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Neonatal Resuscitation Program

(NRP) 2011
New Science, New Strategies
Jeanette Zaichkin, RN, MN, NNP-BC; Gary M. Weiner, MD, FAAP

ABSTRACT
In spring 2011, the American Academy of Pediatrics (AAP) will release sixth edition materials for the Neonatal
Resuscitation Program (NRP). This edition brings changes in resuscitation practice and a new education methodology that
shifts the instructor from “teacher” to “learning facilitator” and requires the NRP course participant to assume more
responsibility for learning. The change from a lecture format to simulation-based learning requires instructors to learn
new skills and meet new requirements to maintain instructor status.
The sixth edition of the Textbook of Neonatal Resuscitation and the fifth edition of the Instructor’s Manual for
Neonatal Resuscitation are currently in press. The AAP granted permission to use material from these forthcoming
publications in this article.

Editor’s note: This article is intended to update neonatal heathcare
professionals on the upcoming NRP changes for 2011. To that end,
this article has been written by authors closely involved in the NRP
updating process and the article has not been peer-reviewed. It is being
published simultaneously in Neonatal Network (30:1) to ensure
that as many care providers as is possible receive this information.
exceeded everyone’s expectations. More than 3 million
health care professionals have received NRP course
completion cards from about 27,000 instructors, and
many hospitals now require NRP provider status as a
condition of employment and staff credentialing2.
For experienced neonatal nurses, the NRP has
become an old friend. Every two years, we pick up

T
he Neonatal Resuscitation Program (NRP) was
launched in 1987 as a learning program, the pri-
mary goal of which was to ensure that at least
one person trained in neonatal resuscitation techniques
was present at every hospital birth1. The program far
Author Affiliations: Jeanette Zaichkin is a consultant for the
American Academy of Pediatrics Neonatal Resuscitation Program
Steering Committee, editor of the Instructor’s Manual for Neonatal
Resuscitation, and associate editor of the Textbook of Neonatal
Resuscitation. She is the neonatal outreach coordinator at Seattle
Children’s Hospital; Jeanette.zaichkin@seattlechildrens.org
The authors wish to acknowledge Rachel Poulin, MPH, manager,
Neonatal Resuscitation Program, American Academy of Pediatrics,
for her assistance with the preparation of this manuscript.
Dr. Gary M. Weiner is a participant in the ILCOR neonatal
delegation and associate editor for the Textbook of Neonatal
Resuscitation. He is a an associate clinical professor at
Wayne State University School of Medicine, Detroit,
Michigan; weinerg@trinity-health.org
Copyright © 2011 Springer Publishing Company, LLC, and The
National Association of Neonatal Nurses.
DOI:10.1097/ANC.0b013e31820e429f
this friendship right where we left off, catch up on
what’s new, and meet our employer’s requirement to
get “checked off” and “recertified.” In many hospitals,
the NRP Renewal course consists of a take-home writ-
ten exam followed by a five-minute Megacode check
off with an NRP instructor. Individuals whose NRP
card expires are required to take the Provider course,
which may include up to eight hours of slides and lec-
ture and a proctored examination prior to the
Megacode check off.
Instructors have followed the American Academy of
Pediatrics/American Heart Association (AAP/AHA)
recommendations for NRP training and have made
NRP convenient for their learners. However, most
NRP instructors and experienced course participants
do not expect to be challenged by their biennial NRP
experience. That is about to change.
WHY CHANGE THE NRP EDUCATION
METHODOLOGY?
Much of the success of the NRP can be attributed to
the commitment and expertise of its Instructors and

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44 Zaichkin and Weiner
Regional Trainers. Since the NRP’s inception,
instructors have been trained to teach learners
(health care) providers in a classroom setting using
lecture materials from the instructor manual, instruc-
tional videos and DVDs, and PowerPoint slides.
Although instructors have done an excellent job
teaching health care providers the course content, the
traditional classroom model may not be the most
effective method for learners to acquire the cognitive,
technical, and behavioral skills essential for newborn
resuscitation. The emphasis on transferring content
knowledge to learners during a full day of lectures
prevents instructors from using their valuable time to
facilitate more productive activities.
