Official reprint from UpToDate®

www.uptodate.com ©2019 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Neonatal resuscitation in the delivery room

Author: Caraciolo J Fernandes, MD
Section Editor: Leonard E Weisman, MD
Deputy Editor: Melanie S Kim, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2019. | This topic last updated: Jan 07, 2019.

INTRODUCTION

The successful transition from intrauterine to extrauterine life is dependent upon significant
physiologic changes that occur at birth. Although most newborns successfully make this transition at
delivery without requiring any special assistance, a small but significant number will require
additional support, including resuscitation in the delivery room.

The indications and principles of neonatal resuscitation will be reviewed here. The physiological
changes that occur in the transition from intrauterine to extrauterine life are discussed separately.
(See "Physiologic transition from intrauterine to extrauterine life".)

ANTICIPATION OF RESUSCITATION NEED

Being prepared is the first and most important step in delivering effective neonatal resuscitation [1].
Most newborns in the United States are healthy and do not require additional special assistance, and
the need for resuscitation is often not anticipated, even in tertiary birth centers [2,3]. However, in the
United States, 10 percent of all newborns need some intervention, and 1 percent will require extensive
resuscitative measures at delivery [1]. As a result, at every birthing location, personnel who are
adequately trained in neonatal resuscitation should be readily available to perform neonatal
resuscitation whether or not problems are anticipated [1].

In all instances, at least one health care provider is assigned primary responsibility for the newborn
infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate
resuscitation procedures, such as positive pressure ventilation and chest compressions. In addition,
either this person or another who is immediately available should have the requisite knowledge and
skills to carry out a complete neonatal resuscitation, including endotracheal intubation and
administration of medications.

Equipment needed for resuscitation should be available at every delivery area (table 1), and routinely
checked to ensure the equipment is functioning properly [1,4].

Training — The neonatal resuscitation program (NRP) was developed by the American Academy of
Pediatrics (AAP) and American Heart Association (AHA) as a training program aimed at teaching the
principles and skills of neonatal resuscitation [4]. Studies have demonstrated that NRP training
improves the correct sequencing and timing of the resuscitative steps and procedures by health care
providers [2], provider knowledge and comfort in performing neonatal resuscitation [5], and five-
minute Apgar scores [6].

In our institution, all health care providers who care for newborn infants (clinicians, nurses, neonatal
nurse practitioners, and respiratory therapists) are required to be NRP trained. It is recommended that
all delivery room personnel complete the NRP in an effort to improve their individual and group
performance in neonatal resuscitation.

High-risk delivery — Infants who are more likely to require resuscitation can be identified by the
presence of one or more of the following risk factors (table 2) [4,7-9]:

● Maternal conditions – Advanced or very young maternal age, maternal diabetes mellitus or
hypertension, maternal substance use disorder, or previous history of stillbirth, fetal loss, or early
neonatal death.

● Fetal conditions – Prematurity, postmaturity, congenital anomalies, intrauterine growth

restriction, or multiple gestations.

● Antepartum complications – Placental anomalies (eg, placenta previa or placental abruption), or

presence of either oligohydramnios or polyhydramnios.

● Delivery complications – Transverse lie or breech presentation, chorioamnionitis, foul-smelling or

meconium-stained amniotic fluid, antenatal asphyxia with abnormal fetal heart rate pattern,
maternal administration of a narcotic within four hours of birth, deliveries that require
instrumentation (eg, forceps or vacuum deliveries) or cesarean delivery for maternal or fetal
compromise.

Individuals fully skilled in neonatal resuscitation should be present to care for the high-risk infant. If
time permits, the team should meet with the parents and discuss the anticipated problems and plans
for care of the infant, and address parental concerns to the best of their ability. In high-risk deliveries
of multiple gestations, each infant will require a full complement of personnel and equipment.

Necessary equipment should be assembled prior to the birth of at-risk newborns as follows [4]:

● Radiant warmer is turned on

● Oxygen source is open with adequate flow through the tubing
● Suctioning apparatus is functioning properly
● Laryngoscope is functional with a bright light
● Testing of resuscitation bag and mask demonstrates an adequate seal and generation of
pressure

Preterm infants — Preterm infants pose a greater challenge than term infants because they are
more likely to require resuscitation and develop complications from the resuscitative process,
particularly extremely low birth weight (ELBW) infants (BW <1000 g) [10]. However, even the majority
of moderately preterm infants (gestational age [GA] between 29 and 34 weeks) require some degree
of delivery room resuscitation with the risk of adverse outcome increasing with the intensity of
intervention required [11].

If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to
delivery to a perinatal center that has fully trained staff with expertise and experience in the care of
preterm infants [12,13].

The following factors make the preterm infant more likely to require resuscitation and develop
complications [4]:

● Hypothermia – The risk of heat loss leading to hypothermia is increased in infants with a large
body surface area to mass, thin skin, and decreased subcutaneous fat. The smaller the infant,
the more difficult it is to prevent hypothermia. (See 'Temperature control' below and "Short-term
complications of the preterm infant", section on 'Hypothermia'.)

● Inadequate ventilation – Immature lungs are deficient in surfactant, and therefore difficult to
inflate and ventilate. Immature respiratory drive and weak respiratory muscles increase the
likelihood of apnea and inadequate respiratory effort.

● Infection – Maternal infection is associated with preterm delivery, and offspring of infected
mothers are at risk for antenatal infection. Preterm infants also have immature immune systems,
increasing the risk of acquired postnatal infection. (See "Pathogenesis of spontaneous preterm
birth", section on 'Bacteria'.)
 ● Organ damage – Immature tissues and capillaries (eg, retina or germinal matrix) are more
vulnerable to injury resulting in complications (eg, retinopathy of prematurity, intraventricular
hemorrhage, bronchopulmonary dysplasia). (See "Retinopathy of prematurity: Pathogenesis,
epidemiology, classification, and screening", section on 'Risk factors' and "Germinal matrix
hemorrhage and intraventricular hemorrhage (GMH-IVH) in the newborn: Pathogenesis, clinical
presentation, and diagnosis" and "Bronchopulmonary dysplasia: Definition, pathogenesis, and
clinical features".)

