Skip to content

Neonatal Resuscitation

Category: Special Populations Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Most neonates transition to extrauterine life without intervention — they breathe, cry, and maintain adequate heart rate and tone. Approximately 10% require some level of resuscitation; fewer than 1% require extensive resuscitation. The decision to escalate interventions is based primarily on heart rate — it is the most important and reliable indicator of effective resuscitation.

The resuscitation sequence: Warm → Dry → Stimulate → Airway → Ventilate → Chest compressions → Medications

Key Points

  • Primary indicator of effective ventilation is improvement in heart rate — not chest rise or color
  • Heart rate assessment: precordium, umbilical stump (preferred), or brachial pulse — check for 6 seconds × 10 = rate per minute
  • Room air (not 100% O2) is the starting point for BVM ventilation in neonates who need it — oxygen concentration increased only if no improvement
  • Three-to-one ratio for neonatal CPR: 3 compressions : 1 ventilation = 90 compressions + 30 breaths/minute
  • Two-thumb encircling hands technique preferred for neonatal compressions
  • Do NOT give naloxone to infants of narcotic-addicted mothers — acute withdrawal can be fatal
  • Keep warm throughout resuscitation — neonates lose heat rapidly
  • Oxygen saturation goal at 10 minutes: 85–95%

Assessment

Immediately assess at birth: 1. Respiratory rate and effort (strong, weak/absent; regular or irregular) 2. Signs of respiratory distress (grunting, nasal flaring, retractions, gasping, apnea) 3. Heart rate (fast, slow, or absent) 4. Muscle tone (poor or strong) 5. Color/Appearance (central cyanosis, acrocyanosis, pallor, normal) 6. APGAR score at 1 and 5 minutes (documentation; does NOT guide immediate resuscitation decisions — see apgar-score) 7. Estimated gestational age (term, near term, premature)

History: - Date and time of birth - Prenatal history (care, substance abuse, multiple gestation, maternal illness) - Birth history (maternal fever, meconium, prolapsed or nuchal cord, maternal bleeding)

Neonatal Resuscitation Algorithm

Step 1: Initial Actions

  1. Clamp and cut cord if still attached
  2. Warm, dry, and stimulate:
  3. Wrap in dry towel or thermal blanket; cover head
  4. Rub back; flick soles of feet
  5. If strong cry, good tone, term gestation, regular breathing → place skin-to-skin with mother; cover with dry linen

Step 2: Assessment

Weak cry, respiratory distress, poor tone, or preterm: - Position airway (sniffing position — slight neck extension) - Clear airway if needed — suction mouth then nose if thick meconium or secretions WITH respiratory distress

Step 3: Based on Heart Rate

Heart rate >100 bpm: - Monitor for central cyanosis → blow-by oxygen as needed - Monitor for respiratory distress → initiate BVM ventilation with room air at 40–60 breaths/min if distress

Heart rate 60–100 bpm: - Initiate BVM ventilation with room air at 40–60 breaths/min - Primary indicator = improvement in heart rate - Use minimum rate and volume to achieve chest rise and HR improvement - If no improvement after 90 seconds → switch to oxygen until HR normalizes

Heart rate <60 bpm: - Ensure effective ventilations with supplementary oxygen and adequate chest rise - Initiate chest compressions: - Two-thumb encircling hands technique (preferred) - Depth: 1/3 AP diameter of chest - Rate: 3:1 ratio — 90 compressions + 30 breaths per minute - Establish IV/IO; consider fluid challenge with Normal Saline 10 mL/kg if hypovolemia suspected - If CPR + O2 BVM does not raise HR >60: Epinephrine 1:10,000 [0.01 mg/kg] IV/IO; repeat every 3–5 minutes - Check BGL: if <45 mg/dL → D10W [1 g/kg] IV/IO over 20 minutes - If non-addicted mother used narcotics within past 4 hours and infant has respiratory depression unresponsive to conventional resuscitation → Naloxone 0.1 mg/kg IV/IO - DO NOT give naloxone to infants of narcotic-addicted mothers (or if addiction status is uncertain) - Transport as soon as possible; contact Medical Control

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope: - Warm, dry, stimulate; clear airway if meconium/secretions + respiratory distress - BVM ventilation at 40–60 breaths/min - Room air initially; O2 if no improvement after 90 seconds - Minimum volume/rate to achieve chest rise and HR change - Primary indicator: improvement in heart rate - Oxygen saturation goal at 10 minutes: 85–95% - Pulse oximetry for prolonged resuscitative efforts

Chest compressions: - Initiated when HR <60 despite effective BVM with O2 - Two-thumb encircling technique preferred - 3:1 ratio: 90 compressions + 30 breaths/min

ALS medications: - EPINEPHRINE 1:10,000: 0.01 mg/kg IV/IO, repeat every 3–5 minutes (if CPR + BVM + O2 not raising HR >60) - BGL check: if <45 mg/dL → D10W 1 g/kg IV/IO over 20 minutes - NALOXONE 0.1 mg/kg IV/IO: ONLY if non-addicted mother, narcotics within 4 hours, respiratory depression unresponsive to resuscitation — NEVER in infants of narcotic-addicted mothers

Note: APGAR may be calculated for documentation but does NOT guide resuscitative decisions.

NREMT Relevance

  • Primary indicator of successful neonatal resuscitation: improvement in heart rate
  • BVM rate: 40–60 breaths/min for neonates
  • CPR ratio: 3:1 (not 30:2 used in adults)
  • Two-thumb encircling technique
  • Do NOT give naloxone to infant of addicted mother
  • APGAR at 1 and 5 minutes: Appearance, Pulse, Grimace, Activity, Respiration
  • Normal neonate HR >100 bpm; if <60 → CPR
  • Warmth: prevent hypothermia throughout resuscitation

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Neonatal Resuscitation (p. 23–24)