In 2004, the Joint Commission investigated 47 cases
of infant death or injury during delivery and found that
ineffective communication and teamwork were the
most common root causes. The findings are detailed in
a Sentinel Event Alert that now includes 109 cases.3 The
agency recommended that health care organizations
conduct the following:
• team training to teach staff how to work
together and communicate more effectively
• clinical drills to help staff prepare for uncom-
mon but high-risk events
• debriefings to evaluate team performance and
identify areas for improvement
The NRP Steering Committee believes that now is
the right time to update the NRP education methodol-
ogy so that it supports these recommendations. They
have carefully reviewed the curriculum and identified
the following key issues that need revision.2
• NRP instructors feed information to passive
learners through slides and lecture. Instructors
report that they spend most of their face-to-face
time lecturing, but also indicate that lectures are
an ineffective way for learners to learn.4 Passive
learners usually do not assume responsibility for
their own learning and are less likely to remem-
ber information. The revised NRP course must
actively engage its participants.
• NRP learners often arrive poorly prepared for
their class. Most instructors can cite instances of
learners arriving at an NRP course with the text-
book still inside its packaging. Lack of learner
preparation decreases the educational efficiency of
the class and prevents instructors from using their
time most effectively. Learners must be expected
to arrive at the new NRP course well prepared.
• The current NRP course teaches content and
technical skills but lacks a component for learning
the communication and teamwork skills that
improve patient safety. Learner demonstration of
skills during the predictable Megacode scenario,
often performed in a classroom instead of a real-
istic delivery room setting, fails to indicate how
the learner and team would behave in an actual
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
emergency under stress and time pressure. The
Megacode actually discourages teamwork and
communication by demanding that assistants
work quietly without providing critical feedback
to the “lead” resuscitator. The new NRP course
will develop teamwork and communication skills.
• The current methodology requires providers to
successfully complete the same NRP course every
two years to receive their course completion card
and remain compliant with hospital requirements.
This inference of competence may give learners a
false sense of security. The NRP course must grad-
ually replace this compliance model of education,
where learners are never challenged to improve
their skills, with a more dynamic continuing edu-
cation model that focuses on developing and
maintaining competence.
• The current paradigm discourages instructors
from challenging their learners. Learners are
expected to demonstrate a “perfect” perform-
ance on their Megacode. Mistakes are often seen
as a sign of failure for both the learner and the
instructor. In fact, health care providers often
learn the most from their mistakes (preferably,
mistakes made during training, not patient care).
Learners should be encouraged to test their skills
in challenging scenarios, make mistakes, identify
their weaknesses, and learn from them.
• NRP instructors are never challenged to update
or improve their own skills. Some NRP instruc-
tors have limited involvement in the program
and maintain their instructor status simply to
avoid taking the written examination every two
years. This diminishes the quality of the NRP and
has prompted a close look at requirements for
becoming an NRP instructor and maintaining
instructor status.
A dramatic change in NRP education methodol-
ogy begins with the new sixth edition NRP materials.
The instructor becomes less of a teacher and more of
a facilitator, allowing participants to assume more
responsibility for their own learning.5
SIGNIFICANT NRP PROVIDER
COURSE CHANGES
At first glance, much of the structure of the revised
NRP curriculum appears unchanged. However,
implementation of the new curriculum reveals signif-
icant changes. Many of these changes, such as online
testing, can be implemented immediately using the
fifth edition NRP materials, but the following
changes are mandated by January 1, 2012.6
• There are no longer separate Provider and
Renewal courses. Everyone will take a Provider
course, tailored by the NRP instructor to meet
each learner’s needs.
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• The learner is required to self-study the Textbook
of Neonatal Resuscitation, sixth edition (or study
the accompanying DVD) prior to attending the
course.
• The learner must pass the online NRP examina-
tion in the 30 days before attending the in-per-
son Provider course. After December 31, 2011,
the hard copy test will no longer be available.
See Table 1 for information about the online
examination.
• The instructor will not lecture or present slides
about content that appears in the textbook.
Before arriving at the course, the learner will
have already mastered this material and passed
the online examination.
• The instructor and learners will use course time
to practice technical skills as needed, to demon-
strate how the cognitive and technical skills are
integrated in accordance with current neonatal
resuscitation guidelines, and to improve team-
work and communication through simulation-
based learning and debriefing.