Additional resources and personnel should be present when a preterm birth is anticipated. These
include:

● Equipment to keep the infant warm. In infants less than 28 weeks gestation, the use of
polyethylene bags and wraps have been used to maintain body temperature. (See "Short-term
complications of the preterm infant", section on 'Hypothermia'.)

● Personnel skilled in intubation, especially for the ELBW infants.

● For infants less than 30 weeks gestation who are more likely to be surfactant deficient,
equipment and personnel should be available to deliver continuous positive airway pressure and
to consider administering surfactant. (See "Prevention and treatment of respiratory distress
syndrome in preterm infants".)

● Compressed air sources, oxygen blenders, and pulse oximeters should be available to allow
delivery of less than 100 percent oxygen and monitoring of both the oxygen content of the air
delivered and the oxygen saturation of the infant. (See 'Supplemental oxygen' below.)

● Prewarmed transport incubator (with the capability to transport a ventilated infant), particularly if
the delivery room is not in close proximity to the neonatal intensive care nursery.

ANTENATAL COUNSELING

Each birth institution should have a consistent approach based upon the best available evidence
regarding clinical care, including parental counseling with information regarding prognosis in cases
where the fetal/neonatal outcome is a concern. In particular, antenatal counseling should be provided
to parents in the setting of an anticipated delivery of an extremely low birth weight (ELBW) infant (BW
<1000 g) as recommended by the American Academy of Pediatrics (AAP) [14]. (See "Periviable birth
(Limit of viability)".)

We agree with the following AAP guidelines:

 ● If there is no chance of survival, resuscitation should not be initiated. (See 'Withholding
resuscitation' below.)

● When a good outcome is considered very unlikely, the parents should be given the choice of
whether resuscitation should be initiated, and clinicians should respect their preference.

● If a good outcome is considered reasonably likely, clinicians should initiate resuscitation and,
together with the parents, continually reevaluate whether intensive care should be continued.
(See 'Postresuscitation' below.)

MANAGEMENT APPROACH

Overview — Guideline recommendations are based upon extensive clinical experience and limited
evidence because randomized trials are difficult to perform in the delivery room. This is due to
inability to obtain consent before resuscitation, difficulty in blinding care providers regarding
intervention, and the relatively uncommon occurrence of a poor neonatal outcome to measure the
effectiveness of an intervention [1,15].

The following discussion and our own practice are in compliance with the 2015 American Heart
Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation
(AHA/AAP/ILCOR) neonatal resuscitative guidelines for neonatal resuscitative care [1,15].

These guidelines begin with a rapid assessment of the neonate's clinical status based on the
following questions:

● Is the infant full-term?

● Does the infant have good muscle tone?
● Is the infant breathing or crying?

If the answer to all three questions is yes, the newborn does not need resuscitation, should not be
separated from the mother, and is managed by routine neonatal care. Apgar scores, first introduced in
1953, are an assessment of newborn infants during the first minutes after delivery, however they are
not used to guide resuscitation, but may be a useful measure of the newborn's overall status and
response to resuscitation [16]. (See "Overview of the routine management of the healthy newborn
infant".)

For infants who require further intervention, the basic steps ("ABCs") in resuscitation in any age group
are still applicable. However, several aspects of neonatal resuscitation are unique and lead to
differences in the initial resuscitative steps. The 2015 AHA/AAP/ILCOR guidelines recommend the
following approach (2015 AHA/AAP/ILCOR neonatal resuscitation algorithm) [1,15]:
 ● Initial stabilization (provide warmth, clear Airway if necessary, dry, and stimulate)
● Breathing (ventilation and oxygenate)
● Chest compressions
● Administration of epinephrine and/or volume expansion

The decision to progress from one step to the next is determined by the response of the infant to the
applied resuscitative effort based upon the respiratory effort and heart rate (2015 AHA/AAP/ILCOR
neonatal resuscitation algorithm).

● No further resuscitative actions are required if the infant responds to initial intervention with
adequate spontaneous respirations and a heart rate above 100 beats per minute (bpm).

● However, for those who fail to respond to initial interventions with persistent findings of gasping,
apnea, labored breathing, persistent cyanosis, or a heart rate less than 100 bpm, further
interventions are required. (See 'Infants who require further management' below.)

It is vital that each step be performed optimally because subsequent resuscitative efforts are
dependent on the success of previous steps. Inadequate attention to ensuring completeness and
effectiveness of earlier steps will jeopardize the utility of subsequent actions and unnecessarily
expose infants to more aggressive intervention when they only required the earlier steps of
resuscitation.

Initial steps — Initial steps in the delivery room are started within a few seconds of birth and should
be applied throughout resuscitation. Our approach outlined below is in agreement with the 2015
AHA/AAP/ILCOR neonatal resuscitative guidelines (2015 AHA/AAP/ILCOR neonatal resuscitation
algorithm) [1,15]. The interventions used are discussed in the following section. (See 'Interventions'
below.)

During the first minute of life, referred to as the "golden minute," all newborn infants are initially
assessed to determine the level of care needed and the following initial steps of stabilization are
completed.

● Warm and maintain body temperature. (See 'Temperature control' below.)

● Position airway and clear secretions if needed

● Dry the infant

● Stimulation – Tactile stimulation of the newborn is initiated promptly after birth. Efforts at
stimulating the infant should not be prolonged and should be no more than 30 seconds before
initiating next resuscitative steps. Drying and suctioning the infant, which are performed as part
of the initial steps, usually provide adequate stimulation. Safe, appropriate ways of providing
 additional stimulation include briefly slapping or flicking the soles of the feet, and rubbing the
infant's back. More vigorous stimulation is not helpful and may cause injury.

Infants who qualify for routine care — Infants at delivery who are born at term, have good tone, and
are crying or breathing without difficulty may stay with the mother and be cared for in a level 1
neonatal care unit. In addition, infants who are breathing and crying after birth may undergo delayed
cord clamping for more than 30 seconds [1,15]. (See "Overview of the routine management of the
healthy newborn infant", section on 'Delivery room care' and "Management of normal labor and
delivery", section on 'Cord clamping'.)

Infants who require further management — Infants who fail to meet the criteria for routine care
during the initial steps are reassessed for their respiratory effort, color, and heart rate.

