NRP Key Points and Flow Diagram

The 10 NRP Key Behavioral Skills are:

Know your environment.
Anticipate and plan.
Assume the leadership role. 
Communicate effectively. 
Delegate workload optimally. 
Allocate attention wisely.
Use all available information. 
Use all available resources.
Call for help when needed.  
Maintain professional behavior. 

Scientific Changes:

1. These are no longer “optional” in the birth setting, and should be available for every birth: 
     a. Compressed air source 
     b. Oxygen blender to mix oxygen and compressed air with flowmeter 
     c. Pulse oximeter for neonatal use and oximeter probe 
     d. Laryngeal mask airway LMA (size 1) 

2. There are 2 levels of post-resuscitation care (instead of 3 levels): 

     a. Routine Care: For vigorous term babies with no risk factors and babies who have responded to the initial steps. Babies who required initial steps may not need to be separated from their mothers after birth to receive close monitoring and further stabilization.  
     b. Post-resuscitation care: For babies who have depressed breathing or activity, and/or require supplemental oxygen. Require frequent evaluation. Some may transition to routine care; others will require ongoing support. Transfer to an intensive care nursery may be necessary. 

3. Prior to beginning the steps in the NRP Flow Diagram, ask the OB provider for relevant perinatal history, including these questions: 
     a. What is the gestational age?   
     b. Is the fluid clear? 
     c. How many babies are expected?  
     d. Are there any additional risk factors? 

4. At birth, answer 3 questions to determine the need for initial steps at the radiant warmer: 
     a. Is the newborn term?  
     b. Is the newborn breathing or crying? 
     c. Does the newborn have good muscle tone? 

If any answer is “No,” the newborn should receive initial steps at the radiant warmer. 

5. The vigorous meconium-stained newborn need NOT receive initial steps at the radiant warmer, but may receive routine care (with appropriate monitoring) with his mother.  

6. Routine care of newborn staying with mother:  
     a. Warm (skin-to-skin contact is recommended), clear airway by wiping the baby's mouth and nose if necessary, dry the newborn, provide ongoing evaluation of breathing, activity, and color.  
     b. Vigorous meconium stained infants may stay with mothers with appropriate monitoring. 

7. SUCTIONING following birth (including bulb suctioning with a bulb syringe) should be reserved for babies that have 
     a. obvious obstruction to spontaneous breathing or 
     b. those requiring PPV.

8. After clearing the airway as necessary, drying and removing wet linen, repositioning, and stimulating, evaluate respirations and heart rate (not color).  
     a. If HR is less than 100 bpm, or if newborn is apneic or gasping, begin positive-pressure ventilation.   
     b. If HR is more than 100 bpm and respirations are labored, consider CPAP, especially for preterm newborns.   

9. Subsequently, evaluation and decision-making are based on respirations, HR, and oxygenation (per pulse oximetry).  

10. Resuscitation of term newborns may begin with 21% oxygen; resuscitation of preterm newborns may begin with a somewhat higher oxygen concentration.   

11. Use pulse oximetry when: 
     a. Resuscitation is anticipated 
     b. PPV is required for more than a few breaths 
     c. Central cyanosis is persistent, or you need to confirm your perception of central cyanosis 
     d. Supplemental oxygen is administered  

12. Place the oximeter probe on the newborn's right hand or wrist (measure pre-ductal saturation) and then connect it to the instrument.  

13. Using pulse oximetry, supplemental oxygen concentration should be adjusted to achieve the target values for pre-ductal saturations summarized in the table on the NRP Flow Diagram. The table is used for both term and preterm babies.  

Target Spo2 after birth: 

 1min   60-65% 

 2min   65-70% 

 3min   70-75% 

 4min   75-80% 

 5min   80-85% 

 10min 85-95% 

14. Indications for positive-pressure ventilation: 
     a. Apnea/gasping 
     b. Heart rate below 100 bpm, even if breathing 
     c. Persistent central cyanosis and low oxygen saturation, despite free-flow O2 increased to 100%.   

15. All positive-pressure devices, including the self-inflating bag, should have an integral pressure gauge, or if there is a site for attaching a pressure gauge (manometer), it should be attached.   

16. When PPV begins, assess for rising heart rate and improving oxygen saturation (per pulse oximetry). If not evident (within 5-10 breaths), ask your assistant to assess bilateral breath sounds and chest movement. If these are not immediately evident, perform as many of the ventilation corrective steps as needed to achieve bilateral breath sounds and chest movement.   

