The Neonatal Resuscitation Program (NRP) will help you learn the cognitive, technical, and teamwork skills that you need to resuscitate and stabilize newborns. Although most newborns make the cardiorespiratory transition to extrauterine life without intervention, many require assistance to begin breathing, and a small number of them require extensive intervention. After birth, approximately 4% to 10% of term and late-preterm newborns will receive positive pressure ventilation (PPV), while only 1 to 3 per 1000 will receive chest compressions or emergency medications. Because the need for assistance cannot always be predicted, teams need to be prepared to provide these lifesaving interventions quickly and efficiently at every birth.¹

In an adult, cardiac arrest is most often a complication of trauma or existing heart disease. It is caused by a sudden arrhythmia that prevents the heart from effectively circulating blood. As circulation to the brain decreases, the adult victim loses consciousness and stops breathing. At the time of arrest, the oxygen and carbon dioxide (CO₂) content of blood is usually normal. During adult cardiopulmonary resuscitation (CPR), chest compressions are used to maintain circulation until electrical defibrillation or medications restore cardiac function.¹ In contrast, most newborns requiring CPR have a healthy heart. When a newborn requires resuscitation, it is usually caused by a problem with respiration leading to inadequate gas exchange.¹

Respiratory failure may occur either before or after birth. Before birth, fetal oxygenation function is performed by the placenta. If the placenta is functioning normally, oxygen is transferred from the mother to the fetus and CO₂ is removed. When placental oxygenation fails, the fetus receives an insufficient supply of oxygen to support normal cellular functions, and CO₂ cannot be removed. The blood level of acid increases as cells attempt to function without oxygen and CO₂ accumulates. Fetal heart rate monitoring may show a decrease in variability with fetal heart rate decelerations, absent variability, or sinusoidal pattern. If placental respiratory failure persists, the fetus will make a series of gasps, followed by apnea and bradycardia. If the fetus is born in the early phase of respiratory failure, tactile stimulation may be sufficient to initiate spontaneous breathing and recovery. If the fetus is born in a later phase of respiratory failure, stimulation will not be sufficient, and the newborn will require assisted ventilation for recovery. The most severely affected newborns may require chest compressions and epinephrine to allow the compromised heart muscle to restore circulation. At the time of birth, you may not know if the baby is in an early or a late phase of respiratory failure. After birth, respiratory failure occurs if the baby does not initiate or cannot maintain effective breathing effort. In either situation, the primary problem is a lack of gas exchange and the focus of the neonatal resuscitation is effective ventilation of the baby’s lungs.¹

The NRP Flow Diagram (Figure 40-1) describes the steps that you will follow to evaluate and resuscitate a newborn.¹ Even though some interventions or required actions (rectangles on the diagram) are provided simultaneously and/or quickly, it is very important to go through the assessments (diamond shape on diagram) and adequately performed.

INITIAL ASSESSMENT

The first NRP responder will determine if the newborn can remain with the mother or should be moved to a radiant warmer for further evaluation.¹ There should be a healthcare staff member assigned to evaluate newborns on all deliveries, usually a nurse certified in NRP training. Nonvigorous newborns with meconium-stained fluid do not require routine intubation and tracheal suctioning; however, meconium-stained amniotic fluid is a perinatal risk factor that requires the presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation.¹ Current evidence suggests that cord clamping should be delayed for at least 30 to 60 seconds for most vigorous term and preterm newborns. If placental circulation is not intact, such as after a placental abruption, bleeding placenta previa, bleeding vasa previa, or cord avulsion, the cord should be clamped immediately after birth. There is insufficient evidence to recommend a specific timed approach to cord clamping for newborns that require resuscitation at birth.¹

AIRWAY

The team of responders will perform the initial steps to establish an airway and support spontaneous respiration.¹ Resuscitation of newborns ≥35 weeks gestation begins with 21% oxygen, which is equivalent to room air. Resuscitation of newborns <35 weeks gestation begins with 21% to 30% oxygen. If a baby is breathing, but oxygen saturation is not within target range (Preductal SpO₂), free flow oxygen administration may begin at 30%. Adjust the flow meter to 10 L/min. By using the blender, adjust O₂ concentration as needed to achieve the oxygen saturation target.¹

After completing the initial steps, PPV is indicated if a newborn is apneic or gasping, or the heart rate is <100 beats/minute. A trial PPV may be considered if the baby is breathing and the heart rate is >100 beats/minute, but oxygen saturation cannot be maintained within target range despite free-flow oxygen or Continuous Positive Airway Pressure (CPAP). When PPV begins, consider using an electronic cardiac monitor for accurate assessment of the heart rate. The most important indicator of successful PPV is a rising heart rate. If the heart rate does not increase, PPV that inflates the lungs is shown by chest movement with ventilation. After intubation or laryngeal mask placement, inflation of the lungs is assessed by chest movement, and bilateral breath sounds with ventilation.¹