In particular, the heart rate is used to evaluate the effectiveness of the neonate's respiratory efforts
and determine whether additional intervention is required. Auscultation of the precordium and the use
of pulse oximetry are routinely used to assess heart rate in the delivery room. However, there is
evidence that auscultation is imprecise and it can take over a minute for a reliable signal to be
established with pulse oximetry [1,15,17,18]. As a result, the 2015 AHA/APA/ILCOR guidelines
suggest that electrocardiography (ECG) may be a reasonable option to provide a more rapid and
accurate estimation of neonatal heart rate in the delivery room [1,15]. However, the use of ECG
monitoring does not replace the need for pulse oximetry, which is still important to assess
oxygenation.

At our center, initial ECG monitoring is used selectively for high-risk births where there is a high
likelihood of need for resuscitation based on the judgement of the pediatric team, and for infants with
antenatally diagnosed cardiac lesions.

Apnea/gasping and heart rate <100 bpm — For infants who are apneic or gasping and have a heart
rate below 100 beats per minute (bpm), the following interventions are performed within one minute
after delivery:

● Positive pressure ventilation (PPV) at a rate of 40 to 60 breaths per minute. (see 'Positive
pressure ventilation' below)

● Monitor with pulse oximetry, which provides a noninvasive, rapid, and continuous assessment of
heart rate during resuscitation and measures oxygen saturation (SpO2) (see 'Pulse oximetry'
below)

● Electrocardiographic monitoring
Further resuscitative efforts are based upon the response of the infant after the initial 15 seconds of
PPV.

● If the heart rate is not increasing, evaluate for chest rise with assisted breaths, if the chest is not
rising appropriately with administered breaths, perform ventilation corrective steps [4]. These
include:

• Mask readjustment
• Reposition airway by ensuring correct head position (figure 1)
• Suction mouth and nose
• Open the mouth and tilt the jaw forward
• Pressure increase using increments of 5 to 10 cm H2O to maximum of 40 cm H2O
• Alternative airway using endotracheal intubation or laryngeal mask (see 'Endotracheal
intubation' below)

● If the heart rate is increasing, continue PPV and check the heart rate again after 15 seconds. The
need for additional interventions is based on the heart rate after a total of 30 seconds of PPV as
follows:

• If the heart rate is ≥100 bpm and spontaneous effective respiration has begun, PPV can be
discontinued and free-flowing oxygen can be administered as needed based on the target
SpO2 after birth. The infant is observed closely (heart rate and SpO2) to determine whether
his/her spontaneous respiratory effort is adequate without need for further intervention.
(See 'Supplemental oxygen' below.)

• If the heart rate remains <100 bpm, continue PPV ventilation and check for chest wall
movement to see if there is effectively delivered ventilation. If not, assess and correct
ventilation technique (see 'Procedure' below). If needed, proceed to endotracheal intubation
(see 'Endotracheal intubation' below) or use of a laryngeal mask airway.

• If the heart rate increases to ≥100 bpm and spontaneous effective respiration has begun,
PPV can be discontinued and free-flowing oxygen administered as needed, based on the
target SpO2 after birth.

• If the heart rate is <60 bpm, intubate the infant or place a laryngeal mask airway if this has
not already been done, initiate chest compression and reassess that adequate positive
pressure ventilation is being delivered. (See 'Chest compressions' below.)

• If the heart rate remains <60 bpm, obtain vascular access (typically by insertion of an
umbilical vein catheter (figure 2) (see "Vascular (venous) access for pediatric resuscitation
and other pediatric emergencies", section on 'Umbilical vein access')) and administer
 intravenous epinephrine. Consider whether the infant is hypovolemic and requires volume
expansion, or if a there is a pneumothorax. (See 'Epinephrine' below and 'Volume expansion'
below.)

Labored breathing or persistent cyanosis and heart rate ≥100 bpm — For infants who have
labored breathing or persistent cyanosis and a heart rate ≥100 bpm, the following interventions are
performed within one minute after delivery.

● Position and clear airway (see 'Airway' below)

● Use of pulse oximetry to monitor SpO2 (see 'Pulse oximetry' below)
● Provide supplemental oxygen to targeted preductal SpO2 (see 'Supplemental oxygen' below)
● Consider the use of continuous positive airway pressure

Preterm neonates — Preterm neonates who are >35 weeks with spontaneous effective respiration
and heart rate depending on hospital policy may be admitted to the "normal" nursery (neonatal level
of care 1). More immature infants require higher levels of care (neonatal level of care 2 or 3) and final
disposition is based on their gestational age and clinical status.

INTERVENTIONS

Interventions used in the delivery room are discussed in the following section. How they are utilized
based on the clinical setting is discussed in the above section on management approach.

Temperature control — Maintaining normal temperature in the newborn is imperative as hypothermia

in the immediate newborn period is associated with increased mortality [15,19,20]. Neonatal
hypothermia increases oxygen consumption and metabolic demands, which can impair subsequent
resuscitative efforts, especially in the asphyxiated or preterm infant. Preterm infants are particularly
prone to rapid loss of body heat because of their large body surface area relative to their mass, thin
skin, and decreased subcutaneous fat. (See "Short-term complications of the preterm infant", section
on 'Hypothermia'.)

To minimize heat loss, the delivered infant is first placed in a warmed towel or blanket. Raising the
environmental (room) temperature to 26°C (78.8°F) will also help in reducing neonatal hypothermia.

Other methods of warming infants are used depending upon the condition of the neonate and the
need for further resuscitative efforts [1]:

● Swaddle after drying

● "Skin-to-skin" contact with mother

 ● Polyurethane bags or wraps in infants with birth weights (BW) less than 1500 g

● Warming pads

● Use of a prewarmed radiant heater during resuscitative efforts – The temperature control of the
warmer is regulated by servo-control and is set to maintain the infant's temperature at 36.5ºC,
which is monitored by a temperature skin probe placed upon the infant's abdomen. This prevents
both hypo- and hyperthermia.

● For infants who require respiratory support – Humidified and heated air, which compared with
nonheated air decreases the rate of both mild (36 to 36.4ºC) and moderate hypothermia (<36ºC)
[21].

