The 4 NRP pre-birth questions, and what each answer changes
Resuscitation starts before the baby is born. Before every birth, NRP 9th Edition has you ask the obstetric provider four short questions. The answers tell you who needs to be in the room and what needs to be ready on the warmer.
The 4 questions
- What is the expected gestational age?
- Is the amniotic fluid clear?
- Are there any additional risk factors?
- What is the umbilical cord management plan?
What each answer changes
1. Gestational age
Birth before 36 weeks, and birth at 41 weeks or later, both count as risk factors that make resuscitation more likely. A very preterm birth also changes your setup: the extra warming steps and equipment for infants under 32 weeks are covered in resuscitation under 32 weeks.
2. Amniotic fluid
Meconium-stained fluid is an intrapartum risk factor, so it raises the level of preparation. It no longer means routine intubation and tracheal suction, though. See what changed with meconium-stained fluid.
3. Additional risk factors
This question covers everything the first two don't. NRP groups risk factors into those present before labor and those that appear during labor and birth. A few examples of each:
| Before labor (antepartum) | During labor and birth (intrapartum) |
|---|---|
| Preeclampsia, eclampsia or maternal hypertension | Emergency cesarean birth |
| Multiple gestation | Forceps or vacuum-assisted birth |
| Fetal growth restriction or macrosomia | Category II or III fetal heart rate pattern |
| Polyhydramnios or oligohydramnios | General anesthesia, or opioids given within 4 hours of birth |
| Significant fetal malformations or anomalies | Placental abruption, intrapartum bleeding or prolapsed cord |
| No prenatal care | Chorioamnionitis or shoulder dystocia |
The full list is in Table 2-1 of the NRP textbook.
4. Cord management plan
Agree on the plan with the obstetric provider before the birth. For most newborns who don't need immediate resuscitation, clamping should be deferred for at least 60 seconds. The details, including when milking is and isn't appropriate, are in umbilical cord management.
How the answers decide who attends
Every birth needs at least 1 qualified person who can start resuscitation and whose only job is the newborn. If any risk factor is present, that becomes at least 2 people there only for the newborn, with the number and skills set by the risks you heard.
If you expect advanced resuscitation, the full team (people who can intubate, do compressions, place emergency vascular access and give medications) should be in the room when the baby is born. Having them on call from home or from another part of the hospital isn't enough.
Then brief the team
Once the team is together, run a short pre-resuscitation briefing, even if you've worked together for years. Review the risk factors and the plan, name the team leader, hand out tasks, decide who documents, check supplies and equipment, agree on how to call for more help, and give everyone a chance to raise concerns.
Frequently asked questions
What are the 4 pre-birth questions in NRP?
NRP 9th Edition has you ask the obstetric provider: What is the expected gestational age? Is the amniotic fluid clear? Are there any additional risk factors? What is the umbilical cord management plan?
How many people should attend a birth with risk factors?
At least 2 qualified people whose only job is the newborn. Every birth needs at least 1 qualified person who can start resuscitation and has no other responsibility. If advanced resuscitation is expected, the full team with intubation, compressions, vascular access and medication skills should be in the room at the birth.
Can a newborn with no risk factors still need resuscitation?
Yes. Risk factors identify most newborns who will need help, but not all of them. That is why every birth needs a qualified person and working equipment, even when all 4 answers sound reassuring.
Studying for the NRP exam? NeoCPR's interactive algorithm opens with these same 4 questions and walks you through every step that follows. See NeoCPR ($29) →
References
- American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 9th ed. Itasca, IL: American Academy of Pediatrics; 2025. Lesson 2: Anticipating and Preparing for Resuscitation; Lesson 3: Initial Steps of Newborn Care.
- Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16 Suppl 2):S385–S423. doi:10.1161/CIR.0000000000001367