Neonatal Resuscitation Program (NRP) common mistakes
Neonatal Resuscitation Program (NRP) · Understand the traps and how to avoid them.
Arriving at the delivery room and immediately turning attention to the baby, without voicing a structured pre-brief: no statement of gestational age/risk factors, no assigned roles (airway, compressions, medications/umbilical line, timekeeper/recorder), no identified team leader, and only a partial equipment check.
Candidates treat the pre-brief as paperwork and rush to the 'real' skill; under time pressure, role ambiguity feels wasteful rather than protective, and equipment gaps (no T-piece, wrong-sized mask, empty oxygen blender) go unnoticed until they matter.
What to do instead
Before every birth with anticipated resuscitation, verbalise a 30-second script: 'Preterm 30 weeks, anticipate PPV and possible intubation - [name] airway, [name] compressions and UVC, [name] leader, [name] recorder; who is calling for extra help if needed.' Then physically test the bag/T-piece, blender, suction, and appropriate mask sizes. Practise the script aloud until it is automatic.
Continuing to dry, rub, reposition and re-stimulate a baby who is apnoeic or gasping, or who has a heart rate below 100, well past the first minute, instead of starting positive pressure ventilation.
The 'warm, dry, stimulate' sequence is the most rehearsed set of steps, so under stress candidates repeat it and mistake ongoing stimulation for active treatment; a crying baby later makes them believe they were 'almost there'.
What to do instead
Anchor on a hard clock: if the baby is not breathing effectively or the HR is under 100 at about 30 seconds of life after initial steps, PPV must be started - target ventilation within the first minute. Say the time out loud ('30 seconds, apnoeic, starting PPV') so the team holds you to it.
Assessing heart rate by feeling/palpating the umbilical cord, by visualising chest movement, or by waiting for a pulse oximeter signal before deciding whether to ventilate; accepting a flat oximeter trace as 'HR zero'.
In a crowded delivery room, palpation feels faster than finding a stethoscope, and the oximeter screen is the most visible monitor; candidates forget that oximetry is unreliable with poor perfusion and cold, wet skin.
What to do instead
Use a stethoscope over the left chest as the primary HR assessment (counting for 6 seconds and multiplying by 10), or apply a 3-lead ECG when oximetry is unreliable. Apply the preductal oximeter on the right hand/wrist but never delay PPV waiting for it. Announce the HR audibly to the team.
Delivering PPV without ever confirming chest rise, or seeing no chest movement and continuing with the same technique and pressure instead of working through MR SOPA (Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway).
Candidates equate 'squeezing the bag' with 'ventilating'; they watch the monitor rather than the chest, and each individual corrective step seems too small to matter, so the sequence is not applied systematically.
What to do instead
Within the first few breaths, look at the chest wall and say aloud whether there is rise. If not, verbalise and complete MR SOPA in order, within seconds, and escalate to a laryngeal mask or endotracheal tube if the face mask still fails. Reassess chest rise after each corrective step.
Ventilating at a rate well above 40-60 breaths/min, forgetting to set PEEP, using a self-inflating bag without a pressure manometer, or setting a PIP that is never adjusted, and simultaneously giving 100% oxygen to a 29-week infant from the first breath or never titrating oxygen at all.
Bagging fast feels effective and 'keeps the baby pink'; free-flow or self-inflating bags give no feedback, and candidates default to the highest oxygen concentration because it is what they associate with emergency care.
What to do instead
Use a T-piece resuscitator (or a bag with a manometer) with set PIP of about 20-25 cm H2O and PEEP of 5, count the rate out loud alongside a partner, and target 40-60/min. Start with 21% oxygen for 35 weeks and above, and 21-30% for under 35 weeks, then titrate against the preductal SpO2 targets using a blender.
Starting chest compressions before 30 seconds of effective PPV has been delivered (or with an HR between 60 and 100), or conversely delaying compressions in a baby whose HR stays under 60; then using a 15:2 or 30:2 ratio, one-handed technique, or failing to increase oxygen to 100% and to reassess every 60 seconds.