Although studies have not examined the effects of postnatal hyperthermia on neonatal outcome,
there are data demonstrating that maternal fever is associated with neonatal respiratory depression,
neonatal encephalopathy, cerebral palsy, and increased mortality [1,15,22]. It is unclear whether
hyperthermia directly contributes to morbidity or whether it is a marker for an underlying pathological
process (eg, chorioamnionitis). Nevertheless, until further data are available, it is prudent to avoid
neonatal hyperthermia, as well as hypothermia, in the delivery room.

Airway — For infants requiring further intervention, the infant is positioned to open the airway by
placing the infant flat on his/her back on a radiant warmer bed with the neck in a neutral to slightly
extended position; the neck should not be hyperextended or flexed (figure 1). The proper position
aligns the posterior pharynx, larynx, and trachea and facilitates air entry. If needed, a rolled blanket or
towel may be placed under the infant's shoulder to slightly extend the neck to maintain an open
airway.

Suctioning immediately after birth is reserved for babies with obvious obstruction due to secretions
or who require positive pressure ventilation [1]. Once the infant has been correctly positioned, the
mouth and nose should be suctioned either with a bulb syringe or mechanical suction device. The
mouth is suctioned first and then the nares to decrease the risk for aspiration. Suctioning of either the
esophagus or stomach should be avoided if not indicated, as it can produce a vagal response,
resulting in apnea and/or bradycardia.

Wiping the mouth and nose may be an alternative to suctioning for removal of secretions in infants
who are ≥35 weeks gestation [23].

Meconium stained amniotic fluid — In the presence of meconium-stained amniotic fluid (MSAF),
intrapartum suctioning for meconium-stained infants is not recommended [1,15]. Care of these
infants should be guided by the same general principles for further intervention that are based on
inadequate respiratory effort (gasping, labored breathing, or poor oxygenation) or heart rate (<100
beats per minute [bpm]) (2015 American Heart Association/American Academy of
Pediatrics/International Liaison Committee on Resuscitation [AHA/AAP/ILCOR] neonatal
resuscitation algorithm). (See 'Infants who require further management' above.)

A more detailed discussion of the management of an infant with MSAF is presented separately. (See
"Prevention and management of meconium aspiration syndrome".)

Pulse oximetry — The 2015 AHA/AAP/ILCOR guidelines recommend the use of pulse oximetry to
determine oxygen saturation (SpO2) in the following settings because skin color (cyanosis) is a poor
indicator of oxyhemoglobin saturation as it normally remains in the 70 to 80 percent range for several
minutes following birth [1]:

● When resuscitation is anticipated

● Positive pressure ventilation is used for more than a few breaths
● Persistent cyanosis
● Use of supplementary oxygen

For these infants, the oximeter probe should be attached to a preductal location on the right upper
extremity, usually the wrist or medial surface of the palm, as soon as possible.

The following are targeted preductal SpO2 levels for term infants born at sea level based on the time
after delivery [1,24]:

● 1 minute – 60 to 65 percent
● 2 minutes – 65 to 70 percent
● 3 minutes – 70 to 75 percent
● 4 minutes – 75 to 80 percent
● 5 minutes – 80 to 85 percent
● 10 minutes – 85 to 95 percent

Although data for preterm infants and term infants born at other altitudes are lacking, the above
levels are thought to be reasonable for these patients.

Supplemental oxygen

AHA/AAP/ILCOR guidelines — Over the last few decades, the standard practice of initial use of
100 percent oxygen, whenever supplemental oxygen is needed, has been challenged, as increasing
evidence has shown that hyperoxia due to oxygen supplementation may result in tissue and organ
injury [25-27]. Based on the available evidence, the 2015 American Heart Association/American
Academy of Pediatrics International Liason Committee on Resuscitation (AHA/AAP/ILCOR)
guidelines provides the following recommendations for the use of supplemental oxygen in neonatal
resuscitation [1,15]:

● For neonates born at ≥35 weeks gestation, resuscitation is initiated with room air (21 percent
oxygen).

● For neonates <35 weeks gestation, resuscitation is initiated with 21 to 30 percent oxygen.

● The oxygen concentration should be adjusted to achieve targeted SpO2 levels, which are
monitored by pulse oximetry. (See 'Pulse oximetry' above.)

● The supplemental oxygen concentration should be increased to 100 percent if chest

compressions are initiated.

Our approach — In our practice, resuscitation begins with blended oxygen or room air depending
on the gestational age of the infant and the concentration of oxygen is adjusted based on targeted
oxygen saturation levels measured by pulse oximetry.

At our institution, we utilize the following approach, which complies with the above guidelines:

● For neonates >30 weeks gestation, we initiate resuscitation with 21 percent oxygen.

● For infants ≤30 weeks gestation, we initiate resuscitation with 30 percent oxygen by use of a
blender.

For all infants, pulse oximetry monitoring guides further adjustments of the delivered supplemental
oxygen in an effort to achieve and maintain the oxygen saturation based on target SpO2. For preterm
infants, we use a target SpO2 of 90 to 95 percent. Target levels for preterm is discussed in greater
detail separately. (See 'Pulse oximetry' above and "Neonatal target oxygen levels for preterm infants",
section on 'Oxygen target levels'.)

Supporting evidence — Data for both term and preterm infants have not shown an additional
benefit in neonatal outcome using 100 percent oxygen compared with lower oxygen concentration as
the initial oxygen concentration for neonatal resuscitation.

● Term infants – A systematic review of the literature and meta-analysis reported a reduction in
mortality in term infants with the use of room air compared with 100 percent oxygen, and no
difference in the risk of hypoxic ischemic encephalopathy or changes in neurodevelopmental
outcome [28].

● Preterm infants – Several systematic reviews of the literature report no difference in mortality
between initial resuscitation with high or low concentration of oxygen. However, these reviews
 varied in the selection process using different initial oxygen concentration for comparison and
gestational age for inclusion:

• In the first review of preterm infants <32 weeks gestation, there was no difference in the
primary outcome of mortality between infants initially resuscitated with low oxygen
concentration (21 to 30 percent) compared with those who received high oxygen
concentration (60 to 100 percent) [29]. There was also no difference in the secondary
outcomes of bronchopulmonary dysplasia (BPD) and intraventricular hemorrhage (IVH).