TABLE 1. About the NRP Online
Examination
The fifth edition NRP online examination will be available
through Exam Web until December 31, 2011. Access codes
(PINs) for the fifth edition examination do not transfer for
use with the sixth edition examination. Continuing educa-
tion credit is offered for the NRP online examination for
nurses (through the Illinois Nurses Association), physicians
(through the AAP), respiratory therapists (through the
American Association for Respiratory Care [AARC]), and
emergency medical services personnel (through the
Continuing Education Coordinating Board for Emergency
Medical Services [CECBEMS]).
The sixth edition NRP online examination will be available
for use in April 2011.
HealthStream is the vendor for the sixth edition NRP
online examination.
If HealthStream is already your institution’s Learning
Management System, contact HealthStream for pur-
chase and delivery of the exam in the same way as you
would for other online courses.
If your facility uses a different Learning Management
System, HealthStream can help your facility receive the
NRP online examination through your existing system.
It is possible to purchase a “batch” of examinations and
take advantage of bulk-order discounts.
It is possible to purchase an individual NRP online examination
by paying online with a credit card.
For more information, visit www.aap.org/nrp and click on
Online Examination.
Advances in Neonatal Care • Vol. 11, No. 1
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
New Science, New Strategies 45
WHAT ARE THE NPR PROVIDER
COURSE COMPONENTS?
The revised NRP Provider course is composed of
three essential components: cognitive skills (from the
textbook), technical skills (hands-on practice and
demonstration at skill stations), and teamwork and
communication skills (simulation and debriefing).
The Performance Skills Stations and Integrated Skills
Station give the learner opportunities to integrate
cognitive and technical components. The simulation
and debriefing component focuses on teamwork and
communication.6
Cognitive Skills
Implementation
Learners are expected to study the sixth edition NRP
textbook or DVD prior to attending the Provider
course. Learners may choose to study independently
or to study together in small discussion groups.
Instructors should be available, as needed, to clarify
material for new providers.
Evaluation
All providers complete the online examination prior
to attending the class. (See Table 1 for additional
details regarding the NRP online examination.) At
the beginning of the classroom component, instruc-
tors may allot a brief period to answer questions or
discuss issues specific to their hospital setting.
Technical Skills
Implementation
Health care providers may choose to learn and practice
basic technical skills at home using the Simply NRP kit.
Alternatively, learners new to the program can acquire
technical skills during the course at Performance Skills
Stations (Table 2). For experienced health care
providers, Performance Skills Stations are an optional
component for fine-tuning skills, reviewing rarely
performed skills (e.g., emergency umbilical venous
catheter placement and medication administration), or
acquiring new skills (e.g., laryngeal mask placement).
TABLE 2. NRP 2011 Performance
Skills Stations
Lesson 1: Equipment Check
Lesson 2: Initial Steps
Lesson 3: Positive-Pressure Ventilation
Lesson 4: Chest Compressions
Lesson 5: Endotracheal Intubation and Laryngeal Mask
Airway Placement
Lesson 6: Medication Administration and Emergency
Umbilical Venous Catheter Placement
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46 Zaichkin and Weiner
The instructor may demonstrate the skill or use a video
clip from the instructor DVD. Performance Checklists
are resources provided in the textbook and the
Instructor’s Manual for Neonatal Resuscitation for reference
and discussion, not for scoring. Each Performance
Checklist uses a scenario that places the skill in context
and builds on the skills from previous lessons. This
reinforces the cognitive learning that has already
occurred through self-study and prepares the learner
for the Integrated Skills Station.
Evaluation
Technical skills are evaluated at the Integrated Skills
Station. This is a required component of an NRP
Provider course. Using the Integrated Skills Station
Checklist (Basic or Advanced), the instructor presents
one or more scenarios that allow learners to demon-
strate their individual resuscitation skills in proper
sequence, using correct technique, without coaching or
prompting. Although the Integrated Skills Station is not
scored, providers should not advance to the simulation
component before their skills are well established.
Technical errors will occur during simulations and can
be discussed during the debriefing, but the focus on
teamwork and communication will be lost if there are
frequent technical errors.
Simulation and Debriefing
Implementation
Simulation and debriefing are required components of
an NRP Provider course. This experience provides a
safe setting to challenge learners at all levels of expert-
ise, integrate cognitive and technical skills, practice
effective teamwork and communication, and identify
areas for improvement. The instructor’s role is to
develop realistic, challenging scenarios based on learn-
ing objectives. Scenarios should progress from simple to
complex and provide even experienced learners with
the opportunity to be challenged. Visual, auditory, and
tactile cues contribute to making the setting as “real” as
possible so that learners are able to “suspend disbelief”
and act as they would during an actual emergency.
