Initial Assessment and Airway/Breathing
The first three questions
At birth ask: Is the baby term? Is tone good? Is the baby breathing or crying? Three yes answers mean routine care with the mother - warm, dry, skin-to-skin, delayed cord clamping when appropriate. Any no answer moves the infant to the radiant warmer for the initial steps: provide warmth, dry, stimulate, position the head neutral with a slight sniffing position, and clear secretions only if they obstruct breathing.
The 30-second assessment
The initial steps should take about 30 seconds, then assess respirations and heart rate. Heart rate is best obtained with a 3-lead ECG when available, otherwise auscultate the precordium for 6 seconds and multiply by 10. Apply a preductal (right hand) pulse oximeter and use published minute-by-minute SpO2 targets rather than color. Persistent labored breathing with a heart rate ≥100 and SpO2 below target may be managed with free-flow oxygen or CPAP; apnea, gasping, or a heart rate under 100 means positive pressure ventilation.
Traps
Routine oropharyngeal/nasopharyngeal suctioning; prolonged or vigorous stimulation (beyond a few seconds is not therapeutic); waiting for a pulse oximeter before starting PPV; using skin color as the trigger; deep suction causing bradycardia.
Rule of thumb
The golden minute. If the infant is apneic, gasping, or has a heart rate under 100 after the initial steps, ventilation should be underway by about 1 minute of life - start PPV and place the oximeter concurrently, not before.