- The Initial Assessment
- The Golden Minute and Escalation
The Initial Assessment
The first seconds after birth are the same every time: three questions, answered immediately, that determine everything that follows.
The three initial assessment questions
Before any intervention, the provider evaluates three criteria simultaneously (Table 5):
Question | If yes | If no |
|---|---|---|
| Term gestation? | Continue assessment | Begin resuscitation steps |
| Good tone? | Continue assessment | Begin resuscitation steps |
| Breathing or crying? | Routine newborn care | Begin resuscitation steps |
If the answer to all three questions is yes, the newborn can receive routine newborn care (drying, warming, and ongoing observation) without separation from the mother. If the answer to any one of the three questions is no, the infant should be moved to the radiant warmer and the initial resuscitation steps begun immediately.
The initial steps
For any infant who doesn't pass all three initial questions, these steps should be done within 30 seconds:
- Provide warmth by placing the newborn under a radiant warmer
- Position the head in a neutral or slightly extended "sniffing" position to open the airway
- Clear the airway if necessary, by suctioning the mouth, then the nose (only if secretions are present and obstructing the airway)
- Dry and stimulate, by drying the infant vigorously with a warm towel (this provides stimulation simultaneously)
- Remove wet linen
Deferred cord clamping
Current guidelines recommend deferred cord clamping (DCC) for at least 30-60 seconds for term and preterm infants who do not require immediate resuscitation. Where DCC is being performed and resuscitation is also needed, initial steps can be initiated at the maternal bedside during the deferral period where staffing and equipment allow. Cord milking may be considered for infants ≥28 weeks when DCC is not feasible, but should not be performed in infants under 28 weeks due to increased risk of intraventricular hemorrhage.
Heart rate and respiratory assessment
After completing the initial steps, the provider evaluates two parameters to determine the next course of action: respiratory effort and heart rate.
Respiratory effort is assessed visually. Effective breathing (regular, spontaneous chest rise) is the goal. Apnea, gasping, or absent respiratory effort requires escalation to PPV regardless of heart rate.
Heart rate is the single most important clinical indicator in neonatal resuscitation. Current guidelines recommend ECG as the preferred method for heart rate assessment during active resuscitation, as pulse oximetry and auscultation both underestimate heart rate in the first minutes of life. A heart rate of 100 bpm or above with adequate breathing is reassuring. A heart rate below 100 bpm, or any infant with absent or inadequate respiratory effort, requires PPV.
ECG is the preferred method for heart rate assessment during active resuscitation. Pulse oximetry and auscultation may underestimate heart rate in the first minutes of life and should not be relied upon as the primary method when a clinical decision depends on the value.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
