Mismanagement of Neonatal Resuscitation

Neonatal resuscitation after birth has become a significant liability exposure for healthcare organizations, practitioners, and resuscitation teams, particularly in cases where the neonate sustained neurological injury. In some cases, it is unclear whether the injury was sustained during the intrapartum period or during or shortly after the neonatal resuscitation. Accurate and complete documentation of the resuscitation is required to help demonstrate the timeliness and adequacy of the emergency interventions. Neonatal intubation is considered a technically complex and high risk procedure with some neonates experiencing ongoing bradycardia and severe oxygen desaturations despite intubation attempts. Infrequently required, maintaining practitioners’ intubation skills remains a challenge. 

Expected Outcomes

Adopt a standardized evidence-based neonatal resuscitation management protocol.

Implement formal strategies to provide ongoing and targeted neonatal resuscitation-related education and training.

Adopt standardized quality indicators to monitor and measure neonatal resuscitations.

Definitions and Acronyms

  • Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
  • Code pink – emergency code for an infant in distress
  • EMS – emergency medical services, also known as ambulance services or paramedic services
  • ETT – endotracheal tube
  • HIE - hypoxic ischemic encephalopathy
  • NICU – neonatal intensive care unit
  • Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning
  • UVC – umbilical venous catheter

Common Claims Themes and Contributing Factors

  • Lack of intra- and / or inter-disciplinary team training / simulations focused on the identification and management of deteriorating neonates including neonatal resuscitation (i.e., 8th edition of the neonatal resuscitation program per Canadian Paediatric Society).
  • Lack of a systematic approach to neonatal quality of care reviews related to neonatal resuscitation efforts.
  • Resource and staffing challenges in responding to neonatal resuscitation i.e., lack of practitioners skilled and / or certified to perform neonatal intubation and endotracheal tube management.
Knowledge and Judgement
  • Failure to or delays calling:
    • A code pink, resuscitation or NICU team in the hospital birth setting where clinically indicated;
    • For EMS or neonatal transport teams where clinically indicated.
  • Lack of awareness or compliance with the program’s or evidence-based neonatal resuscitation protocol. 
  • Concerns surrounding the performance of neonatal resuscitation efforts, including: 
    • Implemented in an unprepared and / or uncoordinated manner (e.g., lacking leadership during the resuscitation); 
    • Excessive time spent on an ineffective intervention before moving to the next and / or calling for assistance; 
    • Lack of familiarity and / or compliance with recommended interventions and / or the organization’s neonatal protocols. 
  • Failure to or delays performing neonatal intubation, suctioning (where indicated), and / or inserting a laryngeal mask airway due to: 
    • Lack of confidence in related skills; 
    • Lack of clarity on which team member is expected to and / or will perform the suctioning and / or intubation; 
    • Assumption that the arrival of the code pink, resuscitation NICU team, or emergency transport was imminent; 
    • Unavailability of or delayed access of suction and / or intubation equipment and supplies. 
  • Lapse in situational awareness, contributing to delayed recognition of and response to insidious and rapid clinical deterioration of the neonate. 
  • Lack of effective team briefings, huddles, and debriefings.
  • Delayed and late entries for care provided, in particular entries made hours or days after the critical incident or clinical deterioration. 
  • Lack of documentation surrounding the: 
    • Specific details of the resuscitation efforts; 
    • Call and pages to EMS, code pink, resuscitation, and NICU teams. 

Mitigation Strategies

Care Processes

  • Adopt a standardized evidence-based neonatal resuscitation protocol to support a systematic and coordinated approach to resuscitation (American Heart Foundation, Canadian Paediatric Society & American Academy of Pediatricians, 2021).
  • Adopt strategies to enhance situational awareness during neonatal resuscitation, suctioning, and intubation interventions (Pinheiro, Munshi, & Chowdhry, 2023) (Hatch, et al., 2016).

