Shaun’s Guide to Basic NRP

Equipment Check
1. Laryngoscope (straight blade)
a. 00 = premature
b. 0 = term
c. 1 = term (big baby)
2. ETT (always mention one size up and one size down)
a. <1kg = 2.5
b. <2kg = 3.0
c. 2-3kg = 3.5
d. >3 = 4.0
3. Suction tube
a. Black – 10 fr (big baby)
b. Blue – 8 fr (term/preterm)
c. Green – 6 fr (preterm)
4. Bag valve mask
a. Check 4 things
i. Fish mouth
ii. Pressure valve
iii. Leakage of main body
iv. Inflation of reservoir (by pumping or by oxygen introduction)
b. Correct sized mask
5. SpO2 machine
6. Adrenaline
a. 1 in 10,000
b. One ampoule = 1ml = 1mg
c. Put 1ml (1 ampoule) into a 10ml syringe filled with 9ml of normal saline (total 10ml)
i. Via ETT = 0.5-1.0ml/kg
ii. Via IVD/UVC = 0.1-0.3ml/kg
7. UVC set
a. Must prepare with sterile technique
b. You will need a sterile kit, sterile gloves, suture, and blade
8. Normal saline for resuscitation
a. 10ml/kg given over 5-10 minutes
9. Surfactant
a. Only needed if baby is preterm and suspected of surfactant deficiency
b. Transport it from NICU via an ice box with ice
c. Warm it up using radiant warmer when you reach standby
d. Must always prepare it in a sterile manner
The Call
You are the MO on-call and the O&G team has decided to ruin your night by telling you that someone is giving birth
soon. There are 5 questions that you will have to ask to have an idea on how your standby is going play out. So
remember!

TWO questions regarding mother

THREE questions regarding the baby

1. Antenatal issues (M)

a. E.g. placenta praevia, GDM mother, unbooked unscreened
2. Liquor (M)
a. E.g. blood stained, meconium stained, clear
3. Gestational age (B)
4. Estimated fetal weight (B)
5. Single or multiple (B)

Arrival to Standby
This is the part where you arrive at the standby and basically what and how you need to prepare your stuff before the
baby is born.

1. Turn on the radiant warmer

2. Prepare 3 towels stacked on top of each other
3. Make sure your laryngoscope has the correct size attached and able to turn on
4. Prepare the ETT tubes, one size appropriate for estimated weight, one higher and one lower
a. E.g. Baby is 3 kg, therefore prepare 3.5, 3.0 (one lower) and 4.0 (one higher)
5. Prepare your suction catheter
a. Connect it to the suction tube and bottle
b. Increase the suction pressure to 80-100 mmhg
c. DO NOT remove suction catheter from the sterile plastic that it comes in
d. Test the suction by occluding the hole
i. You will see the plastic being sucked in
6. Place your SpO2 monitor aside
7. Place your timer at an easy to reach and easy to see spot
8. Connect your bag valve mask to the oxygen and blender
a. Oxygen 10L/min
b. FiO2 21%
9. Wash your hands and prepare sterile gloves
10. As for the surfactant and adrenaline just leave it aside for now until the situation where you’ll need them arrives
When the Baby is Born
This is the part where the fun begins! The baby has arrived and there are 3 questions you need to ask yourself before
proceeding to the next step.

1. Is the baby term? Does it look term?

a. Sometimes the O&G peeps could make a mistake regarding the gestational age
b. So make sure you check and ask yourself if this baby truly looks term or not
2. Is the baby crying or breathing spontaneously?
3. How is the tone of the baby?

Phase 1a – the initial steps

Once you’re done asking those 3 main questions, you have approximately 30 seconds to complete your ‘initial steps’
before the next phase begins. There are 5 things you need to do.

1. Warm the baby (remember turning on the radiant warmer in the beginning?)
2. Dry the baby with the towel
3. Whilst drying the baby, stimulate the baby by rubbing back or flicking soles of feet
4. Throw away the wet towel
5. Suction
a. Measure the suction catheter length from the mouth to tragus
b. Suction mouth first, then nostrils

Your initial steps should take roughly 30 seconds to complete. Once you reach 30 seconds, there are 2 questions that
you need to ask/assess yourself.

1. What is the heart rate of the baby?

a. Can be done via auscultation of the heart or by palpating the umbilical cord
b. Count for 6 seconds and times it by 10 (this is to save time)
2. Is the baby breathing spontaneously?

*DO NOT attach the SpO2 monitor at this point*

If the baby comes out crying, good tone, breathing spontaneously, HR >100, then congrats! You can go back to sleep!
Phase 2 – the resuscitation
But what if it doesn’t?

Based on what the answers are to the 2 questions above, the next step will be decided accordingly.

IMPORTANT: Even if the heart rate of the baby is >100 or <100 BUT the baby is not breathing/has no breathing effort,
PPV MUST be started. If the breathing effort is good but the SpO2 is low, just maintain via CPAP or nasal prong and
adjust FiO2 accordingly.

e.g.

 HR 100, no breathing effort = PPV

 HR 100, breathing effort = oxygen support
 HR 80, no breathing effort = PPV
 HR 80, gasping = PPV

But now what about this?

 HR 40, no breathing effort

As you know in NRP there are 2 magic numbers. First one being 100, and the second one being 60. These two numbers
correspond to the heart rate of the baby. There are two rules that are always applied to these two numbers.

