brought a significant change: for infants not requiring additional resuscitation, leaving the cord unclamped for at least 60 seconds is now recommended as the preferred strategy, whereas for nonviable infants early clamping with umbilical cord access is suggested; however, this recommendation does not cover infants under 28 weeks because in the 23-27 week group, umbilical cord access significantly increased the rate of severe intraventricular hemorrhage (approximately 22% vs 6%), and therefore umbilical cord access is avoided in extremely preterm infants. Sodium bicarbonate and routine naloxone administration, once considered part of delivery room resuscitation, have now been abandoned; there is no evidence that sodium bicarbonate improves survival or neurological outcomes, and naloxone is not recommended even if respiratory depression is opioid-related because the primary therapeutic intervention is ventilation.

Similarly, routine tracheal aspiration is no longer recommended in meconium-stained, pale, or hypotonic infants because this practice delays the start of ventilation and there is no evidence that it improves the outcome.

Critical complications

• Hypoxic-ischemic encephalopathy develops after prolonged or severe asphyxia; a fifth-minute Apgar score of 0-3 and a blood gas pH of 7.0 or below or a base deficit of 15 mEq/L or more indicate increased risk, and these infants should be evaluated for therapeutic hypothermia.
• Pneumothorax, especially following high-pressure or prolonged mask ventilation, can occur; it presents with sudden desaturation, bradycardia, and asymmetric chest movement, and in suspected tension pneumothorax, emergency needle decompression is life-saving.
• Rib fracture or liver/spleen injury related to chest compressions is a rare but known complication; correct technique (thumb-encircling, lower third of sternum, depth as one-third of the anterior-posterior diameter of the chest) reduces this risk.
• Adrenaline dose or concentration errors (using a 1 mg/mL or 1:1000 ampoule by mistake) can lead to severe hypertension, arrhythmia, and myocardial damage; therefore, the dose and volume should be verbally confirmed by two people.
• Excessively rapid or high-volume fluid replacement, especially in infants with hypoxic-ischemic myocardial dysfunction, can contribute to pulmonary edema and intraventricular hemorrhage in preterms; therefore, the volume should not be given in less than 5-10 minutes.
• Misplacement during endotracheal intubation (esophageal or unilateral bronchial) aggravates hypoxia and bradycardia; placement must be confirmed by chest rise, bilateral breath sounds, colorimetric carbon dioxide detector, and, if possible, chest X-ray.
• Post-resuscitation hypoglycemia and hypothermia are secondary factors that worsen brain injury; blood glucose and body temperature should be closely monitored during the first hours after resuscitation.
• Excess oxygen exposure, especially in preterm infants, can increase the risk of retinopathy and bronchopulmonary dysplasia; therefore, it is important not to exceed minute targets for preductal saturation and to titrate FiO2.

Special considerations

• Heat loss is rapid in very low birth weight and extremely preterm infants under 28 weeks; these babies are placed directly into a plastic bag or wrap without being dried, kept under a radiant heater, and the initial FiO2 is maintained at a low range of 21-30% because higher initial oxygen is not required compared to term infants and there is a greater risk of oxidative damage.
• Umbilical cord clamping is not recommended in preterm infants under 28 weeks because it has been shown to increase the rate of severe intraventricular hemorrhage; in this group, if additional resuscitation is not needed, leaving the cord unclamped for at least 60 seconds is preferred.
• Therapeutic hypothermia in term or late-preterm asphyxiated infants (with signs of encephalopathy) is applied by initiating cooling to 33.5 degrees Celsius within the first 6 hours after birth and maintaining it for 72 hours, and if this window is missed, the treatment is not considered effective; therefore, the appropriate infant should be identified early and quickly referred to a specialized center.
• Positive pressure ventilation with a mask is avoided in infants with suspected or diagnosed congenital diaphragmatic hernia because air entering the stomach further compresses the lungs; early intubation and gastric decompression with an orogastric tube are preferred in these infants.
• In infants born to mothers with a history of opioid use, naloxone is not the first-line treatment even if respiratory depression occurs; effective ventilation is the treatment because naloxone can cause seizures in newborns and may trigger acute withdrawal symptoms in infants born to opioid-dependent mothers.
• Routine tracheal aspiration is no longer recommended in babies born through meconium-stained amniotic fluid who are pale or have low tone; these infants are followed using the same algorithm as other newborns, and ventilation is not delayed.
• Whether to initiate resuscitation in a baby with a known severe congenital anomaly (e.g., lethal skeletal dysplasia) or very early gestational age (e.g., under 22 weeks) is determined according to pre-birth discussions between the family and the care team regarding care goals; this situation requires a separate ethical assessment outside the standard resuscitation algorithm.

Follow-up plan

In the first hours after resuscitation, body temperature should be maintained within the normothermic range (avoiding overheating and excessive cooling), blood glucose, preductal and postductal saturation differences, work of breathing, and heart rate should be closely monitored; in an asphyxiated term or late-preterm infant, signs of encephalopathy should be investigated and eligibility for therapeutic hypothermia should be assessed within the first 6 hours because the benefit of treatment is lost if this window is missed. An infant who does not improve despite effective ventilation and requires intubation or continuous respiratory support should be transferred safely and without delay to an advanced neonatal intensive care unit; during transfer, monitoring of temperature, glucose, and saturation should be continued uninterrupted.

Every step of the resuscitation event (heart rate values, interventions performed, medication doses and times) should be recorded with a timestamp, and a brief team debrief should be conducted after the event. Parents should be informed about the event as early and transparently as possible, and in cases of severe asphyxia, the neurodevelopmental follow-up plan (neurology and developmental pediatrics check-ups) should be shared with the family before discharge.