Transition to Extrauterine Life and Resuscitation
The NRP 8th-edition sequence
At birth, warm, dry, stimulate, and clear the airway if needed; assess tone, breathing, and heart rate by about 30 seconds. Apnea, gasping, or HR below 100 bpm means PPV. Use 21% oxygen for term infants and 21-30% for preterm infants under 35 weeks, titrating to 90-95% preductal SpO2. The best indicator of effective ventilation is a rising heart rate.
If PPV fails, use MR SOPA: Mask adjustment, Reposition, Suction, Open mouth, Pressure increase, Alternative airway. If HR remains below 60 after 30 seconds of effective PPV, start compressions at 3:1 (90 compressions and 30 breaths per minute) and increase oxygen to 100%. Epinephrine is 0.01-0.03 mg/kg IV (0.02 mg/kg typical) or 0.05-0.1 mg/kg via ETT. Volume is 10 mL/kg normal saline or blood.
Thermoregulation and team factors
Preterm under 32 weeks: plastic wrap, hat, warm mattress, room 23-25 degrees C; target 36.5-37.5 degrees C. Delayed cord clamping 30-60 seconds benefits term and preterm infants who do not need immediate resuscitation. APGAR scores describe condition; they do not drive resuscitation.
Worked example
A term infant born through meconium-stained fluid is limp with HR 50. Reasoning: do not routinely intubate and suction the trachea. Dry, stimulate, and start PPV; if HR stays 50, begin compressions with 100% oxygen and give epinephrine. Consider pneumothorax, hypovolemia, and airway obstruction if response is poor.
Traps
- Starting compressions before effective ventilation.
- Using 100% oxygen for preterm PPV.
- Prolonged stimulation instead of escalating to PPV.
- Giving epinephrine before correcting ventilation.