2.1 Delivery-Room Management & Neonatal Resuscitation

The NRP Algorithm: A Systematic Approach

The Neonatal Resuscitation Program (NRP), developed jointly by the American Academy of Pediatrics (AAP) and American Heart Association (AHA), provides the internationally recognized algorithm for managing the newly born infant at delivery — the framework tested throughout the delivery-room portion of the ABHS Pediatrics Part 1 written exam. Roughly 85% of term newborns begin spontaneous breathing within the first 10-30 seconds of life, about 10% need some stimulation or assisted ventilation, and only around 1% require extensive measures such as chest compressions or medications. The algorithm is built around a rapid, repeated cycle — assess, decide, act — with reassessment approximately every 30 seconds.

The Golden Minute

Within 60 seconds of birth (the "Golden Minute"), the team must complete the initial steps and, if indicated, establish effective ventilation. Three rapid questions guide the first decision at birth: (1) Is the infant term gestation? (2) Does the infant have good muscle tone? (3) Is the infant breathing or crying? If the answer to all three is yes, the infant stays with the mother for routine care. If any answer is no, the infant is moved to a radiant warmer for the initial steps.

Initial Steps: Warm, Dry, Stimulate

The initial steps are: providing warmth (a radiant warmer, or for infants under 32 weeks, a polyethylene occlusive wrap plus a warmed cap to prevent hypothermia), positioning the head in a neutral "sniffing" position to open the airway, clearing secretions only if the airway is obstructed or PPV is anticipated, drying the infant (omitted for very preterm infants placed directly under the polyethylene wrap), and tactile stimulation such as rubbing the back or flicking the soles of the feet. These steps should take no more than about 30 seconds. Afterward, the two vital signs that drive every subsequent decision are respirations and heart rate, assessed primarily by auscultating the precordium, since palpating the umbilical cord tends to underestimate the true heart rate.

Positive-Pressure Ventilation (PPV)

Positive-pressure ventilation (PPV) is indicated if, after the initial steps, the infant is apneic, gasping, or has a heart rate below 100 bpm. PPV is the single most important intervention in neonatal resuscitation — the exam repeatedly tests that ventilating the lungs, not starting compressions or giving epinephrine, is the priority action in a poorly responding newborn. PPV is delivered at 40-60 breaths per minute, and its effectiveness is judged first by a rising heart rate and then by visible chest rise. If the heart rate does not increase and the chest is not moving, the MR SOPA corrective sequence applies: Mask adjustment, Reposition the airway, Suction the mouth and nose, Open the mouth, increase Pressure, and consider an Alternative airway (laryngeal mask or endotracheal tube). Resuscitation of a term infant begins with room air (21% oxygen); preterm infants begin with a blended low concentration (21-30%), titrated by pulse oximetry targets specific to minutes of life rather than starting at 100% oxygen.

Chest Compressions

Chest compressions begin if the heart rate remains below 60 bpm despite 30 seconds of PPV confirmed to be effective (usually delivered via endotracheal tube by this point, to be certain ventilation is truly adequate). Compressions use the two-thumb, encircling-hands technique over the lower third of the sternum, to a depth of about one-third the anterior-posterior chest diameter. The compression-to-ventilation ratio is 3:1 (three compressions, one breath), producing a combined rate of 120 events per minute — 90 compressions and 30 breaths. Supplemental oxygen is increased to 100% once compressions start. Heart rate is reassessed roughly every 60 seconds; if it remains below 60 bpm despite adequate ventilation and compressions, intravenous (preferably umbilical venous) epinephrine 0.01-0.03 mg/kg of the 1:10,000 concentration is the next step. If there is suspected blood loss (pale skin, weak pulses, poor response to resuscitation), a volume expander such as normal saline 10 mL/kg given slowly over 5-10 minutes via umbilical venous catheter is indicated before or alongside epinephrine.

APGAR Score

The APGAR score, devised by Dr. Virginia Apgar in 1952, is a standardized, reproducible way of reporting a newborn's condition to the care team — a communication and prognostic tool, not a guide for resuscitation decisions, which instead follow respirations and heart rate assessed continuously rather than waiting for a scheduled score. The five components, each scored 0-2, spell the mnemonic APGAR:

Scores are assigned at 1 and 5 minutes of life; if the 5-minute score is below 7, additional scores are assigned every 5 minutes up to 20 minutes while resuscitation continues. A frequent exam trap: a low score is nonspecific — it can reflect prematurity, maternal sedation, congenital anomalies, or true asphyxia, and a normal score does not exclude significant acidemia. The APGAR score should never be used alone to diagnose birth asphyxia or to predict long-term neurologic outcome.

Meconium-Stained Liquor

When meconium-stained amniotic fluid is present, current guidance no longer recommends routine intrapartum oropharyngeal or nasopharyngeal suctioning on the perineum, nor routine tracheal suctioning of a vigorous infant. Management instead follows the infant's condition at birth: a vigorous infant (good tone, strong respiratory effort, heart rate above 100) receives routine initial steps. A non-vigorous infant (poor tone, weak or absent respirations) receives the initial steps and PPV exactly as any depressed newborn would; direct tracheal suctioning is reserved only for a non-vigorous infant with evidence of airway obstruction during PPV, not performed routinely beforehand.

Cord Clamping

For vigorous term and preterm infants who do not need resuscitation, delayed cord clamping (DCC) for at least 30-60 seconds after birth improves iron stores in term infants and reduces the risk of intraventricular hemorrhage in preterm infants. When DCC is not feasible, umbilical cord milking is a reasonable alternative for infants at 28 weeks gestation or beyond, but should be avoided in extremely preterm infants under 28 weeks because of an association with increased severe intraventricular hemorrhage risk.