Neonatal Resuscitation Program (NRP Skills Check Off)

How to prepare for your NRP Skills Check-Off

Preparation is key! All the resuscitation equipment checklists will be included in the NRP textbook. It is our job as NRP providers to be able to prepare the proper equipment needed to assist an apneic infant or neonates requiring chest compressions and epinephrine. Most of all of our equipment will be located in the drawer of the warmer or close to the warmer. All steps of resuscitation must be performed quickly and efficiently. Be familiar with where your facility keeps its equipment and we will be demonstrating how to use the equipment in our skills session.

Assess Prenatal Risk Factors?

  • Gestational Age?
  • Clear Fluid?
  • Umbilical Cord Management?
  • Additional Risk Factors?

Initial Steps of Resuscitation

The initial steps of neonatal resuscitation include drying, stimulation, and perhaps suctioning.
  • You must dry the infant with a towel then throw the towel away from the infant.
    • If you leave a wet towel on the infant, the infant will get cold and your resuscitation will be inefficient.
    • Next, you must stimulate gently. There is no need to stimulate vigorously.
    • In addition, you are required to suction the mouth and then the nose if there are copious secretions. If you suction the nose before the mouth your resuscitation will be inefficient.
    • In fact, suctioning the nose first causes the infant to snort and pull secretions from his/her mouth into the lung and your resuscitation will be inefficient.

Apenic or gasping infant?

  • Provide PPV
  • Deliver 1 breath every 3 to 5 seconds with a bag-mask device
  • What’s the point of providing positive pressure ventilation if air does not enter the lungs!
  • Do not provide PPV too rapidly – slow down. For instance, I like to say “bag the baby” during PPV so that I don’t deliver PPV too rapidly. 
    • If you “bag the baby” too rapidly, you will cause a pneumothorax and your resuscitation will be compromised.
  • Moreover, do not provide PPV too aggressively with too much pressure.
    • To much pressure will cause a pneumothorax and your resuscitation will be compromised.
  • Remember “breathe baby, breathe baby, breathe baby”


  • Mask Reposition
  • Suction
  • Open the mouth
  • Pressure Increase
  • Alternative Airway

Place pulse oximeter on R hand

  • Have someone place a pulse oximeter on the right hand as soon as possible.
  • It takes time to place the pulse oximeter and if it’s not attached as soon as possible, your resuscitation will be inefficient.
  • If you place the pulse oximeter any other place than the right hand, you will get post-ductal saturation and not preductile saturation. Thus, your resuscitation will be inefficient.
  • You want to know the saturation of the blood as it initially enters the heart and not what comes out of the heart.

Calculate HR

  • Have someone place cardiac leads as soon as possible.
  • If you palpate the umbilical cord for the pulse you may be mistaken and your resuscitation will be inefficient.
  • You must calculate the heart rate in 6 seconds and multiply that number by 10.
  • For example if you auscultate or palpate 10 beats in 6 seconds multiply 10 x 10. The correct answer is 100 bpm

