Neonatal Resuscitation (NRP 2025)

Algorithm Steps

1. ▶

   Start

   Birth - Initial Assessment

   Newborn delivered - rapid evaluation needed

   1. ◆

      Decision

      Initial Questions

      Assess newborn transition

      • Term gestation?
      • Good tone?
      • Breathing or crying?
      1. ✓

         Outcome

         Routine Care

         Newborn is transitioning normally

         • Provide warmth (skin-to-skin with parent)
         • Clear airway if needed (suction mouth then nose)
         • Dry and ongoing evaluation
         • Delayed cord clamping (≥60 seconds)
      2. ●

         Action

         Initial Stabilization Steps

         Perform within 30 seconds

         • Warm: Radiant warmer, plastic wrap if preterm <32 wks
         • Position: Head in neutral/sniffing position
         • Clear airway: Suction if secretions obstructing
         • Dry: Stimulate by drying (term infants)
         • Consider delayed cord clamping if feasible
         1. ◆

            Decision

            Assess Breathing & HR

            Evaluate after initial steps

            • Is baby breathing/crying?
            • Heart rate >100 bpm? (assess by auscultation or pulse oximetry)
            1. ●

               Action

               Positive Pressure Ventilation (PPV)

               Apnea, gasping, or HR <100 - start PPV

               • Rate: 40-60 breaths/min
               • Pressure: Start 20-25 cm H2O (term)
               • Use room air initially for term (21% O2)
               • Use 21-30% O2 for preterm <35 weeks
               • Assess chest rise - adjust as needed
               • Apply pulse oximeter to right hand
               1. ⚠

                  Warning

                  MR SOPA - Ventilation Corrective Steps

                  If chest not rising, correct technique

                  • M - Mask adjustment (ensure seal)
                  • R - Reposition airway (neutral position)
                  • S - Suction mouth then nose
                  • O - Open mouth slightly
                  • P - Pressure increase (up to 40 cm H2O)
                  • A - Alternative airway (ETT or LMA)
                  1. ◆

                     Decision

                     HR <60 after 30 sec PPV?

                     Reassess HR after adequate ventilation

                     • Ensure effective ventilation (MR SOPA)
                     • Consider intubation
                     • If HR remains <60 despite effective ventilation...
                     1. ✓

                        Outcome

                        Post-Resuscitation Care

                        Monitor and stabilize

                        • Continue monitoring HR, SpO2
                        • Maintain normothermia
                        • Check glucose
                        • Consider therapeutic hypothermia if moderate/severe HIE
                        • Transfer to NICU
                     2. ●

                        Action

                        Chest Compressions + PPV

                        HR <60 despite effective ventilation

                        • Intubate if not already done
                        • Increase O2 to 100%
                        • Two-thumb technique (preferred)
                        • Compress lower 1/3 of sternum
                        • Depth: 1/3 AP diameter of chest
                        • Ratio: 3 compressions : 1 breath (90:30/min)
                        • Coordinate with ventilation
                        1. ◆

                           Decision

                           HR <60 after 60 sec CPR?

                           Reassess after 60 seconds of coordinated CPR

                           1. ●

                              Action

                              Epinephrine Administration

                              HR <60 despite PPV and compressions

                              • IV/IO route (preferred): 0.01-0.03 mg/kg (1:10,000)
                              • UVC is preferred IV access
                              • ETT route (if no IV): 0.05-0.1 mg/kg (1:10,000)
                              • May repeat every 3-5 minutes
                              • Consider volume expansion if hypovolemia suspected
                              1. ●

                                 Action

                                 Volume Expansion

                                 If blood loss or hypovolemia suspected

                                 • Normal saline or O-negative blood
                                 • 10 mL/kg IV over 5-10 minutes
                                 • May repeat if needed