Neonatal Resuscitation Learning App

NRP Learning App

Antenatal counseling.

Team briefing.

equipment check.

⬇️
Birth
⬇️
Is baby
1. Full Term?
2. Have good muscle Tone?
3. Breathing or crying?
Click yes or no for the next step.
Yes: full term, have good muscle tone, normal breathing or cry

Baby will stay with mother for routine care:
1. Warm and maintain normal temperature,
2. Position airway, clear secretions if needed,
3. Dry
4. Ongoing evaluation.

Poor muscle tone, Weak cry, Labored breathing
  • Warm the baby and maintain normal temperature
  • Position airway
  • Clear secretions if needed
  • Dry and,
  • Stimulate the baby.
⬇️

Now Check for:

  • Apnea
  • Gasping
  • HR below 100 bpm?
⬇️
NO gasping, NO apnea, HR >100

Check for:

  • Labored breathing
  • persistent cyanosis?
⬇️
Labored breathing/Cyanosis Present

1. Position and clear airway.
2. SpO2 monitor.
3. Supplemental O2 as needed.
4. Consider CPAP.

⬇️

Provide

  • Post-resuscitation care
  • Team debriefing
Yes, HR <100, Apnea/Gasping Present

Start:

  • Positive Pressure Ventilation
  • SpO2 monitor
  • Consider ECG monitor
⬇️

Check Heart Rate Again:

⬇️
If, HR >100

Provide

  • Post-resuscitation care
  • Team debriefing.
If, HR is still < 100 bpm

Check if, HR is between 60-100 bpm or HR <60 bpm?

⬇️
If, HR is 60-100 bpm:

Alert

  • Check Chest movement
  • Ventilation corrective steps if needed
  • EndoTrachealTube or laryngeal mask if needed
⬇️

Check HR again

If, HR <60 go to the next step

If, HR 60-100 bpm, go to the previous step

⬇️
If, HR below 60 bpm?

Alert

  • Intubate if not already done
  • Start Chest compressions
  • Coordinate with PPV
  • Provide 100% O2
  • ECG monitor
⬇️

Check the HR again,

⬇️
if HR persists below 60 bpm?
⬇️

Give

IV epinephrine.

⬇️

If HR persistently below 60 bpm:

consider hypovolemia,
consider pneumothorax.




Case Scenario

Case Scenario
Case 1: Term Newborn with Clear Amniotic Fluid

Scenario:

A 39-week gestation newborn is delivered vaginally with clear amniotic fluid. The baby is crying and has good muscle tone.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head (slight sniffing position)
  3. Clear airway if necessary
  4. Stimulate breathing
  5. Evaluate respirations, heart rate, and color
  6. Provide routine care
Case 2: Late Preterm with Respiratory Distress

Scenario:

A 35-week gestation newborn is delivered via C-section. The baby has irregular breathing and mild retractions.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Stimulate breathing
  5. Evaluate respirations, heart rate, and color
  6. Provide positive pressure ventilation (PPV) with room air
  7. Reassess after 30 seconds
  8. Continue PPV if needed
  9. Consider CPAP if breathing improves
Case 3: Term Newborn with Meconium-Stained Amniotic Fluid

Scenario:

A 40-week gestation newborn is delivered with thick meconium-stained amniotic fluid. The baby is not breathing and has decreased muscle tone.

Simplified NRP Steps:

  1. Do not suction mouth and nose before delivery of shoulders
  2. Warm and dry the baby
  3. Position the head
  4. Clear airway if necessary
  5. Stimulate breathing
  6. Evaluate respirations, heart rate, and color
  7. If not breathing or heart rate < 100 bpm, begin PPV
  8. Consider intubation if no improvement with PPV
  9. Reassess every 30 seconds
  10. Escalate interventions if needed (chest compressions, epinephrine)
Case 4: Preterm Newborn with Respiratory Failure

Scenario:

A 28-week gestation newborn is delivered. The baby is not breathing, has poor muscle tone, and heart rate is 80 bpm.