• In the second review of extremely preterm (EPT) infants <28 weeks gestation, there was no
difference between infants initially resuscitated with low oxygen concentration (≤30 percent)
compared with those who received high oxygen concentration (≥60 percent) in overall
mortality, BPD, IVH, retinopathy of prematurity, patent ductus arteriosus, and necrotizing
enterocolitis [30].

• In a third review of preterm infants (majority born <32 weeks gestation), there was no
difference in mortality between infants randomly assigned to low (<40 percent) versus high
(≥40 percent) initial oxygen concentrations targeted to oxygen saturation [31]. Although data
were more limited, there was no difference in neurodevelopmental disability at 24 months
between the two groups.

• A fourth review of preterm infants <35 weeks gestation reported no difference in short- and
long-term mortality, neurodevelopmental outcome, or other major morbidities between
groups of infants assigned to low versus high oxygen concentration [32].

Follow-up studies have reported no difference in mortality and neurodevelopmental outcome at

18 to 24 months corrected age [33-36].

Positive pressure ventilation — Positive pressure ventilation (PPV) is required if heart rate <100 bpm,
or is apneic or gasping. (See 'Apnea/gasping and heart rate <100 bpm' above.)

Equipment — PPV is administered to the newborn infant by a self-inflating bag, flow-inflating bag,

or T-piece resuscitator [1]. The method of choice varies with the availability of a gas supply, the skills
of the resuscitator, and the need to deliver positive end expiratory pressure (PEEP) or continuous
positive airway pressure (CPAP). Self-inflating bag is the most effective method in resource-limited
settings, as it does not require a gas supply. T-piece resuscitator is the only device that can provide
consistent delivery of both positive inspiratory pressure (PIP) and PEEP.

In our center, we use all three devices because we have a large diverse group of health care givers,
including many trainees. The more experienced clinicians prefer either the T-piece resuscitator or the
flow-inflating bag for their advantages of providing a continuous flow of supplemental oxygen and if
needed, CPAP in addition to its ability to deliver PPV.

● Self-inflating bag – The self-inflating bag reinflates when it is released. Unlike the other BMV
methods, it does not require a compressed gas source. Thus, it is the only method used when
compressed gas sources are not available in resource-limited areas. The self-inflating bag has a
pressure-release valve, commonly called a pop-off valve that is set by the manufacturer to
release at approximately 30 to 40 cm H2O pressure. However, for the newborn who has not taken
its first breath, it may be necessary to occlude this pop-off valve in order to generate sufficient
pressure to effectively inflate a newborn's nonaerated lungs. In such instances, care should be
taken not to overinflate the lungs because this may increase the risk of causing pulmonary air
leak. (See "Pulmonary air leak in the newborn".)

It has been assumed that the delivered oxygen concentration using a bag without a reservoir is
40 percent when using a source of 100 percent oxygen. However, one study demonstrated that
delivered oxygen concentration exceeded 60 percent at a minimum flow rate of 1 L/min and rose
as the flow rate increased [37]. When the pop-off valve was opened at 35 to 40 cm H2O, oxygen
concentrations fell to levels of 30 and 45 percent at flow rates ≤2 L/min.

With a self-inflating bag and a reservoir, oxygen delivery is thought to be approximately 90 to 100
percent oxygen with a 100 percent oxygen source. However, a study in resource-limited settings
reported that oxygen concentration can be controlled from <40 to >60 percent without a blender
using self-inflating bags with a reservoir by varying the oxygen flow rate from 0.25 L/min to 1
L/min regardless of positive inspiratory pressure (PIP) with PIP levels from 20 to 25 cm H2O [38].

● Flow-inflating bag – The flow-inflating bag (also referred to as an anesthesia bag) fills only when
gas from a compressed source flows into it. It is technically more difficult to master than the
self-inflating bag because a tight face-mask seal is needed for the bag to inflate; however, this
feature may be considered an advantage because it assures that an optimal face-mask seal is
obtained necessary for effective PPV. Because the flow-inflating bag does not have a pressure
release valve, a pressure manometer should always be used to minimize the risk of overinflation
resulting in pulmonary air leak.

● T-piece resuscitator – The T-piece resuscitator is similar to the flow-inflating bag, but with the
addition of an adjustable flow-control valve, which more precisely controls the peak inflating
pressure applied to the infant's lungs. It can also be used to set PEEP and CPAP. Like the flow-
inflating bag, it requires a compressed gas source. Limited data suggest using a T-piece
resuscitator reduces the rate of intubation compared with use of a self-inflating bag [39,40].
● Laryngeal mask airway (LMA) – In term infants and preterm infants with birth weights greater
than 1500 g (≥34 weeks gestation), laryngeal mask airway (LMA), which fits over the laryngeal
inlet, has been found to be effective when BMV or endotracheal intubation is unsuccessful, or
endotracheal intubation is not possible [41]. The LMA is a soft mask with an inflatable cuff
attached to a silicone rubber airway, which is inserted through the mouth by the clinician using
his/her index finger to guide "blind" insertion along the hard palate without the use of visualizing
instruments. Following insertion and inflation of the cuff, the LMA covers the laryngeal opening
and its rim conforms to the contours of the hypopharynx occluding the esophagus with a low-
pressure seal. LMA may be considered as an alternative to endotracheal intubation if BMV is
unsuccessful in providing adequate ventilation, and endotracheal intubation is unsuccessful or
not feasible. [41-43].

Procedure — The following steps are required to effectively and safely provide PPV using BMV:

● Position – The infant should be positioned with the neck in a neutral to slightly extended position
to ensure an open airway (figure 1). The clinician should stand at the head or side of the warmer
to view the chest movement of the infant to assess whether ventilation is effectively delivered.
(See 'Airway' above.)

● Suction – The nose and mouth should be suctioned as needed to clear any mucous to prevent
aspiration prior to delivery of assisted breaths.

