# Initial Assessment and Preparation for Neonatal Resuscitation -- AHA/AAP 2020

## Anticipation and Preparation

Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and initiate positive pressure ventilation (PPV), and whose only responsibility is the management of the newborn (COR 1, LOE C-EO). Additional personnel with full resuscitation skills should be immediately available (COR 1, LOE C-EO).

### Key Risk Factors Requiring a Full Resuscitation Team

- Gestational age < 36 weeks
- Meconium-stained amniotic fluid
- Multiple gestation
- Fetal bradycardia or non-reassuring fetal heart rate tracing
- Maternal general anesthesia
- Placental abruption or placenta previa
- Prolapsed umbilical cord
- Shoulder dystocia
- Known congenital anomalies

### Equipment Checklist

A standardized equipment checklist should be used before every delivery to ensure readiness of supplies, including a radiant warmer, suction equipment, PPV device (self-inflating bag, flow-inflating bag, or T-piece resuscitator), pulse oximeter, cardiac monitor, and medications (COR 2a, LOE C-LD).

## Rapid Assessment at Birth

Within the first seconds after birth, assess 3 questions simultaneously:

1. **Term gestation?** (greater than or equal to 37 weeks)
2. **Good muscle tone?**
3. **Breathing or crying?**

### Decision Logic

- **If YES to all 3 questions:** The newborn does not require resuscitation. Provide routine care: warmth, dry, ongoing assessment, and delayed cord clamping.
- **If NO to any question:** Move to the initial steps of resuscitation under a radiant warmer.

## Initial Steps (Complete Within 30 Seconds)

Perform the initial steps within approximately 30 seconds:

1. **Provide warmth:** Place the newborn under a radiant warmer. For preterm infants < 32 weeks, place the infant (without drying) in a food-grade polyethylene bag/wrap from the neck down and apply a hat (COR 1, LOE B-NR).
2. **Position the airway:** Place the head in a neutral or slightly extended "sniffing" position to open the airway.
3. **Clear the airway (if needed):** Gentle suctioning of the mouth, then nose, only if secretions are visibly obstructing the airway. Routine suctioning is not recommended (COR 2b, LOE C-LD).
4. **Dry and stimulate:** Dry the infant thoroughly (for term infants) and provide gentle tactile stimulation (rubbing the back, flicking the soles of the feet).

## Heart Rate Assessment

Heart rate is the most important indicator of effective resuscitation.

### Methods (in order of reliability)

| Method | Recommendation |
|--------|---------------|
| **3-lead ECG (cardiac monitor)** | Recommended for rapid and reliable heart rate assessment during resuscitation (COR 2a, LOE C-LD). Provides continuous display. |
| **Pulse oximetry** | Place probe on the right hand or wrist (preductal). May take 1-2 minutes to acquire reliable signal. |
| **Auscultation** | Acceptable for initial assessment. Stethoscope on the left side of the chest. |
| **Umbilical cord palpation** | Least reliable; tends to underestimate heart rate. Should not be used as the sole method. |

### Heart Rate Thresholds (Critical Decision Points)

- **Heart rate >= 100 bpm:** Reassuring. Continue observation and supportive care.
- **Heart rate < 100 bpm:** Initiate positive pressure ventilation (PPV) if the newborn is apneic, gasping, or has labored breathing.
- **Heart rate < 60 bpm (after 30 seconds of effective PPV):** Initiate chest compressions coordinated with PPV. Increase FiO2 to 100%.

## Umbilical Cord Management

- **Term and late preterm infants not requiring resuscitation:** It is reasonable to delay cord clamping for longer than 30 seconds (COR 2a, LOE C-LD). Delayed cord clamping increases hemoglobin concentration and ferritin stores in the first 3 to 6 months.
- **Preterm infants not requiring resuscitation:** Delayed cord clamping (longer than 30 seconds) is reasonable, as it is associated with reduced need for blood pressure support and transfusion and may improve survival (COR 2a, LOE B-R for preterm; COR 2a, LOE C-LD for term).
- **Infants requiring resuscitation at birth:** There is insufficient evidence to recommend for or against delayed cord clamping. Initial steps may be performed with an intact cord where feasible, but resuscitation should not be delayed.

## Meconium-Stained Amniotic Fluid

- **Vigorous infant (good tone, breathing, HR >= 100):** No special intervention beyond standard initial steps. Routine suctioning of the oropharynx and nasopharynx is not recommended.
- **Nonvigorous infant (poor tone, apneic/gasping, HR < 100):** Routine direct laryngoscopy and intubation for tracheal suctioning is NOT recommended (COR 2b, LOE C-LD). Instead, proceed with the standard initial steps and PPV as needed. If the airway is obstructed, suctioning of the trachea under direct visualization may be considered.

> **OpenMedicine Calculator:** `calculate_apgar` -- available via MCP for automated scoring. Apgar scores should be assigned at 1 and 5 minutes, and every 5 minutes thereafter until 20 minutes if the score remains < 7. The Apgar score is used to communicate newborn status, NOT to guide resuscitation decisions.

## Limitations

- Gestational age estimation may be inaccurate by 1-2 weeks, which can affect management decisions near the threshold of viability.
- Heart rate assessment by auscultation and cord palpation can be inaccurate; cardiac monitors and pulse oximeters provide more reliable readings but may have signal acquisition delays.
- The Apgar score is limited as a predictor of long-term neurological outcomes and should not be used in isolation for prognostication.
- Clinical judgment remains essential -- algorithms provide a framework, but individual patient factors must be considered.