Simplified NRP Steps:

  1. Warm and dry the baby (use plastic wrap for very preterm infants)
  2. Position the head
  3. Clear airway
  4. Stimulate breathing briefly
  5. Begin PPV with 30% oxygen
  6. Apply pulse oximeter and ECG leads
  7. Reassess every 30 seconds
  8. Adjust oxygen as needed based on saturation targets
  9. Consider intubation if no improvement with PPV
  10. Start chest compressions if heart rate remains < 60 bpm despite effective ventilation
Case 5: Term Newborn with Congenital Diaphragmatic Hernia

Scenario:

A 39-week gestation newborn is delivered with a known diagnosis of left-sided congenital diaphragmatic hernia. The baby is cyanotic and has severe retractions.

Simplified NRP Steps:

  1. Immediately intubate the baby
  2. Avoid bag-mask ventilation
  3. Place orogastric tube and connect to suction
  4. Provide PPV through ET tube with 100% oxygen
  5. Apply pulse oximeter and ECG leads
  6. Establish IV access
  7. Consider surfactant administration
  8. Prepare for possible need of inotropic support
  9. Consult with NICU team for further management
Case 6: Term Newborn with Shoulder Dystocia

Scenario:

A 41-week gestation newborn experiences shoulder dystocia during delivery. After resolution, the baby is limp and not breathing.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Stimulate breathing
  5. Evaluate respirations, heart rate, and color
  6. Begin PPV with room air
  7. Apply pulse oximeter and ECG leads
  8. Reassess every 30 seconds
  9. If no improvement, consider intubation
  10. Start chest compressions if heart rate remains < 60 bpm despite effective ventilation
  11. Administer epinephrine if no response to chest compressions
Case 7: Preterm Twins with Twin-to-Twin Transfusion Syndrome

Scenario:

32-week gestation twins are delivered via emergency C-section due to twin-to-twin transfusion syndrome. Twin A (recipient) is plethoric and hydropic, while Twin B (donor) is pale and growth-restricted.

Simplified NRP Steps for Twin A (recipient):

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Provide PPV with room air
  5. Apply pulse oximeter and ECG leads
  6. Consider early CPAP
  7. Monitor for signs of heart failure
  8. Establish IV access
  9. Prepare for possible partial exchange transfusion

Simplified NRP Steps for Twin B (donor):

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Provide PPV with 30% oxygen
  5. Apply pulse oximeter and ECG leads
  6. Adjust oxygen as needed based on saturation targets
  7. Establish IV access
  8. Consider volume expansion
  9. Monitor for anemia and hypoglycemia
Case 8: Term Newborn with Hydrops Fetalis

Scenario:

A 38-week gestation newborn with known hydrops fetalis is delivered. The baby is extremely edematous, pale, and not breathing.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway (consider oropharyngeal suctioning)
  4. Intubate immediately
  5. Provide PPV with 100% oxygen
  6. Apply pulse oximeter and ECG leads
  7. Establish emergency umbilical venous access
  8. Consider thoracentesis and/or paracentesis if severe effusions present
  9. Administer volume expanders
  10. Start chest compressions if heart rate remains < 60 bpm despite effective ventilation
  11. Administer epinephrine if no response to chest compressions
  12. Prepare for possible exchange transfusion
Case 9: Late Preterm with Maternal Opioid Use

Scenario:

A 36-week gestation newborn is delivered to a mother with a history of opioid use during pregnancy. The baby has a weak cry and decreased respiratory effort.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Stimulate breathing
  5. Evaluate respirations, heart rate, and color
  6. Provide PPV if needed
  7. Apply pulse oximeter and ECG leads
  8. Consider naloxone administration only after effective ventilation is established
  9. Monitor closely for signs of neonatal abstinence syndrome
  10. Consult with NICU team for further management
Case 10: Term Newborn with Perinatal Asphyxia

Scenario:

A 40-week gestation newborn is delivered after a prolonged second stage of labor with fetal bradycardia. The baby is pale, limp, and not breathing, with a heart rate of 40 bpm.