Compressions feel like the decisive intervention, so candidates jump to them when anxious; the 3:1 neonatal ratio and two-thumb technique are counterintuitive to anyone trained in adult or paediatric CPR.
What to do instead
State the gate explicitly: HR under 60 after 30 seconds of effective ventilation (with an alternative airway in place if possible) is the trigger. Then use two-thumb encircling technique, one-third anterior-posterior depth, 90 compressions with 30 breaths per minute (3:1, counting 'one-and-two-and-three-and-breath'), 100% oxygen, and pause every 60 seconds to auscultate and announce the HR.
Giving epinephrine before effective ventilation and compressions have been established, or with the wrong concentration/dose/route (e.g., the 1 mg/mL concentration, or an ET dose without follow-up IV access), omitting the saline flush, or giving a 10 mL/kg fluid bolus to every baby who fails to respond without evidence of hypovolaemia.
Epinephrine is memorised as 'the drug for slow heart rate', so it is reached for during a bradycardia caused by inadequate ventilation; dose concentrations are easy to confuse under stress, and a volume bolus feels like a harmless rescue.
What to do instead
Sequence-gate the drug: HR under 60 despite 30 seconds of compressions with effective ventilation and 100% oxygen. Give 0.1-0.3 mL/kg of the 0.1 mg/mL solution IV (umbilical venous catheter preferred; ET 0.5-1 mL/kg only if no access), flush with 0.5-1 mL saline, and repeat every 3-5 minutes. Restrict 10 mL/kg normal saline or blood over 5-10 minutes to babies with history or signs of blood loss and poor response.
Handing over a resuscitated baby without checking and documenting glucose, without a temperature-management plan (including assessing eligibility for therapeutic hypothermia within the 6-hour window for infants of 36 weeks or more with encephalopathy), and without defined SpO2 and blood pressure targets or a clear escalation plan.
Adrenaline from the resuscitation makes the team want to 'close the case' at return of a normal heart rate; post-resuscitation care is perceived as NICU territory rather than a delivery-room responsibility.
What to do instead
Use a post-resuscitation checklist before transfer: glucose checked and treated if low, temperature monitored with a target of 36.5-37.5°C, eligibility for cooling actively assessed and the clock noted, preductal SpO2 targets and blood pressure goals documented, and a named clinician informed. Hand over verbally with a structured summary.
Skipping the structured team debrief after a resuscitation and leaving parents without a timely, plain-language explanation of what happened to their baby, or briefing them only in technical jargon after the fact.
Debriefs feel optional when the next delivery is waiting, and clinicians fear saying the wrong thing or pre-empting outcome; the emotional discomfort of talking to parents immediately after a resuscitation leads to postponement.
What to do instead
Make debrief a fixed step in the resuscitation workflow: a 2-3 minute huddle covering what went well, what to change, and any equipment or role issues, led by the team leader and logged. Provide parents a short, jargon-free account ('your baby needed help breathing; the heart rate was low; here is what we did and what happens next') within the hour, and offer a follow-up conversation.
Applying general rules without situational adjustment: routinely intubating and suctioning every meconium-stained infant regardless of vigour, managing an extremely preterm infant without a thermoregulation plan (plastic wrap, hat, thermal mattress, warmed gases), or missing a pneumothorax or congenital diaphragmatic hernia when ventilation suddenly deteriorates.
Old teaching about meconium and a single 'standard newborn' mental model persist; candidates rehearse the common pathway far more than the special-circumstance branches, so deterioration is attributed to poor technique rather than a mechanical problem.
What to do instead
Apply the situational add-ons explicitly: suction only if the airway is obstructed in a meconium-stained infant (no routine intubation for a non-vigorous baby); for infants under 32 weeks use plastic wrap, hat, warm gases and blended oxygen, and consider early CPAP; when ventilation abruptly fails despite MR SOPA, examine for asymmetric chest movement and shift of heart sounds (pneumothorax) and for scaphoid abdomen with distant heart sounds (CDH), and treat accordingly.