THE NRP 9TH EDITION ALGORITHM

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

NRP 9th Edition Algorithm — Neonatal Resuscitation Step by Step

The Neonatal Resuscitation Program (NRP) 9th edition, based on the 2025 AHA/AAP guidelines, puts team preparation and a cord plan first, then ventilation, compressions, and epinephrine in order. This guide covers the algorithm, what changed from the 8th edition, the key numbers, special situations, and post-resuscitation care.

🎯 AT A GLANCE — THE 9TH EDITION NRP

The Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP) is updated from the 2025 AHA/AAP guidelines; the 9th edition was released in November 2025

About 10% of newborns need some help to breathe and fewer than 1% need intubation, compressions, or medicines — effective ventilation is the key step

The algorithm now starts with birth and a cord management plan; it then asks gestational age, tone, and breathing to decide between routine care and resuscitation

Corrective ventilation steps (MR. SOPA) are now chosen by what is wrong, and the laryngeal mask can be a first airway choice

Check your hospital's current version. NRP instructors were to teach the 9th edition by 1 June 2026; the full algorithm card should be obtained from the AAP.

🆕 WHAT CHANGED — 8TH TO 9TH EDITION

Topic	9th edition
Start of the algorithm	Birth → initiate cord management plan appears at the top, with the pre-birth team briefing
Cord clamping	Deferred clamping for at least 60 seconds (earlier advice: 30–60 seconds) in most newborns who do not need immediate resuscitation
Cord milking (intact cord)	35–42 weeks: may be considered in non-vigorous newborns; 28–34 weeks: insufficient evidence; under 28 weeks: not recommended (severe IVH risk)
Suction	Not routine — clear the airway only if needed
Ventilation rate	30–60 breaths per minute (was 40–60)
Initial pressure	Initial PIP 25 cm H₂O; PEEP 5 cm H₂O (about 20–25 in preterm and 25–30 in term babies)
Oxygen saturation targets	Table now starts at 2 minutes (the 1-minute row was removed)
Initial oxygen	≥ 35 weeks: 21%; 32–34 weeks: 21–30%; under 32 weeks: ≥ 30%
Corrective steps (MR. SOPA)	Prioritised by what is wrong, not in a strict sequence
Laryngeal mask	May be used as a first airway to start ventilation, not only as a rescue
Endotracheal tube depth	Measured tip-to-gum (upper gum, midline), not tip-to-lip
New lessons	Congenital heart disease; resuscitation in the NICU; prehospital (neonatal chain of care)

STEP 1 · THE ALGORITHM — from birth to post-resuscitation care

🧭 NRP 9TH EDITION — ALGORITHM STEP BY STEP

BIRTH — PREPARE BEFORE THE BABY ARRIVESTeam briefing (leader, roles, risk factors), equipment check, and initiate the cord management plan

▼

THREE QUICK QUESTIONSGestational age (term or late preterm)? Tone good? Breathing or crying?

▼all YES

STAY WITH MOTHER — ROUTINE CAREWarm and dry, skin-to-skin, clear the airway only if needed, ongoing observation; delayed cord clamping ≥ 60 seconds

▼any NO

INITIAL STEPS (within about 1 minute)Warm and maintain normal temperature; position the airway; clear secretions only if needed; dry and stimulate

▼Evaluate breathing and heart rate

APNOEA, GASPING, OR HEART RATE < 100Start positive-pressure ventilation (PPV) at 30–60 breaths/min; SpO₂ probe on the right hand; consider ECG monitor

LABOURED BREATHING OR PERSISTENT CYANOSISPosition and clear airway; SpO₂ monitor; supplemental oxygen as needed; consider CPAP (PEEP 5)

▼after 15 seconds of PPV — heart rate and chest rise

IS THE CHEST MOVING? HEART RATE RISING?If not, correct the ventilation: Mask, Reposition, Suction, Open mouth, Pressure, Alternative airway (laryngeal mask or endotracheal tube) — by the problem seen

▼heart rate below 60 after 30 seconds of ventilation that moves the chest

CHEST COMPRESSIONSIntubate (or laryngeal mask) if not done; 100% oxygen; 3 compressions : 1 ventilation (90 : 30 per minute); ECG monitor; emergency umbilical venous catheter (UVC)

▼heart rate still below 60 after 60 seconds of compressions

EPINEPHRINE ± VOLUMEIV/UVC epinephrine 0.02 mg/kg (0.2 mL/kg of 0.1 mg/mL), repeat every 3–5 minutes; 10 mL/kg normal saline if hypovolaemia is suspected; check for pneumothorax

▼heart rate ≥ 100 and breathing

POST-RESUSCITATION CAREStabilise in the NICU or a monitored area: temperature, glucose, oxygen, family communication, and assess for cooling therapy

Summary of the algorithm structure. Always check heart rate, breathing, and SpO₂ after each step; ventilation is the most important action, and compressions start only when ventilation is effective and the heart rate is still below 60.

STEP 2 · THE DETAILS — oxygen, ventilation, airway and compressions

🫁 OXYGEN AND SPO₂ TARGETS

Time after birth	Target SpO₂ (right hand)
2 minutes	65–70%
3 minutes	70–75%
4 minutes	75–80%
5 minutes	80–85%
10 minutes	85–95%

Gestation	Starting oxygen (FiO₂)
35 weeks or more	21% (room air)
32–34 weeks	21–30%
Under 32 weeks	30% or higher
During chest compressions	100%; wean when the heart rate recovers

Titrate to the SpO₂ table, not to a fixed starting oxygen — avoid hyperoxia, especially in preterm babies.