Simplified NRP Steps:

  1. Warm and dry the baby
  2. Position the head
  3. Clear airway
  4. Begin PPV with 100% oxygen
  5. Apply pulse oximeter and ECG leads
  6. Intubate if no response to PPV
  7. Start chest compressions
  8. Establish emergency umbilical venous access
  9. Administer epinephrine if no response to chest compressions
  10. Consider volume expansion
  11. Reassess every 30 seconds and continue interventions as needed
  12. If ROSC achieved, begin therapeutic hypothermia protocol
  13. Consult with NICU team for further management and consideration of additional neuroprotective strategies


Viva Question and Answers

Set 1: 25 NRP Viva Questions and Answers
  1. Q: What is the first step in neonatal resuscitation?

    A: The first step is to provide warmth by placing the newborn under a radiant warmer and drying them thoroughly.

  2. Q: At what heart rate should chest compressions be initiated?

    A: Chest compressions should be initiated when the heart rate remains below 60 beats per minute despite 30 seconds of effective positive pressure ventilation.

  3. Q: What is the recommended compression-to-ventilation ratio in neonatal resuscitation?

    A: The recommended ratio is 3:1, with 3 compressions followed by 1 breath, aiming for 90 compressions and 30 breaths per minute.

  4. Q: What is the initial oxygen concentration recommended for preterm infants (<35 weeks) during resuscitation?

    A: The initial oxygen concentration recommended for preterm infants is 21-30% (room air to 30% oxygen).

  5. Q: How do you assess the effectiveness of positive pressure ventilation (PPV)?

    A: Effectiveness of PPV is assessed by observing chest rise, auscultating breath sounds, and monitoring improvement in heart rate and oxygen saturation.

  6. Q: What is the preferred route for epinephrine administration in neonatal resuscitation?

    A: The preferred route is intravenous (IV) through an umbilical venous catheter. If IV access is not available, endotracheal administration can be considered as a temporary measure.

  7. Q: What is the recommended dose of epinephrine in neonatal resuscitation?

    A: The recommended dose is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 concentration) given intravenously.

  8. Q: How often should you reassess the newborn's status during resuscitation?

    A: Reassessment should occur every 30 seconds during active resuscitation.

  9. Q: What is the recommended depth for chest compressions in a newborn?

    A: The recommended depth is approximately one-third of the anterior-posterior diameter of the chest, which is about 4 cm (1.5 inches) in most newborns.

  10. Q: When should you consider intubation during neonatal resuscitation?

    A: Intubation should be considered when bag-mask ventilation is ineffective, prolonged PPV is required, or when administering surfactant or performing special resuscitation circumstances (e.g., congenital diaphragmatic hernia).

  11. Q: What is the significance of the "golden minute" in neonatal resuscitation?

    A: The "golden minute" refers to the first 60 seconds after birth, during which initial steps (warming, drying, stimulating, and assessing) should be completed and ventilation initiated if necessary.

  12. Q: How do you determine the appropriate ETT size for a newborn?

    A: ETT size can be estimated using the formula: ETT size (mm) = (gestational age in weeks / 10) + 0.5. Alternatively, a size 3.5 tube for term newborns and 2.5-3.0 for preterm infants can be used.

  13. Q: What are the indications for discontinuing resuscitation efforts?

    A: Resuscitation efforts may be discontinued if there is no detectable heart rate after 10 minutes of adequate resuscitative efforts, including effective ventilation, chest compressions, and epinephrine administration.

  14. Q: What is the recommended method for maintaining a newborn's temperature during resuscitation?

    A: Use a radiant warmer, warm and dry the baby immediately after birth, use pre-warmed blankets, and consider using a plastic bag or wrap for very preterm infants (<32 weeks).

  15. Q: How do you assess the need for supplemental oxygen during resuscitation?

    A: Use pulse oximetry to monitor oxygen saturation and follow target SpO2 ranges based on the infant's age in minutes. Adjust oxygen concentration accordingly.

  16. Q: What is the current recommendation for suctioning meconium-stained amniotic fluid?

    A: Routine intrapartum suctioning of the oropharynx and nasopharynx for meconium-stained amniotic fluid is not recommended. Only suction the mouth and nose if obstruction is suspected after birth.

  17. Q: When should you consider volume expansion during neonatal resuscitation?

    A: Consider volume expansion when there are signs of shock or a history of acute blood loss, and the baby has not responded to other resuscitative measures.

  18. Q: What is the recommended fluid for volume expansion, and what is the typical dose?

    A: The recommended fluid is 0.9% sodium chloride (normal saline), and the typical dose is 10 mL/kg given over 5-10 minutes.