17. Note that the timeline down the side of the NRP Flow Diagram stops here, but it may take longer than 30 seconds to establish effective positive-pressure ventilation (defined by bilateral breath sounds and chest movement).   

18. Use MR SOPA to help you remember the ventilation corrective steps in order:  

M: Adjust the MASK on the face. 
R: REPOSITION the head to ensure an open airway. Re-attempt ventilation.  If not effective, 
S: SUCTION the mouth and nose 
O: Ventilate with the baby's mouth slightly OPEN and lift the jaw forward. Re-attempt ventilation If not effective, 
P: Gradually increase PRESSURE every few breaths, (cautiously, and to a maximum of 40 cm H20), until bilateral breath sounds and visible chest movement present. If still not effective, 
A: Consider AIRWAY Alternative (endotracheal tube or laryngeal mask airway)  

19. Establishing effective ventilations is the highest priority in neonatal resuscitation. Do not start chest compressions without first establishing effective ventilation (defined by audible bilateral breath sounds and chest movement). If heart rate is still below 60 bpm despite 30 seconds of effective positive-pressure ventilation, increase the oxygen concentration to 100% and begin chest compressions.   

20. When the heart rate is below 60 bpm, the oximeter may not function. When chest compressions begin, increase the oxygen concentration to 100% until the oximeter is giving a reliable signal and can guide the appropriate adjustment of supplemental oxygen.  

21. Intubation is strongly recommended when chest compressions begin to help ensure effective ventilation.  

22. The intubation procedure ideally should be completed within 30 seconds (not 20 seconds). Do not administer free-flow oxygen during the intubation procedure to an apneic newborn.   

23. Interruption of chest compressions to check the heart rate may result in a decrease of perfusion pressure in the coronary arteries. Therefore, continue chest compressions and coordinated ventilations for at least 45-60 seconds before stopping briefly to assess the heart rate.   

24. If you anticipate the need to place an emergency umbilical venous catheter, continue chest compressions by moving to the head of the bed (near the infant's head) and continuing the 2-thumb technique. This is most easily accomplished if the newborn is intubated.   

25. The laryngeal mask airway has been shown to be an effective alternative for assisting ventilation. Use may be indicated when 
     a. Facial or upper airway malformations render ventilation by mask ineffective. 
     b. Positive-pressure ventilation with a face mask fails to achieve effective ventilation and intubation is not possible.  

26. Epinephrine is indicated when the heart rate remains below 60 bpm after 30 seconds of effective assisted ventilation (preferably via endotracheal tube) and at least another 45-60 seconds of coordinated chest compressions and effective ventilation.   

27. The intratracheal route is associated with unreliable absorption and is likely to be ineffective. Nevertheless, since the endotracheal route is the most readily accessible, administration of a dose of epinephrine via an endotracheal tube may be considered while the intravenous route is being established.   

28. Epinephrine administration (IV parameters unchanged; note NEW dose for intratracheal epinephrine) 
     a. Recommended concentration: 1:10,000 (0.1 mg/mL) 
     b. Recommended route: Intravenous (umbilical vein). Consider endotracheal route ONLY while IV access being obtained 
     c. Give rapidly – as quickly as possible. 
     d. Recommended IV dose: 0.1-0.3 mL/kg of 1:10,000 solution per umbilical vein in a 1-mL syringe. Follow IV administration of epinephrine with 0.5 – 1 mL flush of normal saline.  
     e. Recommended intratracheal dose: 0.5 – 1 mL/kg of 1:10,000 solution per endotracheal tube in a 3-6 mL syringe.  Epi can be given again immediately after UVC placement if given initially down ETT.
     f. Check the newborn heart rate about 1 minute after administering epinephrine (longer if given endotracheally). Epinephrine dose may be repeated every 3-5 minutes. 

29. Therapeutic hypothermia following perinatal asphyxia should be  
     a. ONLY for babies > 36 weeks' gestation who meet previously defined criteria for this therapy 
     b. Initiated before 6 hours after birth 
     c. Used only by centers with specialized programs equipped to provide the therapy 

30. To help keep the preterm baby warm, 
     a. Increase the temperature of the delivery room and the area where the baby will be resuscitated to approximately 25⁰C to 26⁰C (77⁰F-79⁰F) 
     b. Use polyethylene plastic wrap for babies delivered at less than 29 weeks' gestation (or 28 weeks and less). Use a sheet of plastic food wrap, a food-grade 1-gallon plastic bag, or a commercially available sheet of polyethylene plastic.  
     c. Place a portable warming pad under layers of towels on the resuscitation table.