● Seal – An airtight seal between the rim of the mask and the face is essential to achieve the
positive pressure required to inflate the lungs. An appropriately sized mask is selected and
positioned to cover the chin, mouth, and nose, but not the eyes of the infant [44]. The mask is
held on the face by positioning the hand of the clinician so that the little, ring, and middle fingers
are spread over the mandible in the configuration of the letter "E" and the thumb and index are
placed over the mask in the shape of the letter "C". The ring and fifth fingers lift the chin forward
to maintain a patent airway. An airtight seal is formed by using light downward pressure on the
rim of the mask and gently squeezing the mandible up towards the mask (figure 3).

● Initial breaths – The initial administered breaths often require pressures of 30 to 40 cm H2O to
inflate the lungs of the term infant. In most preterm infants, an initial inflation pressure of 20 to
25 cm H2O is usually adequate. Adequacy of ventilation is demonstrated by improvement in
heart rate. Chest wall movement should be assessed if heart rate does not improve. The infant
should be ventilated at a rate of 40 to 60 times per minute to achieve a heart rate >100 bpm.

When initiating ventilation, the care provider should try to avoid excess volume or pressure, which
can result in volutrauma resulting in lung injury or pulmonary air leak, especially in the preterm
infant [45]. To minimize volutrauma, the positive pressure should be adjusted to deliver an initial
 starting tidal volume of 4 to 5 mL/kg. In addition, positive end-expiratory pressure (PEEP) of 4 to
5 cm H2O should be used to prevent atelectasis [45]. The self-inflating bag does not provide
PEEP. (See "Pulmonary air leak in the newborn" and "Bronchopulmonary dysplasia: Prevention",
section on 'Noninvasive mechanical ventilation'.)

CPAP — Continuous positive airway (CPAP) in preterm infants at risk for respiratory distress
syndrome (RDS) with spontaneous ventilation is the preferred intervention versus the combined
regimen of endotracheal intubation, surfactant therapy, and mechanical ventilation [1,15]. CPAP and
neonatal RDS are discussed separately. (See "Prevention and treatment of respiratory distress
syndrome in preterm infants", section on 'Nasal continuous positive airway pressure'.)

Endotracheal intubation — Endotracheal (ET) intubation allows direct access to the upper trachea for
delivery of PPV. Intubation is a skill that must be learned and takes practice for one to become
accomplished. While BMV may suffice in most instances of neonatal resuscitation, there are
instances when ET intubation may be preferred. Thus, when a high-risk delivery is anticipated, at least
two individuals should be present for the birth to assist with resuscitation of the infant, and one
should be skilled in ET intubation.

ET intubation may be indicated if [1]:

● BMV is ineffective or prolonged

● Chest compressions are being performed

In addition to the above, ET intubation may be electively chosen in certain special circumstances,
such as congenital diaphragmatic hernia, airway stabilization of the extremely low birth weight infant
(ELBW; BW <1000 g), and for administration of surfactant.

Procedure — Two care providers are required for ET intubation, one to perform the procedure and
the other to assist and monitor the status of the infant during the intubation. To minimize hypoxemia,
time needed for intubation should be limited to 30 seconds, and free flowing oxygen is administered
during the procedure.

All necessary supplies should be readied for intubation, including appropriate size ET tubes (ETT).
The neonatal resuscitation program (NRP) guidelines recommend using birth weight or gestational
age to determine the appropriate ETT size (table 3) [4].

Suction device should be available to remove secretions in the posterior oropharynx and
laryngopharynx that may obstruct the view of the trachea and vocal cords.

The following steps are required for successful intubation of the neonate:

● Initial stabilization – Unless contraindicated, the patient should be stabilized by BMV.

● Positioning – The infant is placed on his/her back with the head in the midline and the neck
slightly extended (figure 1).

● Insertion – The laryngoscope is held in the left hand of the clinician between the thumb and the
first two or three fingers, with the blade pointing away from the clinician. The right hand
stabilizes the head of the infant. The laryngoscope blade is inserted over the right side of the
tongue pushing the tongue to the left and is advanced until the blade lies in the vallecula, just
beyond the base of the tongue. The entire blade is lifted in the direction of the laryngoscope
handle to allow visualization of the vocal cords. It is important not to twist the laryngoscope like
a lever, the so-called "can opener" maneuver, as this can elevate the vocal cords out of view and
can damage the alveolar ridge. Once the vocal cords are visualized, an appropriate-sized ETT is
inserted through them with the right hand until the vocal cord guide line (heavy black line near
the tip of the tube) is at the level of the vocal cords.

Some individuals prefer to use a stylet to provide rigidity and curvature to the tube; if a stylet is
used, care should be taken that it does not protrude out of the tip of the tube, and when it is
removed the tube is not inadvertently dislodged.

● Assessment of successful intubation – Successful intubation following institution of PPV is

associated with a prompt increase in heart rate. Other indicators of successful intubation include
auscultation of audible breath sounds over both lung fields, vapor condensation inside the ETT
during exhalation, and symmetrical chest movement; however, these findings have not been
systematically studied in neonates. Chest radiography is needed to confirm that the ETT is
correctly placed above the carina of the trachea.

Exhaled carbon dioxide (CO2) detectors can be used to confirm ETT placement, especially in very
low birth weight infants [46-49]. At our institution, we use CO2 detectors to confirm ETT
placement as endorsed by the 2015 AHA/AAP/ILCOR guidelines [1].

● Insertion depth and securing ETT – The depth of insertion is determined by gestational age, birth
weight or the nasal-tragus length (NTL, distance between the nasal septum and tragus of the ear)
(table 4) [4,50]. Correct placement is initially confirmed by the presence of equal breath sounds
on both sides detected by auscultation using a stethoscope.

If the ETT is used for ventilation, it needs to be secured using water resistant tape after noting
the centimeter marking adjacent to the infant's upper lip. Final confirmation of ETT placement is
verified by a chest radiograph, which should be obtained as soon as possible.

● PEEP – In infants who require PPV, PEEP is likely to be beneficial, and should be used if suitable
equipment is available. In our practice, we routinely use PEEP in accordance with the 2015
 AAP/AHA/ILCOR guidelines that suggest 5 cm H2O PEEP be used whenever PPV is provided to
neonates [1].

Chest compressions — Chest compressions are initiated if the infant's heart rate remains <60 bpm
despite adequate ventilation for 30 seconds [1].

