7.3 Neonatal Resuscitation Program (NRP) 9th Edition Core Algorithm

7.3 Neonatal Resuscitation Program (NRP) 9th Edition

Core Focus: Most newborns transition without intervention. When support is needed, ventilation of the lungs is the decisive step. Resuscitation follows physiology and heart-rate response, not an APGAR score.

Anticipation and initial assessment

Before every birth, identify risk, brief roles, check the warmer and ventilation equipment, and confirm an escalation plan. At birth ask: term gestation? good tone? breathing or crying? If yes, provide warmth, skin-to-skin care, and ongoing observation. If no, move to the warmer and perform initial steps: warm, position the head neutrally, dry, stimulate, and clear secretions only if obstructing.

Use auscultation and ECG when available for rapid heart-rate assessment. Place a preductal pulse-oximetry sensor on the right hand or wrist when resuscitation is anticipated, oxygen is used, PPV continues, or cyanosis persists. Normal saturation rises gradually after birth, so visible cyanosis alone is imprecise.

Positive-pressure ventilation

Begin PPV for apnea, gasping, or heart rate below 100/min after initial steps. For term and late-preterm infants, begin with 21% oxygen. For 32–35 weeks, 21%–30% is reasonable; very preterm starting concentration is individualized within the current guideline range and titrated with preductal oximetry.

Use 30–60 inflations/min with enough pressure to produce gentle chest movement and rising heart rate. Apply PEEP when the device and protocol support it. After about 30 seconds of ventilation, a rising heart rate is the best sign of effectiveness.

If the chest does not move or heart rate does not improve, perform ventilation-corrective steps: adjust the mask, reposition the airway, suction only if obstruction is suspected, open the mouth, increase pressure cautiously, and use an alternative airway. A laryngeal mask is an option for an infant of appropriate size when face-mask ventilation is ineffective and intubation is not feasible or successful.

Oxygen-saturation targets

Use the NRP minute-specific preductal targets rather than immediately forcing saturation to adult levels:

Titrate oxygen to the target and clinical response. Excess oxygen contributes to oxidative injury; inadequate oxygenation also harms.

Compressions and epinephrine

If the heart rate remains below 60/min after at least 30 seconds of effective ventilation that moves the chest, coordinate compressions and ventilation at a 3:1 ratio. Use the two-thumb encircling-hands technique over the lower third of the sternum, compress about one-third of the anterior-posterior chest diameter, insert an advanced airway, and increase oxygen to 100% while compressions are underway. The coordinated pattern produces 90 compressions and 30 breaths per minute.

Reassess after 60 seconds. If the heart rate remains below 60/min, give epinephrine by an intravascular route, 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 0.1 mg/mL concentration) and repeat according to the algorithm while optimizing ventilation/compressions. Endotracheal epinephrine may be used while access is obtained but is less reliable and uses a different dose. Flush intravascular medication per protocol.

Consider hypovolemia when there is shock, pallor, weak pulses, and a history of blood loss; give volume only when indicated. Evaluate pneumothorax, equipment failure, airway obstruction, and other reversible causes when response is poor.

Post-resuscitation care

An infant requiring prolonged PPV, compressions, epinephrine, or high oxygen needs monitored post-resuscitation care. Reassess glucose, temperature, oxygenation, ventilation, perfusion, neurologic status, and organ function. Avoid hyperthermia. Screen eligible infants with evidence of hypoxic-ischemic encephalopathy promptly for controlled therapeutic hypothermia. Debrief the team and communicate clearly with the family.

Cord management, temperature, and special populations

For a vigorous term or preterm newborn who does not require immediate resuscitation, delayed cord clamping for at least 30 seconds is generally beneficial when the obstetric and neonatal situation permits. When resuscitation is needed, follow the team's cord-management protocol; urgent effective ventilation should not be delayed while debating cord timing.

Preterm infants require additional thermal protection: increase room warmth, use a plastic wrap or bag without drying for very preterm infants, apply a hat and thermal mattress as indicated, and monitor temperature continuously. Avoid both hypothermia and hyperthermia. Use preterm-sized masks and pressure devices, and titrate oxygen with preductal saturation because both oxygen deficiency and excess are harmful.

For diaphragmatic hernia, avoid bag-mask ventilation that inflates the bowel; intubate and decompress the stomach under the specialty pathway. For a newborn with an open neural-tube defect or exposed abdominal contents, protect the lesion while maintaining airway, warmth, and perfusion. These modifications do not change the central principle: establish effective ventilation and assess heart-rate response.

Team performance and family support

Use closed-loop communication: state the heart rate, intervention, dose/concentration, and response aloud; repeat back critical instructions; and record time points. After resuscitation, conduct a brief team debrief to identify equipment, role, or communication improvements. Give the family an honest, plain-language account of what occurred and what monitoring is next.