SPECIAL NOTE:  Maternal estimates of “due date” may be inaccurate.  Very premature infants and infants of certain other high-risk pregnancies may be very small.  Determination of fetal viability is best left to trained hospital personnel.   As such, attempts should be made to resuscitate all infants, unless BioTel or a Medical Command Physician advises otherwise.

Basic Level

  1. Within the first 30 seconds:
    1. Warm and dry the infant – take care to avoid hypothermia (increased ambient temperature).
    2. Position the infant to facilitate drainage of airway secretions.
    3. Stimulate by gently rubbing the back.
    4. Clear the airway, if needed, for clear or meconium-stained amniotic fluid, if the infant cannot clear his/her own airway due to apnea or “drowning” in secretions:
      1. Perform deep tracheal suctioning before instituting other resuscitative measures. Refer to the CHILDBIRTH-ABNORMAL Special Procedures section or contact BioTel for detailed instructions.
  2. Assess respirations:
    1. If respirations are inadequate or gasping after suctioning or heart rate is less than 100, gently assist ventilations at a rate of 40 to 60 per minute, using an infant BVM with room air.
    2. Monitor the infant’s SpO2 on the right hand or wrist – supplemental oxygen to achieve mean per-minute goal saturations** (see next page) is secondary to effective ventilation.
  3. Assess heart rate:
    1. If the heart rate remains less than 100 after respiratory interventions, take corrective steps to improve ventilation, according to the “MRSOPA” algorithm:
      1. Mask: check the seal
      2. Reposition: make sure infant is in the sniffing position (do not flex or hyper-extend the neck)
      3. Suction (mouth before nose)
      4. Open the mouth
      5. Pressure increase (gentle!)
      6. Alternative airway (either intubate or place LMA, if available: advanced level providers only)
    2. If heart rate remains less than 60, increase oxygen concentration to 100% and begin chest compressions:
      1. Use the 2-thumb/encircling hands technique (thumbs side by side, just below nipple line).
      2. Compression-to-ventilation RATIO for neonates is 3 to 1.
      3. The compression rate is 120 events per minute (90 compressions interspersed with 30 ventilations).
  4. Assess skin color (for APGAR score only – see next page):
    1. Score: Blue/pale = 0 points; Body pink/extremities blue = 1 point; Completely pink = 2 points.
    2. Provide oxygen supplementation to maintain mean per-minute goal saturations** (see below).
  1. Clamp and cut the umbilical cord; place a vigorous infant skin-to-skin on the mother’s chest to retain warmth.
  2. Calculate and record the APGAR score at 1 minute and again at 5 minutes postpartum (see next page).
  3. Once advanced level providers arrive on-scene, give report and transfer care.
  4. Notify the receiving hospital or contact BioTel as early as possible for destination recommendations and early receiving hospital notification.
  5. Monitor ECG and SpO2 continuously on the infant’s right hand or wrist until hospital arrival; prevent heat loss and hypothermia.
    1. Oxygen may be supplemented to achieve mean per minute goal saturations**, but this is secondary to effective ventilation.
  1. If the infant does not respond to CPR, obtain vascular access with Normal Saline and perform POC glucose analysis:
    1. For hypoglycemia (POC glucose less than 45 mg/dL) administer:
      1. 10% dextrose @ 2 mL/kg IV/IO; OR
      2. Glucose (40%) gel @ 0.5 mL/kg (0.2 g/kg), massaged into the mucosa of the cheek pocket:
        1. Exercise extreme caution administering to a depressed infant without a gag reflex
    2. For heart rate less than 100 bpm during CPR, administer epinephrine 1:10,000 0.01 mg/kg (0.1 mL/kg) IV/IO, followed by a flush with 5 mL Normal Saline; repeat every 3 to 5 minutes, as needed.
    3. For suspected narcotic toxicity, provide positive pressure ventilation with supplemental oxygen, as needed, to maintain mean per-minute saturation goals**, until transfer of care to hospital personnel.
  2. Transport as soon as possible.
  3. For additional patient care considerations not covered under standing orders, consult BioTel.

*APGAR Score:

  0 Points
Appearance Blue, pale
Pulse Rate Absent
Grimace No response
Activity Limp
Respirations Absent
  1 Point (each)
Appearance Body Pink, extremities blue
Pulse Rate Less than 100 per minute
Grimace Grimaces
Activity Some flexion
Respirations Slow, irregular
  2 Points (each)
Appearance Completely pink
Pulse Rate Greater than 100 per minute
Grimace Cough, sneeze, cry
Activity Active motion
Respirations Good, crying

**Oxygen Saturation (SpO2) Goals per Minute of Life

Time (minutes) O2 Saturation (SpO2) Goal
1 60-65%
2 65-70%
3 70-75%
4 75-80%
5 80-85%
10 85-95%