Additional Considerations

Examples of strategies to enhance situational awareness during neonatal resuscitation:
  • “PETT” mnemonic – proactively seek information related to the patient (P), environment (E), task (T) and time (T), assess the information, think ahead and consider ‘what if’; 
  • The use of:
    • Checklists and rapid response algorithms;
    • Effective handovers and structured communication practices such as SBAR;
    • Institute for Health Improvement’s intubation “timeout tool”.
  • Conduct a post incident management process for all births with challenging resuscitations or intubations that includes (but is not limited to) conducting team debriefs, arterial and venous blood cord gases analysis, and pathological placental examinations. 

Team Training and Education

  • Implement formal strategies to support and enhance the teams’ clinical knowledge, skills (technical and non-technical), and practical experience surrounding neonatal resuscitation including (but not limited to), scheduled interprofessional and cross-department skill drills and simulations (Lindhard, et al., 2021) (McMullen, Kalaniti, & Campbell, 2016) (Ghoman, et al., 2020) (Yang & Oh, 2022). 
  • Ensure the team training and education strategies address or involve:
    • Knowledge, skills, and practical experience required for both hospital and community birth and postpartum locations (Association of Ontario Midwives, 2021); 
    • Team and practitioner situational awareness and human factors; 
    • Program areas or sites with limited practical experience with neonatal resuscitation such as emergency departments, low volume birth sites, and rural sites (Yousef, Moreau, & Soghier, 2022) (Hand, 2022); 
    • Unregulated care providers (where employed), locums, travel agency, contracted care providers in addition to regulated health professionals.

Equipment, Supplies and Technology 

  • Implement formal strategies to ensure the immediate availability of the required resuscitation, ventilation, suction, and intubation equipment and supplies for all hospital and community birth and postpartum locations; for the hospital birth setting, consider the need for the immediate availability to electrocardiography; for community birth locations, ensure neonatal resuscitation equipment is set up for all births; ensure the process includes a formal contingency plan for missing or faulty equipment and supplies; consider adopting standardized resuscitation and intubation carts or kits for all for all birth and postpartum locations to help ensure familiarity with the equipment, supplies, and setup by all teams (Chan, et al., 2016) (Maul, Latham, & Westgate, 2016) (Milloy & Bubric, 2018).


  • Adopt a standardized neonatal resuscitation flowsheet / record / dictation aid (Perinatal Services BC, 2022a) (Association of Ontario Midwives, 2021) (Braga, et al., 2015) (Southwestern Ontario Maternal, Newborn, Child and Youth Network, 2016).

Additional Considerations

Elements to consider including in the standardized neonatal resuscitation flowsheet / record / dictation aid:
  • Actual time or age in minutes;
  • Respiration efforts (e.g., gasping, apneic, or absent respiratory effort);
  • Heart rate per minute; 
  • Oxygen saturation; 
  • Colour (e.g., pink, mottled / pale, or cyanosed);
  • Tone; 
  • Timing of specific interventions (e.g., ventilation, suctioning, chest compressions, intubation), the response to and / or effectiveness of interventions;
  • Type of suctioning;
  • ETT and UVC insertion, including tube and catheter size, insertion depth, number of attempts, who inserted, and confirmation method;
  • Medications administered including dose, route, and name of person administering; 
  • Time help called and arrived, and who they were;
  • The neonate’s post resuscitation condition, and any subsequent transfer of care and ongoing care;
  • Signature of the practitioner(s) performing the resuscitation;
  • Signature of the designated script (where used).

Monitoring and Measurement 

  • Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving neonatal resuscitation resulting in client harm or death; incorporate system thinking and human factors concepts into the review process (Perinatal Services BC, 2017a) (Perinatal Service BC, 2017b) (The National Center for Fatality Review and Prevention, n.d.) (PMRT development working groups, 2022) (Machen, 2023).
  • Adopt standardized quality indicators for neonatal resuscitation (Hill, Clark, Narayanan, Wright, & Vivio, 2014) (Perinatal Services BC, 2022b).
  • Incorporate learning from local, provincial, and national neonatal safety reviews and data into local protocols as well as staff and client education and training. 