If the heart rate is less than 60 bpm, you must call for intubation

  • Keep providing PPV until the doctor is ready to establish an advanced airway.
  • Securing an airway is important in the newborn resuscitation effort then proceed with chest compressions after the airway is secure.
  • The doctor arrives and takes over the bag/mask, move to the left of the Intubationist and prepare the instruments.
  • The laryngoscope blade size is 0 for the preterm infant and 1 for the term infant.
    • If you have the wrong size laryngoscope, your doctor will have difficulty intubating and your resuscitation will be inefficient
  • Next, check the light source and battery supply prior to handing the laryngoscope to the provider. If you do not have a light source your resuscitation will be inefficient.
  • Most facilities will have a disposable light handle/blade that is one time use only be sure to check at your facility
  • Put the blade in a locked position.
  • The Intubationist will lower his/her head to view the glottis. At this point, He/she is no longer looking at you.
  • You must hand the laryngoscope into the LEFT hand of the Intubationist. If you hand the laryngoscope to his right hand, the light source of the laryngoscope will be directed outward and the intubationist will not be able to view the glottis and your resuscitation will be inefficient.
  • Push the ET tube between the fingers of the Intubationist.
    • Remember, he/she is not looking up. If the intubationist has to take his/her eye off the target, your resuscitation will be inefficient.
    • 6 plus the weight of the infant in Kg. That’s the intubationist responsibility!
    • The laryngoscope blade is then removed.
    • The stylet is then removed if one is used.
    • A CO2 detector is then placed on the end of the ET tube.
      • If you don’t have one handy, your resuscitation will be inefficient.
      • It comes out of the package all purple. When it turns gold, it indicates the presence of CO2. “Gold is Good.”
    • Next, check for stomach gurgling during PPV.
    • If epigastric gurgling is present this is a bad sign because the stomach was intubated. Take out the ET tube and try again.
    • If you check the lung sounds before abdominal sounds, your resuscitation will be inefficient.
    • Then check for bilateral breath sounds.
      • If you don’t check both sides, your resuscitation will be inefficient.

ETT Tube Sizes

  • You must have the right size ET tube for the gestational age of the infant.
  • A 25 weeker requires a 2.5 ET tube
  • A 30 weeker requires a 3.0 ET tube
  • A 35 weeker requires a 3.5 ET tube
  • A 40 weeker requires a 4.0 ET tube

Chest Compressions if HR <60

  • If the heart rate is less than 60 bpm, begin chest compression’s at a ration of 3 chest compression to 1 breath.
  • Prepare for chest compression’s by:
    • Placing a 3-lead ECG on the infant’s chest. If you don’t use the 3-lead ECG, you may not get an accurate heart rate and your resuscitation will be inefficient.
  • Increase the FiO2 to 100%
    • If you do not increase the FiO2 to 100%, your resuscitation will be inefficient.
  • Chest compressions and Ventilation are required with a 3:1 ratio.
    • Do 3 compressions and then pause for 1 ventilation.
    • This cycle should take only 3 seconds.
    • If you do not do this rapidly, your resuscitation will be inefficient
  • Compress the chest 1/3 the anterior to the posterior depth of the chest.
    • If you do not compress deeply, your resuscitation will be inefficient.
  • Continue chest compressions with ventilations for 60 seconds.
  • Then check the heart rate again.
    • This can be accomplished with the 3-lead ECG.

Epinephrine if HR remains <60

  • If the heart remains less than 60 bpm, prepare for the administration Epinephrine.
  • If you do not have Epinephrine ready, your resuscitation will be inefficient.
  • The Endotracheal route is the route to be used initially.
    • It’s not the best way, but the fastest way.
  • The dose for Epinephrine through the ET tube is:
    • 5 mg – 1.0 mg/kg
    • It may be easier for you to use the 0.5 mg/kg to determine the dose.
    • For a 3 kg infant, the dose would be 1.5 ml.
    • The dose is administered rapidly and PPV follows.
    • Wait 60 seconds to check the heart rate.
  • Someone should be delegated to begin flushing the UVC.
    • Attach a stop-cock
    • If you don’t have a stop-cock handy, your resuscitation will be inefficient.
    • Flush with Normal Saline 3 mL
    • Can be administered q3-5 mins

UVC Placement

  • f the heart rate remains less than 60 bpm, the UVC is inserted just far enough the get blood return.
  • The Epinephrine is then administered through the UVC.
  • The dose of Epinephrine via the UVC is 0.1 mg/kg – 0.5 mg/kg
  • It may be easier for you to use 0.1 mg/kg for the UVC access
  • For an infant weighing 1 kg the dose becomes 0.1 ml. (if you are using the 0.1 mg/kg dose.)
  • Flush the UVC with normal saline.
  • Wait 60 seconds and check the heart rate.
    • If you do not wait 60 seconds, you may be apt to repeat the Epinephrine too soon.

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