Chest compression applies pressure to the lower one-third of the sternum visualized as an imaginary
line between the nipples and the xiphoid process. Although two methods are available, we prefer the
two thumb technique because it generates higher systolic and coronary perfusion pressure, and it
allows better access for umbilical line insertion and is consistent with the 2015 AHA/AAP/ILCOR
guidelines [1,15,51-56].

● Two-thumb technique – In this method, both hands encircle the infant's chest with the thumbs on
the sternum and the fingers under the infant (figure 4). If the infant is intubated, the person
performing chest compressions should move to the head of the bed to perform chest
compression. This will allow another team member access to the infant to insert an umbilical
line should it be deemed necessary.

● Two-finger technique – In this method, the tips of the first two fingers, or the middle and ring
finger, are placed in a perpendicular position over the sternum (figure 5).

Pressure is applied downward perpendicular to the chest wall sufficient to depress the sternum
approximately one-third of the anteroposterior diameter of the chest, and then pressure is released to
allow the heart to refill. Care should be taken to avoid applying pressure directly over the xiphoid, as
this may cause hepatic injury.

Chest compression is always accompanied by PPV. During neonatal resuscitation, the chest
compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation
interposed after every third compression. Thus, the ventilation rate is reduced from the 40 to 60
breaths per minute in the absence of chest compression to 30 breaths in the presence of chest
compression. Whenever chest compressions are provided, the oxygen concentration is increased to
100 percent [1].

After 60 seconds of chest compression and PPV, reassessment of the infant's heart rate, color, and
respiratory rate should determine whether further interventions are required (eg, intubation or
administration epinephrine).

Epinephrine — Although epinephrine is universally accepted as an intervention in neonatal

resuscitation, it has never been prospectively studied and validated in placebo-controlled clinical trials
[41,57]. Nevertheless, intravenously administered epinephrine at a dose of 0.01 to 0.03 mg/kg (0.1 to
0.3 mL/kg of a 1:10,000 solution [concentration 0.1 mg/mL]) is recommended when the heart rate is
<60 bpm despite adequate ventilation and chest compressions (table 5) [1] (2015 AHA/AAP/ILCOR
neonatal resuscitation algorithm).

Epinephrine may be repeated every three to five minutes if the heart rate remains <60 bpm. It remains
uncertain what the optimal dose should be. Some data suggest higher doses are not more effective
and may result in brain and cardiac injury [4,42]. However, one study reported that most patients
required multiple intravenous doses of epinephrine, including larger initial doses of 0.05 mg/kg before
there was a return of spontaneous circulation [58].

Epinephrine given intravenously is more efficacious than ETT administration [58,59]. However, the
ETT route may be used while intravenous access is being obtained, but the safety and efficacy of this
practice has not been evaluated. If epinephrine is given through an ETT, a dose of 0.05 to 0.1 mg/kg
(0.3 to 1 mL/kg of a 1:10,000 solution) should be used [1]. After ETT administration, another dose of
epinephrine could be administered intravenously when vascular access is obtained [4].

If there is no response to administration of epinephrine, the clinician should reassess the earlier
resuscitative steps to ensure that they have been performed correctly. If resuscitative efforts were
completed correctly, then another problem such as hypovolemia might be present (2015
AHA/AAP/ILCOR Neonatal Resuscitation Algorithm)  

Volume expansion — In the delivery room, neonatal hypovolemia requiring volume expansion is rarely
needed and should only be considered if the heart rate remains < 60 bpm despite adequate
ventilation and administration of epinephrine (2015 AHA/AAP/ILCOR neonatal resuscitation
algorithm). Hypovolemia may be suspected if there is ante- or intrapartum hemorrhage, (which may
be due to an umbilical cord accident, placenta previa, placental abruption, or trauma), or if there are
clinical signs of hypovolemia seen despite an adequate heart rate, such as pallor, poor perfusion, and
weak pulses. (See "Etiology, clinical manifestations, evaluation, and management of neonatal shock",
section on 'Clinical manifestations'.)

We agree with the current guidelines to administer a10 mL/kg bolus of normal saline over 5 to 10
minutes to correct hypovolemia [1]. This dose can be repeated if necessary based upon the response
to the initial bolus. (See "Etiology, clinical manifestations, evaluation, and management of neonatal
shock", section on 'Fluid resuscitation'.)

Other acceptable solutions include Ringer's lactate or O Rh-negative blood. The latter may be
preferable if severe blood loss and/or anemia is suspected or documented.

Nonrecommended interventions

Naloxone — Administration of naloxone, a narcotic antagonist, is not recommended as part of

initial resuscitation in the delivery room because data are lacking demonstrating its efficacy, and
there remains uncertainty regarding its dosing, routes of administration, and safety [42,60]. Although,
maternally administered opioids in the perinatal period may cause neonatal respiratory depression,
attention to ventilation and oxygenation is generally adequate for neonatal resuscitation.

Sodium bicarbonate — There is insufficient evidence to determine whether sodium bicarbonate is

beneficial or harmful in neonatal resuscitation [4,61,62]. Although theoretically sodium bicarbonate
should be beneficial to correct acidosis, there is also evidence that sodium bicarbonate adversely
affects myocardial and cerebral function [63]. Given the uncertainty of benefit and the potential for
adverse effects, we do not recommend the routine use of sodium bicarbonate as part of neonatal
resuscitation. (See "Approach to the child with metabolic acidosis", section on 'Neonates'.)

If sodium bicarbonate is used, it should be given only after adequate ventilation and circulation has
been established to prevent increased CO2 retention. Sodium bicarbonate is a caustic and hypertonic
agent, and, if administered, it must be given through a large vein. Given the controversy over its use in
neonatal resuscitation, no dose for sodium bicarbonate use has been established. If it is used, the
usual dose is 1 or 2 mEq/kg, given at a rate no faster than 1 mEq/kg per minute. (See "Primary drugs
in pediatric resuscitation", section on 'Sodium bicarbonate'.)

FAILURE OF INITIAL RESUSCITATION

Rarely, infants will not respond to the initial resuscitative efforts. In this setting, the clinical team
needs to review that all the resuscitative steps have been fully and properly administered.

