Neonatal Resuscitation
Introduction
Neonatal resuscitation is an emergency procedure performed on newborns who fail to initiate or
sustain effective respiration after birth. Globally, around 10% of newborns require some form of
resuscitation at birth, and approximately 1% require extensive measures. Proper training and
timely intervention can drastically reduce neonatal morbidity and mortality. The Neonatal
Resuscitation Program (NRP), developed by the American Academy of Pediatrics (AAP),
provides evidence-based guidelines that form the cornerstone of neonatal care during the first
minutes of life.
Aims and Objectives
To understand the physiological transition from intrauterine to extrauterine life.
To identify newborns who need resuscitation.
To describe the sequential steps of neonatal resuscitation.
To learn the roles of the resuscitation team and the importance of teamwork.
To become familiar with necessary equipment and medications.
Physiological Changes After Birth
➢ At birth, several physiological changes occur, such as:
➢ Closure of fetal circulatory shunts (foramen ovale, ductus arteriosus).
➢ Initiation of pulmonary respiration.
➢ Increased pulmonary blood flow.
➢ Transition from placental to lung oxygenation.
➢ Failure of these transitions can result in respiratory depression or apnea, requiring
resuscitation.
Risk Factors for Neonatal Resuscitation
Antepartum Risk Factors:
Maternal diabetes or hypertension
Intrauterine growth restriction (IUGR)
Multiple gestation
Oligohydramnios/polyhydramnios
Fetal anomalies
Intrapartum Risk Factors:
• Meconium-stained amniotic fluid
• Premature rupture of membranes
• Prolonged labor
• Use of general anesthesia or sedatives
• Fetal distress
APGAR Scoring System
The APGAR Score is used to assess newborns at 1 and 5 minutes post-delivery.
Each of the five components is scored 0–2.
Component 0 1 2
Appearance Blue/pale Body pink, extremities blue Completely pink
Pulse Absent <100 bpm ≥100 bpm
Grimace No response Grimace Cry or active withdrawal
Activity Limp Some flexion Active motion
Respiration Absent Slow, irregular Strong cry
Score 7–10: Normal, 4–6: Moderate depression, 0–3: Severe depression
Neonatal Resuscitation Steps (NRP 8th Edition)
Initial Assessment (within the first 30 seconds):
Ask three key questions:
1. Is the baby term?
2. Is the baby crying or breathing?
3. Does the baby have good muscle tone?
If YES to all → Provide routine care.
If NO to any → Proceed with resuscitation.
Initial Steps:
Warm and maintain normal temperature.
Position head in "sniffing" position.
Clear secretions if needed.
Dry the baby and stimulate breathing.
Ventilation:
If baby is apneic, gasping, or HR <100 bpm → Start positive pressure ventilation (PPV).
Use a self-inflating bag, flow-inflating bag, or T-piece resuscitator.
Ensure chest rise; adjust mask seal or reposition if needed.
Oxygen Use:
Begin with 21% oxygen for term infants, adjust based on SpO₂.
Place pulse oximeter on right hand or wrist.
Chest Compressions:
Indicated if HR remains <60 bpm after 30 seconds of effective PPV.
Compression to ventilation ratio: 3:1
Method: Two-thumb encircling technique
Medications:
Epinephrine: 0.01–0.03 mg/kg (1:10,000) via umbilical vein.
Consider volume expanders (normal saline, 10 mL/kg) in case of blood loss or shock.
Post-Resuscitation Care:
Ongoing monitoring in NICU.
Management of hypoglycemia, hypothermia, and seizures.
Documentation and parental counseling.
Equipment Checklist for Neonatal Resuscitation
• Radiant warmer
• Suction device and catheters
• Laryngoscope and appropriate blades
• Bag and mask (appropriate sizes)
• T-piece resuscitator
• Endotracheal tubes (sizes 2.5, 3.0, 3.5)
• Oxygen source and blender
• Pulse oximeter
• Medications: Epinephrine, IV fluids
• Umbilical catheter tray
Team Roles in Neonatal Resuscitation
1. Team Leader – Coordinates and directs resuscitation steps.
2. Airway Manager – Handles ventilation and airway placement.
3. Compressor – Performs chest compressions.
4. Medication Nurse – Prepares and administers drugs.
5. Recorder – Documents every step and time interval.
Effective communication, role clarity, and practice drills are essential for a well-coordinated
response.
Documentation During Resuscitation
Time of birth
Time of each intervention (PPV, compressions, meds)
APGAR scores
Vital signs
Outcome and baby’s condition
Name of personnel involved
Ethical Considerations
Parental consent in advance for high-risk deliveries.
Decision-making for extremely preterm infants (<23 weeks).
Withdrawal of support in case of poor prognosis.
Psychological support for parents.
Conclusion
Neonatal resuscitation is an essential clinical skill that requires a blend of theoretical knowledge,
practical training, and teamwork. The first few minutes of life are critical, and timely
intervention can be lifesaving. Healthcare professionals must stay updated with current NRP
guidelines and engage in regular simulations to ensure preparedness.
References
1. American Academy of Pediatrics. Neonatal Resuscitation Program (NRP), 8th Edition.
2. WHO. Essential Newborn Care Course.
3. Indian Academy of Pediatrics. IAP NRP-FGM Guidelines 2021.
4. Cloherty JP, Eichenwald EC. Manual of Neonatal Care.