Although high-fidelity simulators may be used if
resources allow, effective simulation-based training can
be achieved with simple, inexpensive materials.
Running a simulation is a new skill for most
instructors. The instructor allows the learners to work
their way through the scenario without coaching or
prompting, even if they make errors. Errors are
opportunities for discussion and learning during the
debriefing session that follows. Filming the scenario
is strongly encouraged because it enhances the
debriefing experience. During the debriefing, the
instructor must avoid giving feedback or lecturing.
Instead, the instructor’s role is to facilitate a discus-
sion by asking open-ended questions that enable
learners to recognize their strengths, discover their
weaknesses, and identify strategies for improvement.
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
Watching videotape and identifying weaknesses in
performance can be uncomfortable for health care
professionals. To maintain a safe environment for
learning, it is essential to assure participants that the
simulation and debriefing events remain strictly con-
fidential. The new NRP Instructor DVD is designed to
help NRP instructors learn how to facilitate scenar-
ios and conduct effective debriefings.
Evaluation
At this time, the NRP simulation and debriefing com-
ponent is strictly for learning. There is no evaluation.
CHANGES FOR NRP INSTRUCTORS
NRP 2011 includes important time-sensitive require-
ments for NRP Regional Trainers and hospital-based
instructors who wish to maintain their instructor status.6
• All NRP instructors must view the NRP Instructor
DVD: An Interactive Tool for Facilitation of Simulation-
based Learning and complete the post-DVD educa-
tion component by January 1, 2012. Individuals or
institutions will find the link for purchasing the
Instructor DVD online for $64.95 at http://www.
aap.org/bookstore.
• Each instructor is required to own a personal
copy of this DVD. The DVD includes instruc-
tor information and tools explaining how to
construct scenarios and prepare for simulation-
based learning using both complex and simple
technology. It also includes interactive media to
teach instructors how to conduct an effective
debriefing. A library of short video clips demon-
strating key technical skills is also included.
Simulation and debriefing are new skills for
most instructors, and debriefing takes observa-
tion and considerable practice. This DVD pro-
vides NRP instructors with a “workshop in a
box” to help them master these new skills.
• Beginning January 1, 2013, NRP instructors
must pass the online examination (Lessons 1–9)
prior to their instructor status renewal date. For
instructors who renew their NRP instructor or
regional trainer status in fall, 2012, the online
examination is not required until fall 2014; how-
ever, instructors do not need to wait that long to
take the online examination. Taking the online
examination earlier will allow instructors to
become familiar with what NRP learners are
expected to complete. Beginning in spring 2011,
every current NRP instructor can take the NRP
online examination without charge once every
calendar year. Continuing education credit is
offered for passing the online examination; how-
ever, credit can only be claimed by instructors
once every two years and in accordance with
state continuing education rules.
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New Science, New Strategies 47

• Only registered nurses (including CNMs with

RN credentials, NNPs, ARNPs, and APRNs), FIGURE 1.
physicians (MD or DO), respiratory therapists,
and physician’s assistants are eligible to become
NRP instructors. Exceptions to these require-
ments will no longer be granted. Health care
professionals without these credentials who pre-
viously became instructors by waiver from the
NRP Steering Committee will maintain their
instructor status if they meet ongoing mainte-
nance requirements.
• NRP instructor candidates (NRP providers who
wish to become instructors) will be required to
meet eligibility prerequisites prior to being given
confirmed registration for an NRP Instructor
course and additional prerequisites prior to attend-
ing the NRP Instructor course. Further details
about Instructor courses are included in the
Instructor’s Manual for Neonatal Resuscitation.

WHERE DO THE NRP TREATMENT

RECOMMENDATIONS COME FROM?
