6.1 NRP Cord Management, Initial Steps & Ventilation

6.1 NRP Cord Management, Initial Steps & Ventilation

Neonatal resuscitation is ventilation-centered. Bradycardia at birth is usually the consequence of inadequate lung inflation and gas exchange, so the first test of every intervention is whether the heart rate rises. The 9th edition incorporates the 2025 AHA/AAP neonatal resuscitation guidance.

Preparation, Cord Management & Initial Assessment

Before each delivery, identify perinatal risk, assign a leader and roles, verify equipment, choose appropriately sized interfaces, and plan thermoregulation and cord management. At least one clinician whose sole responsibility is the newborn must be able to provide assisted ventilation.

For term and preterm newborns who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds is generally appropriate while drying, stimulation, and ongoing assessment occur. For nonvigorous infants born at 35 weeks or later, intact cord milking may be reasonable compared with immediate clamping when the local team is trained. Do not milk the cord in infants born before 28 weeks because of concern for severe intraventricular hemorrhage. When immediate advanced resuscitation is required, coordinate cord timing with obstetrics and follow the institutional pathway.

Ask whether the infant is term, has good tone, and is breathing or crying. A well-transitioning infant receives warmth, skin-to-skin care, airway positioning, and observation. A compromised infant moves to a radiant warmer. Warm, position the head in a neutral sniffing posture, dry when appropriate, stimulate, and clear the airway only if secretions appear to obstruct breathing or ventilation. Routine suctioning is not recommended, including through meconium-stained fluid. Very preterm infants need plastic wrap or bag, a cap, a thermal mattress when available, warmed humidified gas, and a target temperature of 36.5 to 37.5 C.

Assisted Ventilation During the First Minute

Provide assisted ventilation within 60 seconds when the infant is apneic, gasping, or remains below 100 beats/min after the initial steps. Begin at 30 to 60 inflations/min with an inflation time of about 0.5 to 1 second. An initial peak inflation pressure of 20 to 30 cm H2O is reasonable, then titrate to effective but not excessive inflation. PEEP may help establish functional residual capacity. The most important response is a rising heart rate; chest movement and exhaled carbon dioxide provide supporting evidence.

Initial oxygen by gestational age

Place a preductal pulse-oximeter sensor on the right hand or wrist as soon as respiratory support or oxygen is needed, and titrate rather than leaving a fixed concentration. The familiar transitional preductal targets rise from approximately 60%-65% at 1 minute to 85%-95% at 10 minutes. Avoid both uncorrected hypoxemia and unnecessary hyperoxia.

Delivery-Room Equipment Check

The prebrief converts risk into equipment and roles. Confirm the radiant warmer, temperature probe, towels or polyethylene wrap, suction with adjustable pressure, appropriately sized masks, T-piece and self-inflating backup bag, blender, flow source, pulse oximeter, ECG leads, laryngoscope or video laryngoscope, tubes, laryngeal mask, colorimetric carbon-dioxide detector, UVC kit, epinephrine, saline, and volume-expansion supplies. Set the blender and pressures before birth, occlude the patient outlet to confirm delivered pressure, and test the suction source.

During ventilation, one team member watches the chest and mask, another watches heart rate, and the leader announces the reassessment interval. If heart rate rises, ventilation is working even when chest movement is subtle. If heart rate does not rise, stop adding oxygen as the sole response and troubleshoot ventilation. A right-hand or wrist oximeter is preductal; a foot reading can lag or differ during ductal shunting.

Brief case

A 33-week infant is apneic after initial steps. Begin assisted ventilation promptly with blended 21%-30% oxygen, place the preductal sensor, and titrate from response. If heart rate remains 70/min and the chest does not move, correct mask and airway mechanics before considering compressions. The heart-rate threshold alone is insufficient when ventilation has not yet inflated the lungs.

Oxygen-titration trap

Initial concentration and subsequent titration are separate decisions. Starting a 36-week infant in air is reasonable, but persistent hypoxemia after effective ventilation is a reason to increase oxygen toward the preductal target. Starting a 29-week infant at 30% does not mean leaving the blender fixed; titrate both upward and downward from the right-hand saturation and heart-rate response. During compressions, 100% oxygen may be reasonable, followed by prompt reduction once spontaneous circulation returns.