Overview & Initial Assessment

Rapid evaluation of 3 key questions immediately at birth:
- Term gestation?
- Good muscle tone?
- Breathing or crying?
If YES to all 3: Infant stays with mother (skin-to-skin) c , routine care (warmth, position airway, clear secretions if needed, dry).
If NO to any: Move to radiant warmer for initial steps of resuscitation.

Initial Steps (First 30 Seconds)

Warm and maintain body temperature: Place under radiant warmer (36.5–37.5°C target).
Position head and neck: “Sniffing position” to open airway.
Clear secretions: Suction mouth then nose (“M” before “N”) only if airway obstructed or PPV required.
Dry and stimulate: Remove wet linens; rub back and extremities to stimulate breathing.
Reassess Heart Rate (HR) and Respirations at 30 seconds.

Indications (at 30 seconds):
- Apnea or gasping OR
- HR < 100 bpm
Initiation:
- Rate: 40–60 breaths/min (“Breathe, two, three, breathe…”).
- Initial FiO2: 21% (Room air) for ≥35 weeks GA; 21–30% for <35 weeks GA.
- Attach Pre-ductal SpO2 monitor to Right wrist/hand.
HR Assessment during PPV:
- First check: After 15 seconds of PPV.
  - If HR increasing: Continue PPV, recheck HR at 30 seconds.
  - If HR not increasing: Assess chest movement. If no chest movement, perform MR SOPA.

Indication: HR < 60 bpm despite at least 30 seconds of effective PPV (moving chest/ETT in place).
Technique:
- Two-thumb encircling hands method over lower 1/3 of sternum.
- Depth: 1/3 anterior-posterior chest diameter.
- Compression-to-ventilation ratio: 3:1 (90 compressions + 30 breaths = 120 events/min).
Oxygenation: Increase FiO2 immediately to 100%.
Airway: Secure via ETT if not already completed.
Reassess HR after 60 seconds of continuous compressions + PPV.

Indication: HR < 60 bpm despite 60 seconds of coordinated chest compressions + 100% FiO2 PPV.
Access: Umbilical Venous Catheter (UVC) is route of choice.
Epinephrine:
- Concentration: 0.1 mg/mL (1:10,000).
- IV/UVC Dose: 0.02 mg/kg (0.2 mL/kg) IV push.
- ET Dose: 0.1 mg/kg (1 mL/kg) — only while IV/UVC access is being established.
- Repeat q3–5 minutes if HR remains < 60 bpm.
Volume Expansion:
- Indication: Suspected hypovolemia/shock (e.g., pale skin, weak pulses, history of placental abruption or blood loss).
- Agent: 0.9% NaCl (Normal Saline) or Uncrossmatched Type O, Rh-negative PRBCs.
- Dose: 10 mL/kg IV over 5–10 minutes.

Presentation: Scaphoid abdomen, respiratory distress, bowel sounds in chest, shifted heart sounds.
High-Yield Management: CONTRAINDICATION to bag-valve-mask (BVM) ventilation/PPV via mask (dilates stomach/bowels in chest, worsening pulmonary hypoplasia/collapse).
Next Step: Immediate ET Intubation + Placement of Orogastric (OG) tube for decompression.

Management: Routine endotracheal suctioning at delivery is NO LONGER RECOMMENDED, regardless of infant vigor.
Follow standard algorithm: If depressed (apneic/hypotonic) → Initial steps under warmer → PPV if HR < 100 or non-breathing.

Infant presents with respiratory depression secondary to maternal intrapartum opioid administration.
High-Yield Management: DO NOT give Naloxone (can precipitate acute withdrawal seizures in opioid-exposed infants).
Next Step: Provide ventilatory support via PPV until respiratory drive recovers.

Management:
- Place infant up to neck in polyethylene plastic wrap without drying skin (prevents evaporative heat loss).
- Use thermal mattress.
- Use CPAP instead of PPV if infant is breathing spontaneously with HR > 100 but has dyspnea/grunting.

Monitor for therapeutic hypothermia eligibility if moderate/severe Hypoxic-Ischemic Encephalopathy (HIE) present (gestation ≥35 weeks, initiate within 6 hours of birth).
Monitor blood glucose (risk of severe hypoglycemia).
Monitor arterial blood gas (ABG), electrolytes, and CXR (verify ETT placement 1–2 cm above carina).

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