Neonatal Resuscitation Program (NRP)
Evidenced-based Updates

Volume/Issue 27 Number (No) 2 Fall/Winter 2018

Updated: December 24, 2018; Published: December 24, 2018

Suctioning: Who, When and Why?

Palm Desert Resuscitation Education (PDRE) and the Neonatal Resuscitation Program (NRP) Steering Committee have been following diligently the steady stream of NRP Instructor Updates for the Fall and Winter Seasons of 2018. These fresh revised guidelines and recommendations for “Newborn Resuscitation” obviously come from the Members of the NRP Steering Committee and the American Heart Association (AHA) developed the 2015 United States (U.S.) Guidelines for Neonatal Resuscitation. The most recent guidelines are also reprinted in the appendix of the Textbook of Neonatal Resuscitation, 7th edition. Palm Desert Resuscitation Education (PDRE) and the NRP education materials via these scholarly provider manuals translate these prominent guidelines and recommendations into medical and clinical practice.

For instance, the NRP Steering Committee receives many questions about the current recommendation for suctioning the newborn at birth. This is actually Part 1 of a three-part series regarding newborn suctioning in the delivery room.

The Obstetric Provider and Newborn Suctioning: When the Amniotic Fluid is Meconium-stained

In the past, obstetric management of the meconium-stained newborn included procedures that were meant to reduce the risk of meconium aspiration syndrome (MAS). These procedures have historically included tracheal suction of vigorous and non-vigorous newborns and suctioning the hypo-pharynx before delivery of the shoulders (intrapartum suction). While intrapartum suctioning and tracheal suctioning of the vigorous newborn have not been recommended since the 2010 Guidelines, the 2015 Guidelines stated there was insufficient evidence to continue routine tracheal suctioning for non-vigorous babies born through meconium-stained amniotic fluid. A definitive randomized controlled trial is still needed.

In 2017, the American College of Obstetricians and Gynecologists (ACOG) published Committee Opinion Number 689 that concurred with the 2015 U.S. Guidelines for Neonatal Resuscitation. The American Academy of Pediatrics (AAP), AHA and ACOG agreed that non-vigorous meconium-stained babies should be moved to the radiant warmer for initial steps and be resuscitated in the same manner as babies with clear amniotic fluid. Implications for not transferring the neonatal baby to the radiant warmer quickly after birth – whether having risk factors or not necessitating neonatal resuscitations dependent on the amount of babies being delivered, gestation age, amniotic fluid consistency and make-up, and perinatal risk factors – may include mild (temperature between 36 C and 36.4 C or 98.6 F and 97.6 F), moderate (temperature between 32 C and 35.9 C or 89.6 F and 96.6 F), and severe (temperature between less than 32 C or less than 89.6 F) hypothermia due to the neonate’s inefficient thermoregulation system and jeopardy for hypothermia and cold stress syndrome which may lead to heat loss, increase in metabolic heat production, tissue hypoxia and neurologic damage with possible cardiorespiratory compromise needing neonatal resuscitation.

When the Amniotic Fluid is Clear

The current Textbook of Neonatal Resuscitation, 7th edition recommends bulb suction as part of the initial steps of newborn care if the newborn is having difficulty clearing the airway, if secretions are obstructing the airway, or if the baby is apneic or gasping and PPV is anticipated. Intrapartum suctioning is not ever recommended.

If a baby is unexpectedly born limp and apneic and the obstetric provider had planned to delay cord clamping, it is reasonable to quickly bulb suction the newborn’s mouth and nose and gently stimulate the baby to breath following delivery of the baby. If the baby does not begin to breathe immediately, the umbilical cord should be clamped and cut, and the baby moved to the radiant warmer for the initial steps of newborn care and further evaluation.

NRP Online Exam – Test Your Knowledge

After chest compressions with coordinated ventilations are started, the heart rate should be assessed:

  1. After 60 seconds
  2. After 30 seconds
  3. After 90 seconds
  4. When spontaneous respirations return

Answer to NRP Online Exam – Test Your Knowledge

The correct answer is: A. After 60 seconds

The heart rate should be assessed after 60 seconds of continuous chest compressions with coordinated ventilations in 100% oxygen.

Studies have shown that it may take a minute or more for the heart rate to increase after compressions are started. When compressions are stopped coronary artery perfusion is decreased and requires time to recover once compressions are resumed. Therefore, it is recommended that you provide 60 seconds of well-coordinated chest compressions and ventilation before briefly pausing compressions to assess the heart rate.

A cardiac monitor is the preferred method for assessing heart rate when chest compressions are required. Auscultation with a stethoscope can be difficult, prolonging the interruption in compressions, and potentially yield inaccurate results. A pulse oximeter may not reliably detect the baby’s pulse, especially when the baby’s perfusion is very poor.


  • 2015 AHA Guidelines Update for CPR and ECC – CERCP
  • The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on Obstetric Practice – Number 767 (Replaces Committee Opinion Number 692) – MS NO: ONG-18-2174


Statements and opinions expressed in this publication are those of the authors of Palm Desert Resuscitation Education LLC (PDRE) and are not necessarily those of the American Academy of Pediatrics (AAP) or American Heart Association (AHA).

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