 Heart rate < 100 indicates the need to start PPV

 Heart rate < 60 indicates the need to start chest compressions

So now what about the example above? The heart rate is 40. So should we skip PPV and go straight to chest
compressions?

The answer is no. You must always follow the NRP algorithm and start with effective ventilation via PPV as the baby’s
heart rate may pick up even without the need for chest compressions.
So, lets go through a scenario. You’ve done all your initial steps and now you’ve asked the two questions. HR is 80 and
the baby is not breathing. So what should you do?

1. Start PPV
a. Mask must not cover eyes, must cover nose bridge and chin with no leakages
2. Attach SpO2 monitor
3. Rate/rhythm of bagging
a. Bag..2..3..bag..2..3..bag..2..3..
4. After 5 bags assess the quality of ventilation
a. The definition of effective ventilation
i. Chest rise
ii. Bilateral audible air entry
5. If the chest is not rising or ventilation is not effective, move on to MR SOPA
6. MR SOPA is a mnemonic used as a correction to ineffective ventilation
a. M – Mask readjustment
b. R – Reposition airway
c. S – Suction
d. O – open mouth
e. P – Pressure increase
f. A – Airway alternative
7. Always do it two by two
a. E.g. do MR first, then bag 5 times and reassess chest rise, if still no chest rise, move on to SO, then bag
another 5 times and reassess chest rise, if still no chest rise, move on to PA
8. Once effective ventilation is achieved, continue PPV for 30 seconds
9. Once 30 seconds are up, ask the three very important follow up questions

NRP is basically like maths. 1 + 1 + 1 = 3. So, there are three variables that will always determine what action you should
be doing next. These three include: heart rate, SpO2, and breathing effort. Now bear in mind that breathing effort and
breathing difficulty are two separate things. What we’re looking at is breathing effort which basically means whether the
baby is breathing on its own or not (with an exception to gasping). So the 3 important questions that you always need to
ask after every step is:

 How is the breathing effort of the baby?

 What is the heart rate of the baby?
 What is the SpO2 of the baby?

The answer to these three questions will help you decide what to do next. For example:

1. If heart rate remains above 60 but the SpO2 is still low, continue PPV but increase the FiO2 slowly
2. If the heart rate drops below 60, move to the next phase and start chest compressions
Phase 3 – chest compressions
Ok, so now let’s say you’ve been providing effective ventilation for the past 30 seconds and now you reassess the baby.
HR has now dropped to 40 and SpO2 is 40% and baby is still not breathing. This is when shit hits the fan. What should
you do next?

1. Ask your assistant to start chest compressions

a. Can be done via two finger technique or thumb technique
b. Just slightly below mid nipple level
c. Rate 100 – 120 bpm
d. Rhythm – 1 and 2 and 3 and bag and 1 and 2 and 3 and bag and……
e. Depth 1/3 of chest
f. The rhythm should be counted by the assistant and he/she must remind the main resuscitator to bag
2. Increase FiO2 to 100%
3. Continue PPV with the above mentioned rhythm
4. Intubate the baby
a. Whenever chest compressions are indicated, ALWAYS prepare to intubate as you require a definitive
airway
b. Stop chest compressions whilst attempting to intubate
c. Insert the ETT until the level of (weight + 6)
d. Connect the bag valve mask and check if the ETT is in place by auscultating the lungs for bilateral air
entry and abdomen for any gurgling sounds and check for chest rise
e. If there is no bilateral air entry or there are gurgling sounds present in the abdomen, pull out the ETT
tube slowly by 0.5cm at a time
f. Anchor the ETT with hyper fix
5. Each chest compression cycle lasts for 1 minute
6. Reassess the baby using the 3 questions above (HR, SpO2, breathing effort) after each cycle

Phase 4 – medication
So when do you decide to give Adrenaline and how do you give it? Let’s say now you’ve provided one minute of
effective ventilation and good quality chest compressions yet after reassessing the baby, HR is still 40 and SpO2 is still
low/undetectable. According to the algorithm, we always give adrenaline after 1 minute of chest compressions, which
also means after the FIRST CYCLE. So a lot of people get confused here as there is a grey area when the chest
compressions are first started and when the ETT and laryngoscope are being prepared/inserted and what constitutes
the ‘first cycle’.

Basically, when you start chest compressions, intubation must be done as soon as possible. Ideally within the next 10
seconds or so. Once the ETT is in and anchored, the ‘true’ first cycle begins and preparation of the adrenaline should be
done/requested now. At the end of one minute, reassess the patient and if the HR is still below 60, give the adrenaline.
 1. Prepare adrenaline 1ml + normal saline 9ml in a 10ml syringe
2. Reassess the heart rate after one minute
3. If HR < 60 then administer adrenaline WITHOUT STOPPING chest compressions
a. Via ETT 0.5 - 1.0 ml/kg
b. Via IVD/UVC 0.1 - 0.3 ml/kg
4. Reattach bag valve mask and bag a few times to push the adrenaline through then return to the normal
resuscitation rhythm
5. Give adrenaline every 3 – 5 cycles (every 3 – 5 minutes)

At this point it may be worth to request for your assistant to insert a UVC. Although we are able to give adrenaline
through the ETT, the efficacy of it is less than that if given via IVD/UVC. Chest compressions (and bagging) must be
continued whilst the UVC is being inserted. Swap to the two finger technique and move to the side or top of the bed to
allow space for insertion. Remember that the dosages for the 2 routes are different so make sure to give a clear
command on what dose should be given if the routes are switched and to flush using normal saline after administering
via UVC.