  • American Heart Foundation, Canadian Paediatric Society & American Academy of Pediatricians. (2021). Textbook of neonatal resuscitation, 8th edition. 
  • Association of Ontario Midwives. (2021). Clinical Record Forms. Retrieved from https://www.ontariomidwives.ca/clinical-record-forms
  • Braga, M., Kabbur, P., Alur, P., Goodstein, M., Roberts, K., Satrom, K., . . . Suresh, G. (2015, 12). Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review. 
  • Chan, J., Chan, B., Ho, H., Chan, K., Kan, P., & Lam, H. (2016, 8). The neonatal resuscitation algorithm organized cart is more efficient than the airway–breathing–circulation organized drawer: a crossover randomized control trial. 
  • Ghoman, S., Patel, S., Cutumisu, M., von Hauff, P., Jeffery, T., Brown, M., & Schmölzer, G. (2020, 1). Serious games, a game changer in teaching neonatal resuscitation? A review. 
  • Hand, I. (2022, 4). Neonatal Resuscitation in Low Volume Hospital Settings. 
  • Hatch, L., Grubb, P., Lea, A., Walsh, W., Markham, M., Maynord, P., . . . Ely, E. (2016, 10). Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. 
  • Hill, K., Clark, P. A., Narayanan, I., Wright, L., & Vivio, D. (2014). Improving Quality of Basic Newborn Resuscitation in Low-resource Settings: A Framework for Managers and Skilled Birth Attendants. Bethesda, MD: University Research Co., LLC .
  • Lindhard, M., Thim, S., Laursen, H., Schram, A., Paltved, C., & Henriksen, T. (2021, 4). Simulation-Based Neonatal Resuscitation Team Training: A Systematic Review. 
  • Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
  • Maul, E., Latham, B., & Westgate, P. (2016, 2). Saving Time Under Pressure: Effectiveness of Standardizing Pediatric Resuscitation Carts. 
  • McMullen, J., Kalaniti, K., & Campbell, D. (2016, 6). Current Practices and Use of Simulation in Neonatal Resuscitation Program Courses Across Canada. 
  • Milloy, S., & Bubric, K. (2018, 10). A Four-Stage Method for Optimizing and Standardizing a Crash Cart Configuration. 
  • Perinatal Services BC. (2017a). Perinatal Mortality Guideline. Vancouver, BC.
  • Perinatal Service BC. (2017b). Improving Perinatal, Maternal, and Infant Mortality and Morbidity Surveillance and Response in BC. Vancouver, BC.
  • Perinatal Services BC. (2022a). BC Newborn Resuscitation Record: A Guide for Completion. Vancouver, BC.
  • Perinatal Services BC. (2022b). Perinatal Health Report: British Columbia 2020/21. Vancouver, BC.
  • Pinheiro, J., Munshi, U., & Chowdhry, R. (2023, 2). Strategies to Improve Neonatal Intubation Safety by Preventing Endobronchial Placement of the Tracheal Tube—Literature Review and Experience at a Tertiary Center. 
  • PMRT development working groups. (2022). PMRT Programme Details. Retrieved from Oxford Population Health National Perinatal Epidemiology Unit: https://www.npeu.ox.ac.uk/pmrt/programme
  • Southwestern Ontario Maternal, Newborn, Child and Youth Network. (2016). Neonatal resuscitation record documentation key. Retrieved from http://www.mncyn.ca/wp-content/uploads/2017/10/2016_Neonatal-Resuscitation-Record-and-Documentation-Key_combined.pdf
  • The National Center for Fatality Review and Prevention. (n.d.). Tools for FIMR Teams. Retrieved from https://ncfrp.org/fimr/tools-for-fimr-teams/
  • Yang, S.-Y., & Oh, Y.-H. (2022, 10). The effects of neonatal resuscitation gamification program using immersive virtual reality: A quasi-experimental study. 
  • Yousef, N., Moreau, R., & Soghier, L. (2022, 4). Simulation in neonatal care: towards a change in traditional training?