Neonatal Resuscitation Program (NRP) cheat sheet

Risk factors that trigger a resuscitation team: preterm <37 weeks or <2500 g, chorioamnionitis, maternal hypertension, IUGR, multiple gestation, emergency cesarean, non-reassuring fetal heart rate, opioid exposure.

At least one provider skilled in neonatal resuscitation attends every birth; anticipated high-risk deliveries need two or more skilled providers plus a team leader.

The antenatal briefing assigns roles (airway, compressions, medications, recorder), verifies equipment, and identifies how additional help is summoned.

Antenatal corticosteroids given before anticipated preterm birth at 24-34 weeks reduce respiratory distress syndrome, intraventricular hemorrhage, and neonatal death.

Delayed cord clamping for at least 30-60 seconds is recommended for term and preterm infants who do not require immediate resuscitation.

Equipment check: radiant warmer on, blended oxygen and air, T-piece or self-inflating bag with PEEP valve, suction, pulse oximeter, ECG leads, hats and wraps.

For infants <32 weeks prepare plastic wrap, thermal mattress, hat, heated humidified gases, and pulse oximetry for preductal saturation targeting.

Routine oropharyngeal or nasopharyngeal suctioning of the newborn at birth is not recommended, even when the fluid is meconium-stained.

Three rapid questions at birth: term gestation? good tone? breathing or crying? If all are yes, the infant receives routine care with the mother.

If any answer is no: warm, dry, stimulate, position the head neutral, clear secretions only if obstructing, then reassess breathing and heart rate.

Heart rate is best assessed with a 3-lead ECG when positive pressure ventilation or chest compressions are underway; auscultation is the fallback.

Apnea, gasping, or heart rate <100/min is the indication to begin positive pressure ventilation, ideally within the first minute of life.

Preductal SpO2 targets: 1 min 60-65%, 2 min 65-70%, 3 min 70-75%, 4 min 75-80%, 5 min 80-85%, 10 min 85-95%.

Heart rate ≥100/min with spontaneous breathing but labored breathing or persistent cyanosis: apply CPAP with blended oxygen and pulse oximetry.

Suction only for visible obstruction, mouth before nose, at ≤100 mmHg for no more than 5 seconds.

The Apgar score at 1 and 5 minutes describes condition and response but does not dictate any resuscitation step.

Start PPV for apnea or gasping, heart rate <100/min, or SpO2 below target despite free-flow oxygen.

Initial settings: peak inspiratory pressure 20-25 cm H2O, PEEP 5 cm H2O, rate 40-60 breaths/min, inspiratory time about 0.3-0.5 second.

Initial FiO2: 21% for infants ≥35 weeks; 21-30% for infants <35 weeks; titrate to the minute-of-life SpO2 target.

MR SOPA for inadequate chest rise: Mask adjustment, Reposition the head, Suction, Open the mouth, Pressure increase, Alternative airway.

A self-inflating bag delivers PEEP only with a PEEP valve; a T-piece device gives consistent PIP and PEEP and can provide free-flow oxygen.

Chest rise is the primary bedside sign of effective ventilation; a rising heart rate confirms the response.

If the heart rate remains <60/min after 30 seconds of effective PPV with 100% oxygen, begin chest compressions.

Consider intubation when PPV is prolonged beyond 4-5 minutes, mask ventilation is ineffective, or compressions are needed; confirm placement with an exhaled CO2 detector.

Indication: heart rate <60/min after 30 seconds of effective positive pressure ventilation with 100% oxygen.

Use the two-thumb encircling technique with hands around the chest and thumbs on the lower third of the sternum.

Compression depth is one third of the anteroposterior chest diameter, with full recoil allowed between compressions.

Ratio is 3 compressions to 1 breath, delivering about 90 compressions and 30 breaths per minute.

Use 100% oxygen during compressions and coordinate each breath with the compression cycle, pausing briefly for the breath.

Reassess heart rate about every 60 seconds, preferably by 3-lead ECG; stop compressions when heart rate is ≥60/min.

