NALS/NRP: Neonatal Resuscitation

Initiate cord management plan

0-30sec: Initial Assessment/Stabilization

[Term gestation? Good muscle tone? Breathing or crying?]

YES to all: skin to skin with parent; routine care; maintain normal temperature, position airway, clear airway if necessary, dry; ongoing evaluation (color, activity, breathing) needed

NO to any: warm and maintain normal temperature, dry, stimulate and clear airway if needed; Info: reserve suctioning with bulb syringe or suction catheter for airway obstruction or if positive pressure ventilation (PPV) needed; ECG if available

30-60sec: Ventilation/Oxygenation

[HR >100/min but labored breathing or persistent cyanosis]

Info: position and clear airway, SpO2 monitoring, supplemental oxygen if needed, consider CPAP; consider intubation/mechanical ventilation in premature neonates

[HR <100/min or apnea or gasping]

Info: provide PPV at 30-60 breaths/min, SpO2 monitoring, supplemental oxygen if needed, ECG if available

Ongoing Evaluation

[assess respirations, HR, oxygenation]

Info: target oxygen saturation 65-70% at 2min, 70-75% at 3min, 75-80% at 4min, 80-85% at 5min, 85-95% at 10min

[HR 60-100/min]

Info: take ventilation corrective steps to keep HR >100/min if necessary; use laryngeal mask or intubate if necessary; ECG

[HR <60/min]

Info: intubation if not already done; begin CPR, continue until HR 60/min or greater; provide PPV and 100% oxygen; consider emergency umbilical catheterization or intraosseous access

[neonate CPR technique]

Info: use 2 thumb-encircling hand technique; coordinate 90 compressions and 30 breaths/min in 3:1 ratio; compress to 1/3 depth of chest, allow complete chest wall recoil; avoid frequent compression interruptions

[HR <60/min despite adequate ventilation with 100% oxygen and CPR]

Info: continue CPR until HR 60/min or greater

Consider epinephrine (0.1 mg per mL solution): 0.01-0.03 mg/kg/dose IV/IO q3-5min prn; Alt: 0.05-0.1 mg/kg/dose ETT q3-5min prn; Info: IV route preferred; safety/efficacy of ETT route not well established

Consider volume expansion: 10-20 mL/kg of isotonic crystalloid or blood, may need to repeat; Info: consider if blood loss known or suspected; avoid rapid infusion in premature neonates

Consider pneumothorax requiring thoracentesis

Withhold or Discontinue

[withhold resuscitation considerations]

Info: if birth is at lower limit of viability or involves a condition likely to result in early death or severe morbidity, or resuscitation efforts appear ineffective or futile based on infant's condition, then withholding of care should be strongly considered after expert consultation and parental involvement in decision-making

[D/C resuscitation considerations]

Info: redirection of care should be discussed with team and family if all resuscitation steps effectively completed and no heart rate response by 20min