The recommendations for neonatal resuscitation prac-
tice described in the Textbook of Neonatal Resuscitation,
sixth edition come from the AHA Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovas-
cular Care.7 A carefully timed process ensures that new
guidelines for resuscitation of adults, children, and
neonates are released at the same time every five
years. This process is outlined in Figure 1. These AHA
Guidelines are used to create educational materials for
the NRP, Pediatric Advanced Life Support (PALS),
Basic Life Support (BLS), and Advanced Cardiac Life
Support (ACLS) programs. Development Process for Neonatal Resuscitation Guide-
The Guidelines document was published in lines and NRP Materials. From: The American Academy of
October 2010 and is the result of a five-year process Pediatrics. How neonatal resuscitation guidelines and NRP
that begins with a review of resuscitation science by materials are developed. Retrieved from http://www.aap.
members of the International Liaison Committee on org/nrp/pdf/ilcorprocess.pdf. Reprinted by permission.
Resuscitation (ILCOR).8 ILCOR begins with a series
of questions designed to evaluate the current state of
resuscitation research for adults, children, and new- HOW WILL NEONATAL
borns. Multinational delegations of experts follow a RESUSCITATION CHANGE?
strictly defined procedure to identify published stud-
ies, evaluate the quality of the research, and assign The Textbook of Neonatal Resuscitation, sixth edition
the studies to levels of evidence. After a series of focuses on practice recommendations to ensure
meetings and debate, the international experts finally adequate ventilation while avoiding lung injury,
reach consensus and publish a document known as hypoxia, and hyperoxia. The following are the most
CoSTR, which is the international consensus on notable changes in the sixth edition.10
resuscitation science for adults, children, and new- • Begin resuscitation of the term infant with room
borns.9 The participating countries and councils air (21 percent oxygen). The ideal oxygen con-
interpret the scientific consensus and develop guide- centration for preterm infants is not known;
lines appropriate for use in their individual countries. however, a concentration at either extreme
The NRP Steering Committee works with the AHA (21 percent or 100 percent) may result in an
to develop guidelines for the U.S. and uses these oxygen saturation that is too low or too high.
guidelines to create the NRP textbook and other edu- • Use pulse oximetry whenever resuscitation is antic-
cational materials. ipated or when supplemental oxygen, positive-

Advances in Neonatal Care • Vol. 11, No. 1

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48 Zaichkin and Weiner
FIGURE 2.
NRP 2006 and NRP 2011 Flow Diagrams for Comparison.
pressure ventilation, or continuous positive airway
pressure (CPAP) is used.
• Every delivery room should have the ability to
provide blended oxygen and pulse oximetry
during resuscitation.
• Oxygen concentration is adjusted to achieve age-
specific preductal (right hand or wrist) oxygen sat-
uration (SpO2) targets as determined by pulse
oximetry. The 2011 NRP Flow Diagram (Figure 2)
includes a table of target oxygen saturation ranges
by infant age in minutes. The target ranges come
from approximations of the interquartile range
values reported by several investigators.11–13
• The 2011 NRP Flow Diagram now includes an
explicit reminder to take ventilation corrective
steps to ensure adequate ventilation before begin-
ning chest compressions. The sixth edition text-
book includes a six-step mnemonic (MR SOPA)
to help learners recall the steps. The MR SOPA
steps are described on page _____.
⬚ All positive-pressure ventilation devices, includ-
ing self inflating bags, should be equipped with
a pressure monitoring device (manometer).
⬚ Laryngeal mask airway placement has been
added to Lesson 5 as an additional perform-
ance checklist.
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
⬚ The endotracheal intubation procedure is now
allowed 30 seconds instead of the previous
recommendation for 20 seconds. Administra-
tion of free-flow oxygen during intubation is no
longer recommended if the baby is not breathing.
⬚ Intubation is recommended before chest com-
pressions are performed.
⬚ Oxygen concentration should be increased
to 100 percent when chest compressions are
performed.
It is beyond the scope of this article to provide the evi-
dence for every change in practice recommendations.
For this important information, see the AHA guidelines
for newborn resuscitation7 and the ILCOR document.9
COMPARING THE 2006 AND 2011
NRP FLOW DIAGRAMS
Figure 2 compares the 2006 NRP Flow Diagram with
the 2011 NRP Flow Diagram. Changes to previous
recommendations are in bold print below.10
• Obtain relevant perinatal history from the obstet-
ric provider prior to the infant’s birth.
⬚ What is the gestational age?
⬚ Is the amniotic fluid clear?
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⬚ How many babies are expected?
⬚ Are there other risk factors?