If heart rate stays <60/min after 60 seconds of compressions with effective ventilation and 100% oxygen, give epinephrine and obtain vascular access.

Keep interruptions to a minimum and do not transport the infant during compressions; summon additional help at the start.

Epinephrine IV/IO: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of the 0.1 mg/mL concentration) as a rapid push followed by a flush.

Epinephrine via endotracheal tube when no access exists: 0.05-0.1 mg/kg (0.5-1 mL/kg of 0.1 mg/mL), recognizing unreliable absorption.

Indication for epinephrine: heart rate <60/min after 60 seconds of chest compressions with effective ventilation and 100% oxygen.

Repeat epinephrine every 3-5 minutes while the heart rate remains <60/min.

Volume expansion: 10 mL/kg of 0.9% sodium chloride or type O Rh-negative blood over 5-10 minutes for suspected hypovolemia with poor response.

Emergency umbilical venous catheter: insert 2-4 cm, confirm free blood return, and use for epinephrine or fluids during resuscitation.

Intraosseous access is the alternative when umbilical venous access cannot be obtained quickly.

Sodium bicarbonate, atropine, and routine naloxone are not recommended during delivery-room resuscitation.

Maintain axillary temperature 36.5-37.5°C; both hypothermia and hyperthermia worsen outcomes after hypoxia-ischemia.

Therapeutic hypothermia for infants ≥36 weeks with moderate-to-severe hypoxic-ischemic encephalopathy: 33.5-34.5°C for 72 hours, started within 6 hours of birth.

Titrate oxygen to a preductal SpO2 of 90-95% and avoid sustained hyperoxia once the infant is stable.

Check blood glucose after resuscitation and treat hypoglycemia promptly; monitor for hypocalcemia and metabolic acidosis.

Monitor heart rate, respiratory rate, blood pressure, perfusion, urine output, and oxygenation continuously in the NICU.

Infants who received positive pressure ventilation or compressions require admission for continuous monitoring and staged reassessment.

Handoff to the NICU team includes antenatal history, interventions performed, responses, times, and current vital signs.

Support early parent-infant bonding and give the family clear, ongoing updates as the infant stabilizes.

The Apgar score is not used to decide whether to begin resuscitation or to judge its effectiveness.

If there is no heart rate after 10-15 minutes of continuous, effective resuscitation, redirecting to comfort care is reasonable and individualized.

At the limits of viability, antenatal counseling presents outcome ranges, uncertainties, and the parents' role in decisions.

Decisions to withhold or discontinue resuscitation weigh the infant's best interests, parental values, and local outcome data.

Pre-birth briefing and post-event debriefing improve team performance and reveal system gaps.

Closed-loop communication: the leader directs an order to a named person, who repeats it back and confirms completion.

Assign a recorder to document interventions and times so the leader can track the course of the resuscitation.

Use plain, respectful language and qualified interpreters when discussing prognosis or bereavement with families.

Meconium-stained fluid: no routine intrapartum suctioning; ventilate a non-vigorous infant; intubate and suction the trachea only if airway obstruction is suspected.

Congenital diaphragmatic hernia: avoid face-mask ventilation, intubate early, place an orogastric tube, and use the lowest effective inflation pressure.

Preterm <32 weeks: plastic wrap or bag, thermal mattress, hat, heated humidified gases, PEEP 5-6 cm H2O, and gentle tidal volumes.

Pneumothorax: sudden deterioration with asymmetric breath sounds and chest movement; treat with needle aspiration at the second intercostal space in the midclavicular line.

Hydrops fetalis: anticipate pleural or pericardial effusions and assign extra personnel and equipment before delivery.

Suspected opioid-induced respiratory depression: ventilate first; naloxone is given only after effective ventilation is established.

Upper airway obstruction such as micrognathia: jaw thrust, prone positioning, and early intubation by the most experienced provider.

Multiple gestation: provide a separate team, warmer, and equipment for each infant.