Birth: rapid assessment of the newborn
Newborn in the first minutes after birth. Team trained in newborn resuscitation, with equipment ready.
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Neonatal Resuscitation (NRP 2025)
Neonatal Resuscitation (NRP 2025): Birth: rapid assessment of the newborn → Term, good tone, and breathing or crying? → Routine care with parent; keep a...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Decision Term, good tone, and breathing or crying?
All three yes: vigorous newborn. Any no: initial steps at the radiant warmer.
- If Yes
- Yes to all
03Outcome Routine care with parent; keep assessing
Vigorous at birth, or breathing well with HR 100/min or more after initial steps. Vigorous at birth: defer cord clamping at least 60 s. Skin-to-skin, dry, keep 36.5-37.5°C.
- Defer cord clamping at least 60 s in a vigorous newborn
- Skin-to-skin with parent; dry; keep temperature 36.5-37.5°C
- Clear the airway only if obstructed
- Keep assessing breathing, tone and colour; start initial steps if they worsen
If No- No to any
04Action Preterm or not vigorous: warm, position airway, dry, stimulate
PPV, if needed, must start within 60 s of birth. Meconium-stained fluid: no routine suction or laryngoscopy.
- Cord, no immediate resuscitation needed: defer clamping (AHA at least 60 s; ANZCOR at least 30 s under 34 weeks). No cord milking under 28 weeks
- Warm under a radiant warmer; aim 36.5-37.5°C
- Under 32 weeks: polyethylene bag or wrap up to the neck without drying the body
- Head neutral; suction mouth then nose only if the airway is obstructed
- Meconium-stained fluid: do not delay PPV for suction; suction the trachea only if obstructed
- Dry and stimulate (term and late preterm)
05Decision Apnoea, gasping or HR below 100/min?
Assess after initial steps. HR by stethoscope; pulse oximeter on right hand; consider ECG.
- If Yes
- Apnoea, gasping or HR <100
06Action Apnoea, gasping or HR below 100/min: start PPV
Start within 60 s of birth. Known or suspected diaphragmatic hernia (CDH): no mask PPV; intubate early. Maternal opioids: ventilate; naloxone is not part of resuscitation.
- Rate 40-60/min (AHA range 30-60/min); inflation pressure 20-30 cm H2O (ANZCOR start: 30 term, 20-25 preterm)
- PEEP 5 cm H2O if the device allows; avoid PEEP over 8 cm H2O
- Initial O2: 21% at 35 weeks or more; 21-30% at 32-34+6 weeks; 30-100% below 32 weeks (ANZCOR: 21-30% for all under 35 weeks)
- Titrate O2 to preductal SpO2 (AHA): 2 min 65-70%, 3 min 70-75%, 4 min 75-80%, 5 min 80-85%, 10 min 85-95%
- Pulse oximeter on right hand; consider ECG for accurate HR
- Use a T-piece where available; keep a self-inflating bag as backup
07Decision HR still below 100/min after 30 s of PPV?
Check HR by stethoscope, oximeter or ECG. Rising HR is the best sign of effective ventilation.
- If Yes
- HR <100
08Warning HR below 100/min: check chest rise and correct ventilation
MR SOPA: Mask seal, Reposition head, Suction mouth and nose, Open mouth, raise Pressure in steps, Alternative airway.
- Laryngeal mask if 34 weeks or more (about 2 kg) and mask PPV fails
- Intubate if mask PPV fails or is prolonged, and before chest compressions
- Confirm ETT position with a colorimetric CO2 detector
09Decision HR below 60/min after 30 s of effective ventilation?
Effective ventilation: chest moves with each inflation, ideally via ETT or laryngeal mask.
- If Yes
- HR <60
10Action HR below 60/min despite 30 s effective PPV: start compressions
Intubate if not done (ETT preferred). Laryngeal mask only at 34 weeks or more if intubation is not possible or fails. Increase O2 to 100%. Call for help; prepare UVC and adrenaline.
- 3 compressions : 1 inflation; 90 compressions + 30 inflations/min
- Two-thumb technique on the lower third of the sternum; depth one-third of the chest AP diameter
- Attach ECG leads for HR
- Place an emergency UVC (IO if UVC not possible)
- Wean O2 from 100% as soon as HR recovers
11Decision HR still below 60/min after 60 s of compressions + PPV?
Check HR with a short pause (ECG preferred).
- If Yes
- HR <60
12Action HR below 60/min: give IV adrenaline (epinephrine)
Use adrenaline 0.1 mg/mL (1:10,000). Only 1 mg/mL at hand: dilute 1 mL to 10 mL with 0.9% sodium chloride first. Continue compressions and PPV. Repeat every 3-5 min while HR is below 60/min.
- IV/IO (UVC preferred): 0.01-0.03 mg/kg = 0.1-0.3 mL/kg of 0.1 mg/mL, then a 0.9% sodium chloride flush
- ETT only while getting IV access: 0.05-0.1 mg/kg = 0.5-1 mL/kg of 0.1 mg/mL
- No response to an ETT dose: give an IV dose as soon as access is ready
- Do not give more than 0.03 mg/kg IV per dose; higher doses are not recommended
13Decision HR still below 60/min after adrenaline?
Keep compressions, PPV and adrenaline every 3-5 min while HR is below 60/min.
- If Yes
- HR <60
14Action Still below 60/min: consider hypovolaemia and pneumothorax
Check ventilation and ETT position. Give volume if blood loss or shock is suspected. HR 60/min or more: stop compressions, continue PPV.