• When the infant is born, ask yourself these
three questions:
⬚ Is the newborn term?
⬚ Is the newborn breathing or crying?
⬚ Does the newborn have good muscle tone?
Note that color is not assessed at birth for the
purpose of resuscitation or oxygen administration.
Clear the airway if necessary. Reserve bulb-suc-
tioning the mouth and nose for infants whose
secretions obstruct breathing and for those new-
borns who require positive-pressure ventilation.
If the newborn is term, breathing, and has good mus-
cle tone, the baby should stay with his mother for rou-
tine care. This includes the vigorous infant with
meconium-stained amniotic fluid. Dry and place the
infant skin-to-skin with his mother, and cover with a
dry blanket. Provide ongoing evaluation of breathing,
heart rate, and color.
If the infant has meconium-stained amniotic fluid
and is not vigorous (defined by breathing, heart rate,
and tone), move the infant to the radiant warmer. Do
not dry or stimulate the infant to breathe. Intubate and
suction the trachea. If intubation is difficult and the
infant is bradycardic, consider moving on to the
next steps of resuscitation rather than delaying
ventilation with unsuccessful intubation attempts.
The initial steps include positioning the head to
open the airway, clearing the mouth and nose with the
bulb syringe if necessary, drying, and stimulating the
infant to breathe. Assess breathing (apnea, gasping, or
labored or unlabored breathing) and heart rate. If the
heart rate is ⬎100 beats per minute (bpm) but breath-
ing is labored, or if there is persistent cyanosis, ensure
a clear airway, and place a pulse oximeter on the
infant’s right hand or wrist. Begin free-flow oxy-
gen if the saturation is less than the minute-spe-
cific target. Consider CPAP for labored breath-
ing. If the infant remains apneic or gasping, or the
heart rate remains ⬍100 bpm after administering the
initial steps, start positive-pressure ventilation.
Resuscitation of term newborns may begin with
blended oxygen titrated to achieve the target oxy-
gen saturation or with room air (21 percent). If
blended oxygen is not immediately available,
begin resuscitation with room air. For preterm new-
borns, a somewhat higher oxygen concentration may
achieve the target oxygen saturation more quickly.
Oxygen concentration is adjusted according to age
in minutes and oxygen saturation (see target box on
2011 NRP Flow Diagram in Figure 2). A system for
blending air and oxygen and pulse oximetry should be
available whenever newborn resuscitation is required.
This means every delivery area should have access
to an air/oxygen blender and a pulse oximeter.
Advances in Neonatal Care • Vol. 11, No. 1
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
New Science, New Strategies 49
• Pulse oximetry is used whenever:
⬚ Resuscitation can be anticipated
⬚ Positive-pressure ventilation is administered
for more than a few breaths
⬚ Cyanosis is persistent
⬚ Supplementary oxygen is administered
To achieve a reliable oximeter signal as quickly as
possible, the pulse oximeter probe is placed on
the infant’s right hand or wrist first, and then
connected to the pulse oximeter.
Positive-pressure ventilation may begin with a self-
inflating bag, flow-inflating bag, or T-piece resuscitator.
Each of these devices has advantages and disadvan-
tages. Whichever device is used, it is essential that oper-
ators fully understand its safety features and how to
troubleshoot problems. The pop-off valves provided
on some self-inflating bags have been shown to be inac-
curate and to allow generation of higher than intended
pressures. All positive-pressure devices, including
self-inflating bags, should have a pressure gauge
(manometer) in place.
A rising heart rate is the best indication of
improvement during positive-pressure ventilation.
An assistant assesses for rising heart rate and
oxygen saturation. If this is not immediately evi-
dent, the assistant assesses for bilateral breath sounds
and chest movement. If these indicators are not evi-
dent in the first 5–10 attempted breaths, the team
proceeds to ventilation corrective steps. A useful
mnemonic for ensuring the proper sequence of
corrective steps is MR SOPA. During corrective
steps, the assistant continuously monitors the
infant for rising heart rate and increasing oxy-
gen saturation.
M Reapply the mask to ensure a good face-to-
mask seal.
R Reposition the head to ensure an open airway.
Reattempt ventilation. If no bilateral breath sounds
and no chest movement:
S Suction the mouth and nose with the bulb
syringe to ensure a clear airway.
• Open the infant’s mouth with your finger to
improve ventilation.
