Newborn · Emergency
Neonatal Resuscitation Algorithm
Interactive newborn resuscitation walk-through based on AAP/AHA NRP 8th Edition (2021) and ILCOR 2020 Consensus on Science.
Last reviewed 26 May 2026
Neonatal resuscitation (NRP 8th ed)
Interactive walk-through
Next step
Initial rapid assessment (within seconds of birth)
- Term gestation?
- Good muscle tone?
- Crying or breathing?
Answer the three questions to start.
NRP minute-specific SpO2 targets (right hand)
- 1 min: 60–65 %
- 2 min: 65–70 %
- 3 min: 70–75 %
- 4 min: 75–80 %
- 5 min: 80–85 %
- 10 min: 85–95 %
Educational tool only — not medical advice. AHA/AAP NRP 8th Edition (2021); ILCOR Neonatal Life Support 2020/2024. Active resuscitation requires NRP-certified personnel and the full algorithm. Every birth needs at least ONE person whose only responsibility is the baby and who is competent at PPV.
What does this mean?
About 10 % of newborns need some help breathing at birth; ~1 % need active resuscitation. The NRP algorithm is a stepwise, time-bounded sequence that the WHO, AAP, AHA, and ILCOR maintain through 5-yearly consensus reviews. Core principles: (1) anticipate — antenatal risk factors (preterm, GDM, FGR, meconium, prolonged ROM) bring extra personnel; (2) warm, dry, stimulate — the first 30 seconds; (3) PPV is the single most important step — do it well, with chest rise and effective mask seal (MR SOPA mnemonic when it’s not working); (4) chest compressions only if HR < 60 despite 30 s of effective PPV; (5) delayed cord clamping ≥ 60 s for all vigorous newborns (WHO 2014, ACOG CO 814 2020) reduces anaemia, IVH, and improves long-term iron status. NRP’s eighth edition emphasises team communication, simulation training, and the rapid, evidence-based pivot to advanced steps when first-line interventions don’t work.
Introduction
About 10 % of newborns need some help breathing at birth. The Neonatal Resuscitation Program (NRP) algorithm — jointly developed by the AAP and AHA, with ILCOR consensus on the underlying evidence — is the international standard. The 8th Edition (2021) is the current reference.
Initial assessment (3 questions)
- Term gestation?
- Good muscle tone?
- Crying or breathing?
Yes to all 3 → routine care with mother. Any No → warmer.
Initial steps under warmer (first 30 s)
- Warm (radiant warmer; plastic bag/wrap for < 32 wk).
- Dry, remove wet linen, position airway (sniffing).
- Suction ONLY if airway obstruction visible.
- Stimulate — flick soles, rub back.
PPV thresholds
- HR < 100 OR apnoea: start PPV at 40–60/min.
- HR < 60 despite 30 s effective PPV: chest compressions 3:1 with PPV.
- HR < 60 despite compressions + 100 % O2: IV epinephrine 0.02 mg/kg.
- HR < 60 at 20 min of effective resus: discuss with team and family.
SpO2 targets (right hand)
- 1 min 60–65 %; 5 min 80–85 %; 10 min 85–95 %.
Limitations
- Educational tool — active resuscitation requires NRP-certified personnel.
- Every birth needs at least one person whose only responsibility is the baby.
- Preterm < 32 wk has specific NRP modifications (warm transport, plastic bag, thermal mattress).
- The algorithm decision is faster than this walk-through — in real time, NRP-trained teams run it in seconds.
Sources
- American Academy of Pediatrics / American Heart Association. Textbook of Neonatal Resuscitation, 8th Edition (NRP 8). 2021.
- Wyckoff MH, et al. (ILCOR Neonatal Life Support Task Force). Neonatal Life Support 2020 International Consensus on CPR and ECC Science with Treatment Recommendations. Circulation 2020;142(suppl 1):S185–221.
- ACOG Committee Opinion 814. Delayed Umbilical Cord Clamping After Birth. 2020.