- 0.9% sodium chloride or O Rh-negative blood 10 mL/kg IV/IO over several minutes
- Repeat 10 mL/kg after reassessment if needed (AHA range 10-20 mL/kg)
- Pneumothorax: unequal breath sounds or sudden deterioration; emergency drainage may be needed
15Outcome No HR response despite all steps: discuss stopping at about 20 min
After all steps and reversible causes are addressed, discuss redirecting care with the team and family at about 20 min after birth. Remote site: phone a neonatologist first.
If No- HR 60 or more
16Action HR 60/min or more: stop compressions, continue PPV
Keep ventilating until HR is 100/min or more with effective breathing.
- Path rejoins step 07Shared downstream outcome
If No- HR 60 or more
- Path rejoins step 16Shared downstream outcome
If No- HR 60-99
17Action HR 60-99/min: continue effective PPV; reassess every 30 s
Keep correcting ventilation. Use an alternative airway if mask PPV is not working. Titrate O2 to SpO2 targets.
- Path rejoins step 07Shared downstream outcome
If No- HR 100 or more
18Action HR 100/min or more: continue PPV until breathing well, then wean
Wean PPV when spontaneous breathing is effective. Consider CPAP if breathing is laboured. Wean O2 to SpO2 targets.
19Outcome HR 100/min or more and breathing: post-resuscitation care
Monitor HR, SpO2 and temperature closely. Check blood glucose soon. Admit to the neonatal unit if more than initial steps were needed. Possible HIE: avoid hyperthermia; call a neonatologist early (cooling must start within 6 h).
- Keep temperature 36.5-37.5°C; avoid hyperthermia, especially if HIE is suspected
- Check blood glucose soon; keep above 2.5 mmol/L; avoid glucose boluses over 2 mL/kg of 10% glucose
- 35 weeks or more with moderate or severe HIE: discuss promptly with a neonatologist; start cooling within 6 h (NICU protocol); arrange retrieval if needed
- Cord blood gases in every resuscitated newborn
- Team debrief; talk with the family
If No- Breathing, HR 100 or more
20Decision Laboured breathing or persistent cyanosis?
Breathing, HR 100/min or more.
- If Yes
- Laboured or cyanosed
21Action Laboured breathing or cyanosis: SpO2, O2 as needed, consider CPAP
Known or suspected CDH: no mask CPAP or mask PPV; intubate early; orogastric tube on suction. Position and clear the airway. Pulse oximeter on right hand. Titrate O2 to preductal SpO2 targets. Apnoea or HR below 100/min: start PPV.
- Consider CPAP, especially under 32 weeks (ANZCOR: at least 5 cm H2O)
- Ongoing distress or O2 need: admit to the neonatal unit
- Path rejoins step 19Shared downstream outcome
If No- Breathing well
- Path rejoins step 03Shared downstream outcome
Guideline Source
Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for CPR and ECC
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- For newborns at birth and in the first hours after birth (older infants: paediatric life support). Does not cover periviability or anomalies other than CDH (e.g. airway obstruction, hydrops).
- AHA/AAP 2025 and ANZCOR differ on preterm starting O2, inflation pressures, SpO2 targets and preterm cord clamping; follow local neonatal policy.
- Special circumstances (upper airway obstruction, pleural effusion or hydrops, periviable birth) need a specialist plan; see ANZCOR 13.8 and 13.10.
- Assumes a trained team with neonatal equipment (T-piece or bag, laryngeal mask, ETT, UVC).
Contraindicated Populations
Infants beyond the newborn period (use paediatric life support)
Applicable Regions
USEUAUNZ
AU: ANZCOR Guidelines 13.1-13.10 apply. ANZCOR differs: start 21-30% O2 for all preterm under 35 weeks; start pressure 30 cm H2O term, 20-25 cm H2O preterm; SpO2 targets 1 min 60-70%, 2 min 65-85%, 3 min 70-90%, 4 min 75-90%, 5 min 80-90%, 10 min 85-90%; defer cord clamping at least 30 s under 34 weeks.
EU: ERC 2025 applies. ERC differs: start inflation pressure 25 cm H2O under 32 weeks, 30 cm H2O at 32 weeks or more; CPAP 6 cm H2O first for spontaneously breathing infants with distress; initial O2 21% at 32 weeks or more, at least 30% under 32 weeks; 5 initial inflations of 2-3 s; ETT adrenaline 0.1 mg/kg.
NZ: ANZCOR Guidelines 13.1-13.10 apply (see the AU note for differences from AHA/AAP 2025).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Neonatal Resuscitation (NRP 2025)?
The Neonatal Resuscitation (NRP 2025) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for CPR and ECC.
What guideline is the Neonatal Resuscitation (NRP 2025) based on?
This algorithm is based on Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for CPR and ECC (DOI: 10.1161/CIR.0000000000001367).
What are the limitations of the Neonatal Resuscitation (NRP 2025)?
Known limitations include: For newborns at birth and in the first hours after birth (older infants: paediatric life support). Does not cover periviability or anomalies other than CDH (e.g. airway obstruction, hydrops).; AHA/AAP 2025 and ANZCOR differ on preterm starting O2, inflation pressures, SpO2 targets and preterm cord clamping; follow local neonatal policy.; Special circumstances (upper airway obstruction, pleural effusion or hydrops, periviable birth) need a specialist plan; see ANZCOR 13.8 and 13.10.; Assumes a trained team with neonatal equipment (T-piece or bag, laryngeal mask, ETT, UVC).. Individual patient factors may require deviation from these recommendations.
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