  19. Q: How do you determine the insertion depth for an endotracheal tube?

    A: Use the NTL (Nasal-Tragus Length) method or the formula: insertion depth (cm) = 6 + weight in kg. Confirm position with chest X-ray.

  20. Q: What are the signs of effective chest compressions?

    A: Signs include improvement in heart rate, audible heart sounds, palpable pulses, and eventual spontaneous breathing.

  21. Q: How do you perform the two-thumb encircling technique for chest compressions?

    A: Place thumbs side by side on the lower third of the sternum, fingers encircling the torso and supporting the back. Compress the sternum approximately one-third of the anterior-posterior diameter of the chest.

  22. Q: What is the role of end-tidal CO2 detection in neonatal resuscitation?

    A: End-tidal CO2 detection is used to confirm endotracheal tube placement and may also be used to assess the effectiveness of chest compressions.

  23. Q: When is delayed cord clamping recommended, and what are its benefits?

    A: Delayed cord clamping (30-60 seconds) is recommended for both term and preterm infants who do not require immediate resuscitation. Benefits include improved transitional circulation, better establishment of red blood cell volume, and decreased need for blood transfusion.

  24. Q: What are the indications for therapeutic hypothermia in newborns?

    A: Therapeutic hypothermia is indicated for term or late preterm infants with moderate to severe hypoxic-ischemic encephalopathy, when initiated within 6 hours of birth.

  25. Q: How do you assess the Apgar score, and what are its limitations in guiding resuscitation?

    A: The Apgar score assesses heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 minutes after birth. However, it should not be used to guide resuscitation efforts, as these should be initiated based on individual components (especially heart rate and respirations) rather than the composite score.

Set 2: 25 Additional NRP Viva Questions and Answers
  1. Q: What is the correct hand placement for cardiac compressions in a newborn?

    A: Place thumbs on the lower third of the sternum, just below the intermammary line, with fingers encircling the torso and supporting the back.

  2. Q: How do you calculate the umbilical venous catheter insertion depth?

    A: Use the formula: insertion depth (cm) = (1.5 × birth weight in kg) + 5.5. Alternatively, use the shoulder-umbilicus length method.

  3. Q: What are the target oxygen saturation ranges for the first 10 minutes of life?

    A: 1 min: 60-65%, 2 min: 65-70%, 3 min: 70-75%, 4 min: 75-80%, 5 min: 80-85%, 10 min: 85-95%.

  4. Q: What is the recommended initial peak inspiratory pressure (PIP) for positive pressure ventilation in term newborns?

    A: The recommended initial PIP is 20-25 cm H2O for term newborns. Adjust as needed based on chest rise and clinical response.

  5. Q: How do you perform tactile stimulation, and when is it indicated?

    A: Tactile stimulation can be performed by gently rubbing the back, trunk, or extremities. It's indicated for newborns with poor respiratory effort after initial steps of resuscitation.

  6. Q: What is the role of laryngeal mask airways (LMAs) in neonatal resuscitation?

    A: LMAs can be used as an alternative to endotracheal intubation for newborns ≥34 weeks gestation or ≥2000g if bag-mask ventilation is unsuccessful and intubation is not feasible or unsuccessful.

  7. Q: How do you determine the appropriate mask size for bag-mask ventilation?

    A: Choose a mask that covers the mouth and nose but not the eyes, creating a good seal without overlapping the chin.

  8. Q: What is the significance of persistent cyanosis despite oxygen therapy?

    A: Persistent cyanosis may indicate congenital heart disease, particularly cyanotic lesions like transposition of the great arteries or tetralogy of Fallot.

  9. Q: How do you manage a newborn with gastroschisis during initial resuscitation?

    A: Cover the exposed bowel with warm, sterile, saline-soaked gauze. Place the lower body in a bowel bag to reduce heat and fluid loss. Monitor for signs of hypovolemia and provide standard resuscitation as needed.

  10. Q: What is the recommended approach for resuscitating extremely preterm infants (≤25 weeks gestation)?

    A: Use a temperature-controlled environment, consider plastic wrap/bag, start with low oxygen (21-30%), use gentle ventilation techniques, and avoid routine intubation for surfactant administration.