Reattempt ventilation. If no bilateral breath sounds
and no chest movement:
P Increase pressure every few breaths until
bilateral breath sounds and chest rise are evi-
dent. Exceeding an inspiratory pressure ⬎40
cmH2O is not recommended.
A If still unsuccessful, use an alternative
airway (endotracheal tube or laryngeal mask
airway).
Once positive-pressure ventilation has achieved
breath sounds and chest movement for 30 seconds,
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50 Zaichkin and Weiner
recheck the heart rate. If the heart rate still remains
⬍60 bpm, consider intubation and begin chest com-
pressions.
The oxygen concentration should be increased to
100 percent during chest compressions. The ratio for
compressions to breaths remains 3:1. The two-thumb
method of chest compressions is preferred over the
two-finger method. Coordinate chest compres-
sions with ventilations for at least 45–60 seconds
before interrupting chest compressions to assess
heart rate. If, after 45–60 seconds of chest compres-
sions, the heart rate is ⬎60 bpm, discontinue chest
compressions and continue ventilation, with heart
rate assessment every 30 seconds. Continue positive-
pressure ventilation until spontaneous breathing
supports a heart rate ⬎100 bpm.
Intubation is recommended when chest com-
pressions are required. Attempt to complete the
intubation procedure within 30 seconds. Ad-
ministering free-flow oxygen to an infant who is not
breathing during an intubation attempt offers no
benefit and is no longer recommended.
Epinephrine (1:10,000 concentration) is indicated
when the heart rate remains ⬍60 bpm after at least
45–60 seconds of chest compressions and coordinated,
effective positive pressure ventilation. Administra-
tion of epinephrine via an emergency umbilical
venous catheter (UVC) is the preferred route. The
dose for intravenous epinephrine is 0.1–0.3 mL/kg in
a 1 mL syringe. Current evidence suggests that intra-
tracheal (IT) epinephrine is likely to be less effective
than intravenous epinephrine.14 IT administration is
acceptable while placement of the emergency UVC is
in progress. The dose for IT epinephrine is 0.5–1
mL/kg (higher than the IV epinephrine dose) and should
be drawn in a clearly labeled 3–6 mL syringe. Do not use
this larger IT dose intravenously.
If the heart rate does not respond to effective positive
pressure ventilation, coordinated chest compressions,
and epinephrine, call for additional expertise, and
consider other complications such as pneumothorax
or hypovolemia. If the heart rate rises to ⬎60 bpm
but remains ⬍100 bpm, reevaluate the effectiveness
of positive-pressure ventilation and consider other
complications.
The sixth edition NRP textbook also includes10
• Recommendations for management of the
preterm infant:
⬚ Pre-warm the delivery room to 26ⴗC (80ⴗF).
⬚ Place the infant under radiant heat (and cover
in plastic wrap if ⬍29 weeks’ gestation).
⬚ Consider using an exothermic mattress.
⬚ Monitor for hyperthermia if using all the above
methods in combination.
• Information about induced therapeutic hypo-
thermia
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
⬚ Infants of ⱖ36 weeks gestational age with evi-
dence of moderate to severe hypoxic-ischemic
encephalopathy (HIE) should be considered
eligible for therapeutic hypothermia.
⬚ Therapeutic hypothermia should begin within
six hours of birth.
⬚ Therapeutic hypothermia should be adminis-
tered with clearly defined protocols in facili-
ties capable of multidisciplinary care and lon-
gitudinal follow-up.
Questions and Answers
Common questions about the content of the sixth edition
NRP appear below, with answers.6 Readers who con-
tinue to have questions about the sixth edition NRP
materials and requirements, even after publication of the
Textbook of Neonatal Resuscitation, sixth edition, and the
Instructor’s Manual for Neonatal Resuscitation, fifth edition,
should direct their questions to lifesupport@aap.org
Q. A lot of things have changed with NRP
2011. What basics of the NRP curriculum
have stayed the same?
A. These facts about the NRP Provider course have
not changed:
• The minimum course requirement is Lessons
1–4 and Lesson 9.
• Any person who works with newborns is eligi-
ble to take an NRP Provider course; however,
the course has little relevance for someone who
has never seen a healthy term newborn at birth.
