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PE19.2 | Neonatal Resuscitation — SDL Guide (Part 3)

Simulation, Debriefing, and Applied Practice

The NMC competency PE19.2 is a procedural skills competency at SH (skill, high priority) — meaning the assessment is performance-based, not knowledge-based. You must be able to demonstrate the neonatal resuscitation algorithm on a manikin in a simulated delivery room scenario, following the NRP or HBB protocol correctly and in the right sequence. Simulation-based training is the standard method for acquiring and maintaining these skills, because the real clinical events (a neonate who requires full CPR) are too infrequent and too high-stakes for trainees to learn by direct observation alone. In a typical teaching hospital, a medical student may observe only a handful of actual neonatal resuscitations during their entire paediatrics posting — and in most of those cases, the intervention will be brief bag-mask PPV that resolves in two minutes, not the prolonged CPR-and-medications scenario depicted in the full algorithm. The implication is that simulation is not supplementary to clinical experience; for this competency, simulation is the primary learning environment. Deliberate practice — defined as structured, repeated rehearsal with specific feedback on each performance gap — on a neonatal manikin is the most evidence-based pathway to procedural competence in resuscitation. The HBB programme, which has been validated across multiple low-resource country settings, uses exactly this pedagogical approach: learners practice the full algorithm on a manikin, receive structured feedback, correct errors, and repeat until they achieve fluency.

Manikin-based HBB/NRP simulation: The Helping Babies Breathe programme uses a purpose-designed neonatal manikin ('Mama Natalie' for obstetric simulation, 'Newborn Annie' for neonatal resuscitation). The simulation involves:
1. Receiving the baby from the 'birth attendant' and placing under the radiant warmer
2. Performing the initial steps in sequence (warm, position, dry, stimulate, clear airway if needed)
3. Assessing breathing and heart rate at 60 seconds
4. Demonstrating PPV with correct mask selection, positioning, E-C clamp grip, and ventilation rate
5. Performing assessment after 30 seconds of PPV and identifying whether compressions are needed
6. Demonstrating the two-thumb encircling compression technique at the correct position, depth, and ratio
7. Verbalising the indication and dose of epinephrine

Team roles in delivery room resuscitation: In a well-staffed delivery room, resuscitation should be a team activity with clearly assigned roles: team leader (directs and assesses), airway provider (maintains position and bag-mask), circulation provider (compressions), and recorder (documents timing). Clear, closed-loop communication ('I am giving PPV at 40 breaths/min', 'Understood') prevents omissions and errors.

Debriefing: After every simulation or real resuscitation, a structured debrief (using the 'describe, analyse, apply' framework) consolidates learning and identifies gaps. Research consistently shows that post-simulation debriefing doubles the learning benefit compared to simulation alone.

Competency assessment checklist items evaluated in PE19.2 OSCE:
- Correct identification of the need for resuscitation (non-breathing or HR <100)
- Completion of initial steps within 60 seconds
- Correct mask size selection and E-C clamp technique
- Correct ventilation rate (40–60/min) and visible chest rise
- Correct application of MR SOPA when asked
- Correct compression:ventilation ratio (3:1) and technique
- Correct statement of epinephrine dose and route

Self-Assessment: Neonatal Resuscitation Decision-Making

Use these integrative questions to consolidate your algorithm knowledge before your simulation OSCE.

Case 1: A term baby delivered after prolonged rupture of membranes is not breathing and has HR 80 bpm after drying and stimulation. What do you do? (Answer: Begin PPV at 40–60 breaths/min. HR ≥60 but <100, with absent breathing = PPV indicated. Reassess HR after 30 seconds of effective PPV.)

Case 2: After 30 seconds of PPV, the chest is not rising despite good technique. Walk through MR SOPA. (Answer: M — re-adjust mask seal; R — reposition neck to neutral sniffing position; S — suction mouth/nose; O — open mouth slightly; P — increase pressure by 5 cm H₂O; A — alternative airway such as LMA or ETT.)

Case 3: HR is 50 bpm after 30 seconds of effective PPV (chest rising). What next? (Answer: Begin chest compressions at 3:1 ratio, two-thumb encircling technique, lower third of sternum, depth one-third AP diameter, at 90 compressions + 30 ventilations per minute.)

Case 4: HR remains <60 after 60 seconds of CPR. What medication and dose? (Answer: Epinephrine 0.1–0.3 mL/kg of 1:10,000 solution IV via umbilical venous catheter. If IV not available: 0.5–1.0 mL/kg of 1:10,000 via ETT.)

Key discriminators for examinations:

Question	Answer
HR threshold for PPV	<100 bpm or apnoea/gasping
HR threshold for compressions	<60 despite 30 s effective PPV
Neonatal C:V ratio	3:1 (NOT 30:2)
Total events/min in neonatal CPR	120 (90 + 30)
Epinephrine dose (IV, 1:10,000)	0.1–0.3 mL/kg
Starting FiO₂ for term neonate	Room air (21%)
Chest compression depth	1/3 of AP chest diameter
Golden minute target	Initial steps + assess HR/breathing within 60 s