  11. Q: How do you recognize and manage pneumothorax during resuscitation?

    A: Suspect pneumothorax with asymmetrical chest movement, sudden deterioration, and decreased breath sounds on the affected side. Manage with needle thoracentesis in acute situations, followed by chest tube placement if necessary.

  12. Q: What are the indications for using naloxone in neonatal resuscitation?

    A: Naloxone is no longer recommended as part of the initial resuscitation of newborns with respiratory depression. Focus on effective ventilation. If used later, it should be for newborns with respiratory depression despite effective ventilation, with known/suspected opioid exposure.

  13. Q: How do you manage resuscitation of a newborn with known congenital diaphragmatic hernia (CDH)?

    A: Immediately intubate, avoid bag-mask ventilation, place an orogastric tube, use gentle ventilation with possible need for high pressures, and prepare for possible need of inhaled nitric oxide or ECMO.

  14. Q: What is the "MRSOPA" acronym used for in neonatal resuscitation?

    A: MRSOPA is used to remember corrective steps for ineffective ventilation: Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase, Alternative airway.

  15. Q: How do you manage a newborn with hydrops fetalis during resuscitation?

    A: Anticipate need for aggressive resuscitation. Consider thoracentesis and/or paracentesis if severe effusions impair ventilation. Be prepared for volume resuscitation and possible blood products.

  16. Q: What is the role of capnography in neonatal resuscitation?

    A: Capnography can be used to confirm endotracheal tube placement, assess the effectiveness of chest compressions, and potentially predict return of spontaneous circulation.

  17. Q: How do you manage resuscitation of a newborn with suspected sepsis?

    A: Provide standard resuscitation measures, obtain blood cultures if possible, and start empiric antibiotics early. Be prepared for possible need of volume expansion and inotropic support.

  18. Q: What are the key differences in resuscitating a newborn with cyanotic congenital heart disease?

    A: Be cautious with oxygen administration, aiming for saturations around 75-85%. Maintain systemic blood flow with prostaglandin E1 if duct-dependent lesion is suspected. Prepare for possible need of inotropic support.

  19. Q: How do you perform cord milking, and what are its potential benefits and risks?

    A: Cord milking involves gently squeezing blood from the umbilical cord towards the baby before clamping. It may improve hemoglobin levels and blood pressure but is not routinely recommended due to potential risks, especially in extremely preterm infants.

  20. Q: What is the role of air versus oxygen in initiating resuscitation for term newborns?

    A: For term newborns, it's recommended to initiate resuscitation with room air (21% oxygen). Supplemental oxygen should be provided only if there's no improvement with effective ventilation, guided by pulse oximetry.

  21. Q: How do you manage resuscitation of a newborn with anhydramnios or oligohydramnios?

    A: Anticipate potential lung hypoplasia and difficulty with ventilation. Be prepared for early intubation, high ventilator pressures, and possible need for surfactant. Monitor for pneumothorax and consider gentle ventilation strategies.

  22. Q: What is the significance of persistent pulmonary hypertension of the newborn (PPHN) in resuscitation?

    A: PPHN can cause severe hypoxemia resistant to oxygen therapy. Management may include optimal lung inflation, avoiding acidosis and hypothermia, and considering inhaled nitric oxide or ECMO in severe cases.

  23. Q: How do you determine the need for and administer surfactant in preterm infants?

    A: Consider early selective surfactant administration for preterm infants with RDS requiring intubation. Use the INSURE technique (Intubate-Surfactant-Extubate) or less invasive surfactant administration (LISA) when appropriate.

  24. Q: What are the key components of post-resuscitation care?

    A: Post-resuscitation care includes maintaining normal temperature, monitoring blood glucose, assessing for organ dysfunction, considering therapeutic hypothermia if indicated, and providing supportive care as needed.

  25. Q: How do you manage resuscitation of a newborn with a known airway anomaly (e.g., Pierre Robin sequence)?

    A: Anticipate difficult airway management. Have specialized equipment ready (e.g., laryngoscopes, LMAs). Consider prone positioning. Be prepared for emergent tracheostomy if other measures fail.

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