• All learners may study, practice, and demon-
strate all NRP skills if desired, including intuba-
tion and emergency line placement. NRP does
not certify or ensure competence in performing
these skills in an actual resuscitation.
• The recommended NRP instructor-to-learner
ratio at a Provider course is one instructor for
each three to four learners.
Q: Do we need a sophisticated electronic
simulator to implement simulation-based
learning?
A: No, you do not need an electronic simulator for the
sixth edition NRP. The methodology is more impor-
tant than the technology. An electronic simulator can-
not make up for a poor curriculum or an instructor who
does not know how to create a scenario, prepare the
setting, orient learners, and conduct an effective
debriefing. The Instructor DVD covers the “how-to” of
simulation and debriefing using simple technology and
traditional mannequins.
Q: How important is filming the scenario
and viewing it during debriefing?
A: Filming enhances learning and is highly recom-
mended. Filming the scenario for use during the
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debriefing saves a lot of time because learners need
not spend time reciting what happened next or argu-
ing about what they remember. Video provides an
objective record of what actually happened during
the scenario. A camcorder with flash memory and
cables can be purchased for between $140 and $200.
A tripod is handy and costs less than $20. A device
for viewing the film is needed, such as a laptop com-
puter, an LCD projector, or a DVD player; prices
begin at about $80, depending on the device selected.
Q: How long does it take to conduct a
Provider course in this new format?
A: Course length depends on the needs of the learn-
ers. A group of experienced physicians and nurses
who work with the NRP instructor and have demon-
strated exemplary skills during actual resuscitations
may not need to go through every Performance Skills
Station. The Integrated Skills Station would ensure
that learners understand new practice recommenda-
tions; most of the course time would then be spent
conducting scenarios and debriefing. On the other
hand, staff who resuscitate newborns infrequently
benefit from reviewing and discussing resuscitation
skills.This group will require more time at the
Performance Skills Stations. The Instructor’s Manual
includes a few sample agendas and examples of how
to tailor Provider courses to meet the needs of learn-
ers. In most situations, 3 instructors can facilitate a
comprehensive course for 12 learners in approxi-
mately four hours.
Q: Our NRP instructors are accustomed to
checking off individuals whenever they
need to renew their provider status. We
rarely schedule a “course” of learners.
How can we do simulation and debriefing
with one learner?
A: An NRP Provider course with one or two learners
is difficult for the learner and an inefficient use of the
instructor’s time. It also precludes simulation and
debriefing unless the learner assembles two or three
volunteers who are willing to actively participate in
simulation and debriefing. Instructors should consider
using this NRP curriculum change to reorganize the
way they conduct NRP training. Multidisciplinary
groups are most useful for simulation and debriefing.
Consider rearranging staff renewal schedules and
putting groups together in courses that allow 1
instructor to lead a team of 3–4 learners through a
course. The number of teams in a course is guided by
the number of mannequins your program can access
for a course. To create these groups, you may con-
sider making individuals’ renewal dates earlier than
Advances in Neonatal Care • Vol. 11, No. 1
Copyright © 2011 Springer Publishing Company, LLC, and The National Association of Neonatal Nurses.
New Science, New Strategies 51
now scheduled and establishing a course schedule
that makes the best use of instructor time and facility
resources.
Q: Some of our instructors are great at
teaching skills one-on-one; however, I cannot
imagine them having the confidence to lead
a group through simulation and debriefing.
What will happen to these instructors?
A: If you are one of a very small number of instructors
in a small hospital, it seems probable that at least 2
instructors will need to work on simulation and debrief-
ing skills. A hospital-based NRP with a larger group of
instructors has the advantage of allowing instructors to
use their strengths where they are most comfortable—
and that may not be conducting simulation and debrief-
ing. Instead, use these instructors to facilitate learning
for small groups at Performance Skills Stations and to
evaluate learning at the Integrated Skills Station. They
may also have talent for writing scenarios, creating
“props,” or being in charge of providing the man-
nequin’s vital signs (e.g., using a metronome for heart
rate). Some NRP instructors may decide that this new
methodology does not relate to any of their interests or
abilities. These instructors may decide to retire their
instructor status and participate as learners in future
Provider courses.
References
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of the Neonatal Resuscitation Program. Neoreviews. 2008, 9:e142–e149.
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Instructor Update. 2008; 17(2): 1, 2, 7.
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http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_30.htm.
2004
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