- WHO. Guideline: Delayed Umbilical Cord Clamping for Improved Maternal and Infant Health and Nutrition Outcomes. 2014.
Frequently asked questions
What is NRP?
The Neonatal Resuscitation Program is the international standard educational program for newborn resuscitation, developed jointly by the American Academy of Pediatrics (AAP) and the American Heart Association (AHA). The 8th edition (NRP 8, 2021) reflects ILCOR's 2020 Consensus on Science with Treatment Recommendations. NRP-certified personnel are required at every delivery to provide effective initial steps, positive-pressure ventilation, chest compressions, and pharmacological resuscitation when needed.
What proportion of newborns need help?
About 10 % of newborns need SOME help breathing at birth (stimulation, positioning, oxygen). About 1 % need active resuscitation with positive-pressure ventilation. Less than 0.1 % need chest compressions or epinephrine. Even at term, ~ 5–10 % of babies require some intervention beyond drying and warmth. Risk increases with prematurity, low birth weight, meconium-stained fluid, maternal sedation, antepartum/intrapartum complications.
What are the three initial assessment questions?
Within seconds of birth: (1) Term gestation? (2) Good muscle tone? (3) Crying or breathing? If ALL THREE answers are YES, the baby goes to the mother for routine care, delayed cord clamping, and skin-to-skin. If ANY answer is NO, the baby goes under a radiant warmer for the initial steps: warm, dry, position, stimulate, suction if airway obstructed.
Why is PPV (positive-pressure ventilation) the most important step?
Because the commonest cause of perinatal bradycardia and arrest is INADEQUATE OXYGEN DELIVERY due to apnoea or ineffective breathing. Restoring ventilation usually restores circulation. NRP teaches that 'effective PPV' is the single intervention with the highest yield. The MR SOPA mnemonic helps when chest rise is inadequate: Mask reposition, Reposition head, Suction, Open mouth, Pressure increase, Alternate airway (intubation or LMA).
When do chest compressions start?
When HR is < 60 beats/min DESPITE 30 SECONDS of effective PPV. Confirm chest rise first. Coordinate 3 compressions : 1 ventilation = 90 compressions + 30 breaths per minute. Two-thumb encircling technique on the lower third of the sternum, depth 1/3 anteroposterior chest. Increase FiO2 to 100 % during compressions. Reassess heart rate every 60 seconds; continue compressions until HR > 60, then PPV alone until HR ≥ 100.
What are the NRP SpO2 targets?
Right-hand (pre-ductal) saturation targets at minutes of life: 1 min 60–65 %; 2 min 65–70 %; 3 min 70–75 %; 4 min 75–80 %; 5 min 80–85 %; 10 min 85–95 %. Term babies start in 21 % O2; preterm 35–37 wk in 21–30 %; < 35 wk in 30 %. Titrate to the minute-specific targets — don't overshoot with 100 % O2 (oxidative injury risk) unless during active chest compressions.
What is delayed cord clamping?
Waiting ≥ 60 seconds before clamping the umbilical cord (WHO 2014, ACOG CO 814 2020). For VIGOROUS newborns it reduces anaemia, increases iron stores at 4 months, reduces IVH in preterms by ~30 %, and improves long-term neurodevelopmental outcomes. For NON-vigorous newborns the choice is between standard early clamping → move to warmer and start resus, vs umbilical-cord milking, vs intact-cord resuscitation (newer approach with mixed evidence; ABC trial 2023 showed safe and feasible).
How does this relate to other calculators on BumpBites?
Companion tools: /calculators/apgar-score for the 1-minute and 5-minute scoring (note Apgar does NOT drive resuscitation decisions — the algorithm does); /calculators/sarnat-hie + /calculators/thompson-hie + /calculators/neonatal-cooling for the HIE pathway if resuscitation reveals significant encephalopathy; /calculators/newborn-bilirubin for post-resus monitoring; /calculators/eos-sepsis for the parallel sepsis decision.