Neonatal Resuscitation (NRP 8th Edition)
The NRP algorithm runs on a tight loop of assess → act → reassess, anchored on heart rate. Ventilation — not compressions or drugs — is the single most important intervention; most depressed newborns respond to effective positive-pressure ventilation (PPV) alone.
Initial assessment (at birth)
Three rapid questions decide whether the baby stays with the mother or moves to the warmer:
| Question | If “yes” to all |
|---|---|
| Term gestation? | Routine care: warm, dry, stimulate, clear airway if needed, ongoing assessment with the mother |
| Good tone? | |
| Breathing/crying? |
If “no” to any: initial steps at the warmer.
The Golden Minute (first 60 seconds)
| Step | Action |
|---|---|
| Initial steps | Warm, dry, stimulate, position airway, clear secretions if needed |
| Assess | Heart rate (HR) and respirations |
| If apnoeic/gasping or HR <100 | Begin PPV — this must be achieved within the first minute |
PPV rate is 40–60 breaths/min. Apply a pulse oximeter (right hand/wrist, pre-ductal) and use targeted pre-ductal SpO₂.
Heart-rate-driven escalation
| Heart rate | Action |
|---|---|
| ≥100, breathing | Routine / observational care |
| 60–99 despite PPV | Optimise ventilation — run MR SOPA corrective steps; consider intubation |
| <60 despite 30 s of effective PPV | Intubate, give 100% O₂, start chest compressions |
MR SOPA: Mask adjustment, Reposition airway, Suction, Open mouth, increase Pressure, Alternative airway.
Chest compressions
| Parameter | Specification |
|---|---|
| Indication | HR <60 after 30 s of effective (ideally via advanced airway) PPV |
| Technique | Two-thumb encircling-hands, lower third of sternum |
| Ratio | 3 compressions : 1 ventilation |
| Rate | 90 compressions + 30 breaths = 120 events/min |
| Oxygen | Increase to 100% |
| Reassess | After 60 s of compressions + ventilation |
Adrenaline (epinephrine)
| Parameter | Specification |
|---|---|
| Indication | HR remains <60 despite ≥60 s of compressions + adequate ventilation |
| Concentration | 1:10,000 (0.1 mg/mL) |
| IV/IO dose | 0.01–0.03 mg/kg (0.1–0.3 mL/kg) — preferred route |
| Endotracheal dose | 0.05–0.1 mg/kg (0.5–1 mL/kg) — while IV access is obtained |
| Repeat | Every 3–5 min if HR stays <60 |
Give a volume expander (normal saline or O-negative blood, 10 mL/kg IV/IO over 5–10 min) if hypovolaemia/blood loss is suspected and the baby is not responding.
Reminders
- Effective ventilation fixes the great majority of neonatal arrests — confirm chest rise before escalating.
- The umbilical vein is the fastest reliable access for adrenaline and volume.
- For the 1- and 5-minute APGAR score, see the APGAR score calculator.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.