NRP Review: Part 1
NRP Review Part 1: Mastering the Basics of Neonatal Resuscitation
Neonatal resuscitation is a critical skill for NICU nurses, and whether you're new to the NICU or a seasoned expert, repetition and preparation are key to success. The first moments of a newborn's life can be unpredictable, and knowing exactly how to respond can make all the difference. In this post, we’ll break down the first steps of NRP, from prebriefing to effective positive pressure ventilation (PPV), with a focus on troubleshooting and best practices.
Prebriefing & Equipment Check: Setting the Stage for Success
Before every high-risk delivery, the resuscitation team should conduct a prebrief. This helps clarify roles, ensure equipment readiness, and align the team on the expected plan of care. Here’s what to check before the baby arrives:
✅ Radiant warmer ON and pre-warmed
✅ PPV device connected and functioning (T-piece or bag-mask)
✅ Suction ready (bulb syringe and meconium aspirator if needed)
✅ Oxygen and blender set (start with 21% for term, adjust for preemies)
✅ Laryngoscope and ETTs available in case of escalation
✅ Medications and umbilical supplies prepared for emergencies
💡 Tip: A well-organized setup ensures smoother resuscitation. Always do a final checklist before delivery!
Initial Steps of Neonatal Resuscitation
Once the baby is delivered, the initial assessment determines whether resuscitation is needed. Follow these key steps:
🔹 Dry, stimulate, and assess breathing & tone
🔹 Clear airway with suction only if necessary
🔹 Assess heart rate (listen with a stethoscope or feel the umbilical cord)
🚨 Decision Point: If the baby is not breathing, is gasping, or has a heart rate <100 bpm, immediate PPV is required!
Positive Pressure Ventilation (PPV) & MRSOPA: The Foundation of NRP
PPV is the most important intervention in neonatal resuscitation. The goal is to establish lung inflation and improve oxygenation. But what if PPV isn’t working? That’s where MRSOPA comes in!
MRSOPA Steps to Optimize Ventilation
M Mask adjustment – Ensure a proper seal.
R Reposition airway – Neutral or sniffing position.
S Suction – Clear mouth and nose if needed.
O Open mouth slightly to reduce resistance.
P Pressure increase if needed (5-10 cmH2O increments).
A Airway alternative – Consider intubation.
How to Apply MRSOPA:
Perform MR → Reassess PPV effectiveness.
If no improvement, perform SO → Continue PPV for 30 seconds.
If HR remains <100, increase P.
If HR remains <100 and/or <60, move to A (intubation and/or chest compressions).
💡 Tip: Effective ventilation is key—if the baby isn’t improving, reassess airway, seal, and pressure before moving to compressions!
Key Takeaways
Preparation is everything! A well-organized team and checked equipment make all the difference.
PPV is the most critical step. Most neonatal resuscitations succeed when ventilation is optimized.
MRSOPA should be second nature. Know how to troubleshoot ineffective PPV before you need to.
Heart rate drives decisions. If HR <100, start PPV. If HR <60, progress to compressions and medications.
Final Thoughts
Mastering neonatal resuscitation requires practice, confidence, and teamwork. Whether you’re a new NICU nurse or an experienced provider, refreshing your knowledge of these first steps ensures you’re always prepared for the unexpected. Stay tuned for NRP Review Part 2, where we’ll dive into advanced resuscitation techniques including chest compressions, epinephrine, and fluid resuscitation!
Don't forget to check out the NRP key takeaways downloadable document on the Resources tab!
