4.2 Warm, Dry, Stimulate, and Position the Airway

Purpose of the Initial Steps

Once rapid evaluation sends the newborn to the radiant warmer, NRP’s initial steps of newborn care create the conditions for spontaneous breathing—or make it obvious within seconds that positive-pressure ventilation (PPV) is required. Initial steps are not a leisurely “settle the baby” routine. They are a compact package of thermal and airway interventions performed while the team starts the clock, calls out findings, and prepares to assess heart rate.

Core elements taught across NRP Provider materials:

1. Provide warmth and maintain normal temperature
2. Dry the infant (with important preterm exceptions) and remove wet linen
3. Stimulate breathing with tactile methods built into drying
4. Position the head and neck to open the airway (sniffing position)
5. Clear the airway if needed (mouth before nose when suctioning)

These steps often occur nearly simultaneously rather than as five isolated rituals. An experienced team warms, dries, positions, and stimulates in one fluid sequence while a second person prepares the PPV device and monitors.

Provide Warmth and Maintain Normal Temperature

Newborns—especially preterm infants—lose heat rapidly by evaporation, convection, conduction, and radiation. Hypothermia increases oxygen consumption, worsens acidosis, and is associated with poorer outcomes. Hyperthermia is also harmful. The practical target is normal temperature, commonly framed around approximately 36.5–37.5°C axillary in many unit protocols (know your local measurement method, but understand the NRP priority: prevent cold stress).

At the warmer:

• Pre-warm the radiant warmer before birth whenever possible
• Place the infant on a warm, dry surface
• Remove wet linen promptly after drying
• Use a hat for many infants once the head is dry (unit practice varies for very preterm thermal bundles)
• Avoid drafts, cold blankets, and prolonged exposure with an open warmer door and no heat
• For longer resuscitations, consider a temperature sensor/servo control when available so the team is not guessing

Warmth is not optional “comfort care.” It is a resuscitation intervention.

Dry—Except When Plastic Wrap Is the Preterm Strategy

For most late-preterm and term infants who need initial steps, thorough drying with warm towels does three jobs at once: removes amniotic fluid that drives evaporative heat loss, provides tactile stimulation, and lets you assess tone and respiratory effort more clearly. Discard wet towels; leaving the baby on wet linen undoes the thermal benefit.

Very preterm infants are different. Thin skin and a high surface-area-to-mass ratio make evaporative losses extreme. NRP and preterm-focused practice emphasize placing many very preterm newborns in a polyethylene plastic wrap or bag (often up to the neck) without routine towel drying, under a radiant warmer, sometimes with additional measures such as a thermal mattress and elevated room temperature. The plastic reduces evaporative heat loss while still allowing visualization and access to the airway. Do not ritualistically towel-dry a 25-week infant the same way you dry a term baby—that “complete drying” habit can worsen hypothermia.

Exam trap: “Always dry every baby completely before any other action.” The correct answer pattern recognizes the preterm plastic wrap exception while still requiring warmth and airway management.

Stimulate Breathing—Effectively, Briefly, and Safely

Tactile stimulation can restart breathing in infants who are in primary apnea or who simply need a prompt after a difficult birth. Stimulation methods taught in NRP are built into ordinary care:

• Drying the body
• Gently rubbing the back, trunk, or extremities

What stimulation is not:

• Slapping, shaking, or spanning the infant
• Prolonged rubbing for many minutes while the baby remains apneic
• Deep, painful stimulation that delays ventilation
• Relying on stimulation when the infant is gasping or has a heart rate that already indicates PPV

If the infant is apneic or gasping after brief initial steps, move to PPV. Stimulation is time-limited. Secondary apnea will not reliably reverse with more rubbing; those infants need inflation of the lungs.

Position the Airway: Sniffing Position

Airway patency depends on head and neck alignment. Place the newborn in the sniffing position: the neck is slightly extended so the face is parallel to the ceiling as if sniffing the air—not hyperflexed with the chin on the chest, and not overextended.

Practical tips:

• A small rolled towel under the shoulders can help achieve sniffing position, especially in infants with a large occiput
• Avoid extreme extension, which can obstruct the airway
• Re-check position continuously; helpers bump the head during equipment placement
• Once an advanced airway is placed later in the algorithm, positioning rules change with tube security—but for mask ventilation and initial steps, sniffing position is foundational

A perfectly dried baby with a flexed neck may still look “not breathing well” because the airway is kinked. Position before you blame the lungs.

Clear the Airway If Needed—Mouth Before Nose

Secretions can obstruct the airway, but routine deep suctioning of every newborn is not NRP practice. Clear the airway when secretions are visible and appear to obstruct, when meconium or blood is pooling, or when you need a clear path to ventilate effectively. Prefer a bulb syringe or suction catheter as indicated; for thick meconium obstructing the airway in a non-vigorous infant, suction may be needed as part of establishing an open airway—but routine intubation solely to suction meconium is not the default modern approach (covered in depth in the meconium chapter).

When suctioning:

1. Mouth first, then nose. Suctioning the nose first can make the infant gasp and aspirate oral material.
2. Be brief. Prolonged suction stimulates the vagus nerve and can cause bradycardia and apnea.
3. Avoid aggressive deep pharyngeal suction as a routine habit.
4. Do not let suction become a reason to delay PPV when the baby is apneic with a clear-looking airway.

Putting the Sequence Together at the Warmer

A high-functioning 20–30 second initial-steps sequence looks like this:

1. Baby placed on pre-warmed radiant warmer (or wrapped if very preterm)
2. Head placed in sniffing position
3. Dry and stimulate (or maintain plastic wrap thermal strategy for eligible very preterm infants)
4. Remove wet linen; keep warm
5. Quickly suction mouth then nose only if needed
6. Assess breathing and heart rate; if apnea/gasping or HR <100, start PPV without further delay

Scenarios That Test Judgment

Scenario 1 — Term, limp, thin secretions. Warm, dry, stimulate, sniffing position. If still apneic after brief steps → PPV. Mild secretions do not justify a long suction session first.

Scenario 2 — 26 weeks, non-vigorous. Plastic wrap, radiant heat, open airway, gentle stimulation as appropriate; avoid evaporative towel-drying ritual; prepare early respiratory support.

Scenario 3 — Copious blood/secretions with poor air entry. Brief mouth-then-nose clearing is appropriate, then ventilate. Do not suction for 60 continuous seconds.

Scenario 4 — Team rubs the back for 90 seconds while the baby remains apneic and HR is 70. Algorithm error: stimulation has exceeded its useful window; start PPV.

Integration With Monitoring

While performing initial steps, apply a pulse oximeter to the right hand or wrist when continuous saturation guidance is needed, and use an ECG monitor early when resuscitation progresses beyond brief initial care. Monitoring never replaces clinical assessment of breathing and heart rate, but it sharpens decisions about oxygen and next steps. Details of target SpO₂ ranges belong to the oximetry lesson; the initial-steps point is simpler: do not postpone life-saving ventilation to perfect the monitor display.

Master warmth, drying strategy, stimulation limits, sniffing position, and judicious suction. Those five skills convert a chaotic first minute into a controlled entry into either spontaneous breathing or effective PPV.