🔧 VENTILATION AND AIRWAY

Item	Recommendation
Device	T-piece resuscitator, self-inflating bag, or flow-inflating bag; mask well sealed
Rate	30–60 breaths per minute; 'breathe–two–three' rhythm
Initial PIP	25 cm H₂O; about 20–25 for babies under 32 weeks and 25–30 from 32 weeks
PEEP	5 cm H₂O
Success	Rising heart rate first; visible chest movement; then rising SpO₂
MR. SOPA	Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase, Alternative airway — apply those that fit the problem
Laryngeal mask	Suitable as a first or rescue airway for babies about 34 weeks or more (and over 2 kg) when mask ventilation or intubation fails
Endotracheal tube (size by weight)	Under 800 g (≤ 25 wk): 2.5 mm (2.0 mm optional); 800–1,200 g: 2.5 mm; 1,200–2,200 g: 3.0 mm; over 2,200 g: 3.5 mm
Tube depth	Tip-to-gum measured at the upper gum; confirm with exhaled CO₂ and rising heart rate

❤️ COMPRESSIONS AND MEDICINES

Step	Details
When	Heart rate below 60 after 30 seconds of ventilation that moves the chest (preferably through an advanced airway)
Technique	Two thumbs over the lower third of the sternum, hands encircling the chest; depth about one-third of chest diameter
Ratio	3 : 1 (90 compressions and 30 breaths per minute); use 100% oxygen; do not interrupt unnecessarily
Epinephrine	IV or UVC: 0.02 mg/kg (0.2 mL/kg) of 0.1 mg/mL (1 : 10,000); repeat every 3–5 minutes
Endotracheal epinephrine	Only while IV access is being established: 0.1 mg/kg (1 mL/kg); give IV as soon as possible
Volume	10 mL/kg normal saline (or O-negative blood) over 5–10 minutes, if blood loss is suspected or the baby is pale with no response
Other causes	Pneumothorax, airway obstruction, severe hypovolaemia, or congenital heart disease — reconsider if the baby does not respond
Naloxone	Not recommended in the delivery room; support ventilation

STEP 3 · SPECIAL SITUATIONS — cord, preterm, meconium and stopping

🔗 CORD MANAGEMENT AND PRETERM BABIES

Cord Management

Plan before birth with the obstetric team

Delay clamping ≥ 60 seconds if the baby does not need immediate resuscitation

Intact-cord milking: ≥ 35 weeks (non-vigorous), 28–34 weeks with limited evidence, never under 28 weeks

Preterm Babies

Plastic wrap or bag and a radiant warmer; keep the room warm (about 23–25 °C)

Start PPV or CPAP with PEEP 5; avoid high pressures

Cap for the head; use a thermal mattress

Prevent both hypothermia and hyperthermia

🌀 MECONIUM, DIFFICULT AIRWAYS AND STOPPING

Meconium-stained fluid: no routine suction and no routine intubation; for a non-breathing baby, start ventilation; suction only if the airway is obstructed

Congenital diaphragmatic hernia, airway malformation, or fetal hydrops: plan with a specialist team before delivery

Persistent heart rate < 60 despite effective compressions and epinephrine: check airway, tube position, pneumothorax, and volume

Stopping resuscitation: redirection of care may be considered if there is no detectable heart rate after 20 minutes of high-quality resuscitation — a decision for the whole team and parents

Parents: explain what is happening, and allow support person presence where possible

🛌 AFTER RESUSCITATION

Area	What to do
Where	Move to a NICU or monitored stabilisation area; continuous heart rate and SpO₂
Temperature	Keep normal (about 36.5–37.5 °C); avoid hypothermia and hyperthermia
Glucose	Check blood glucose early and treat hypoglycaemia
Oxygen and ventilation	Titrate oxygen; avoid hyperventilation and hyperoxia
Hypoxic-ischaemic encephalopathy	Assess for therapeutic hypothermia: in babies of about 36 weeks or more with moderate or severe encephalopathy, start within 6 hours under controlled NICU conditions — never during the resuscitation itself
Record	Cord clamping time, Apgar scores, time to first breath, to ventilation, and every intervention
Debrief	Review the team's performance, communication, and equipment; support the family and the team

Neonatal chain of care: the 9th edition links prevention, resuscitation, and post-resuscitation care — hand over clearly to the NICU team.

⚠️ COMMON PITFALLS

Starting compressions before effective ventilation — chest rise and a rising heart rate come first

Routine suction and stimulation for too long — it delays ventilation

Using high oxygen routinely in preterm babies, or forgetting to wean oxygen to the SpO₂ table

Putting the SpO₂ probe on the wrong site — use the right hand or wrist for pre-ductal readings

Poor team briefing: no leader, no cord plan, or equipment not tested

Forgetting temperature and glucose in the first hour

Memory Aid

BREATH

Six anchors for the 9th edition NRP algorithm.

B

Brief the team and make a cord plan before birth

R

Routine care if term, good tone, and breathing; otherwise resuscitate

E

Evaluate heart rate, breathing, and SpO₂ at every step

A

Assist ventilation at 30–60 per minute; correct with MR. SOPA

T

Tube or laryngeal mask, then compress 3 : 1 if heart rate is below 60

H

Hit with epinephrine IV 0.02 mg/kg, and hypovolaemia check — then debrief

Remember: ventilation first, then compressions, then epinephrine — and reassess heart rate, breathing, and oxygen at every step.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary of the 2025 American Heart Association (AHA) and American Academy of Pediatrics (AAP) neonatal resuscitation guidelines and the NRP 9th edition; this is not a replacement for the official NRP algorithm card and provider course; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.