If the infant fails to respond despite properly executed resuscitation, the following findings may help
ascertain and possibly identify the cause:

● Failure to respond to positive pressure ventilation (PPV):

• Mechanical blockage (eg, meconium, mucus, choanal atresia, pharyngeal airway

malformation [Robin sequence], or laryngeal web)

• Impaired lung function (pneumothorax, pleural effusions, congenital diaphragmatic hernia,

pulmonary hypoplasia, congenital pneumonia, or hyaline membrane disease)

● Central cyanosis – Congenital heart disease

● Persistent bradycardia – Heart block

● Apnea – Brain injury (hypoxic ischemic encephalopathy), congenital neuromuscular disorder, or

respiratory depression from maternal medication
DISCONTINUING RESUSCITATION

Resuscitation efforts may be discontinued after 10 minutes of effective resuscitation including

intubation and the use of epinephrine, if the neonate has demonstrated no signs of life (no heart beat
or respiratory effort for > 10 minutes). While there are reports of rare survivors who are
developmentally normal at 18 months of age, the outcome of the vast majority of infants with no
signs of life after 10 minutes of resuscitation remains poor due to either death or survival with
neurodevelopmental impairment [1,64-67].

As previously discussed, if after resuscitation is started, additional data demonstrates that the
outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if
agreed upon by the parents and health care team.

WITHHOLDING RESUSCITATION

With antenatal screening, it is now possible to identify conditions associated with high neonatal
mortality or poor outcome. In these settings, intensive therapy, including neonatal resuscitation may
result in prolongation of dying with significant neonatal pain and discomfort, or survival with
unacceptable quality of life. Decisions regarding whether intervention should be initiated and to what
degree are difficult and are made together by parents and care providers, guided by their
understanding of the child's best interests.

Our approach in deciding whether resuscitation should be initiated or withheld is consistent with the
recommendations of the American Academy of Pediatrics (AAP) and includes the following [1,68].

● The decision not to initiate intensive therapy is made together by the parents and the health care
team. Parents should be active participants in the decision-making process. Discussion, if
possible, should occur prior to the birth of the infant.

● Noninitiation of resuscitation may be considered if early death is very likely and survival would be
accompanied by unacceptably high morbidity. These clinical conditions include infants with
gestational age <23 weeks or birth weight <400 g, anencephaly, or chromosomal abnormalities
incompatible with life (eg, trisomy 13 or 18). (See "Periviable birth (Limit of viability)", section on
'Management approach'.)

● Intensive care including neonatal resuscitation is always indicated when there is a high likelihood
of survival and acceptable morbidity.
 ● When the prognosis of the infant is unclear but likely poor, and survival may be associated with a
diminished quality of life, parental wishes should determine management decisions.

● At delivery, if the appropriate course is uncertain, it is preferable to initiate resuscitation. After

delivery, the health care team can review with the parents the clinical status and prognosis of
their infant. If the outcome is almost certain early death or unacceptably high morbidity, support
can be discontinued if agreed upon by the parents and health care team. (See 'Discontinuing
resuscitation' above.)

● Basic care that provides comfort to the infant must be given at all times, even when intensive
therapy is not initiated.

● When there is disagreement between the parents and health care team, continued discussion is
recommended. Other resources useful in resolving disagreement include consultation with the
hospital's ethics committee or finding health care providers that will provide care for the infant in
the manner desired by the parents. At times, unresolved disagreement may result in the
involvement of the court system.

● At all times, the clinician must serve as an advocate of the infant and what he/she judges to be in
the infant's best interest.

● The clinician needs to know the relevant laws in his/her local area of practice.

POSTRESUSCITATION

Infants who required resuscitation are at risk of developing postresuscitative complications [69].
These include:

● Hypo- or hyperthermia (see "Short-term complications of the preterm infant", section on

'Hypothermia')

● Hypoglycemia (see "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia")

● Central nervous system (CNS) complications: apnea, seizures, or hypoxic ischemic

encephalopathy (see "Clinical features, evaluation, and diagnosis of neonatal seizures" and
"Clinical features, diagnosis, and treatment of neonatal encephalopathy")

● Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or transient

tachypnea of the newborn (see "Overview of neonatal respiratory distress: Disorders of
transition")
 ● Hypotension (see "Etiology, clinical manifestations, evaluation, and management of neonatal
shock")

● Electrolyte abnormalities (see "Fluid and electrolyte therapy in newborns")

● Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing (see

"Neonatal oral feeding difficulties due to sucking and swallowing disorders")

The longer and the greater the extent of resuscitation, the more likely that there will be subsequent
and serious complications. Thus, infants who required resuscitation should be placed in a setting in
which close monitoring and ongoing appropriate care can be provided [70].

SUMMARY AND RECOMMENDATIONS

● Although most infants successfully transfer from intrauterine to extrauterine life without any
special assistance, approximately 10 percent of newborns will need some intervention, and 1
percent will require extensive resuscitative measures at birth. Because the need for resuscitation
is not anticipated in the majority of neonates, personnel who are adequately trained should be
readily available to perform neonatal resuscitation at every birthing location, whether or not
problems are anticipated. (See 'Anticipation of resuscitation need' above.)

● Infants who are more likely to require resuscitation can be identified by maternal and neonatal
risk factors, and the presence of antepartum and delivery room complications (table 2). Care
providers skilled in neonatal resuscitation should be present and equipment should be prepared
prior to the birth of the high-risk infant. (See 'High-risk delivery' above.)

● Preterm infants are more likely to require resuscitation and develop complications from
resuscitation than term infants. If a preterm birth can be anticipated and time permits, it is
preferable to transfer the mother prior to delivery to a perinatal center. (See 'Preterm infants'
above.)

Resuscitation steps — We suggest the following practices that are outlined in the 2015American
Heart Association/American Academy of Pediatrics/International Liaison Committee on
Resuscitation (AHA/AAP/ILCOR) guidelines for neonatal resuscitation be used when providing
resuscitation to newborn infants (2015 AHA/AAP/ILCOR neonatal resuscitation algorithm) (Grade
2C).

● Initial care includes providing warmth to the infant, clearing his/her airway, and drying and
stimulating the infant. (See 'Initial steps' above.)
● Further intervention is required for infants who are preterm, do not have good muscle tone, and
are not breathing or crying. (See 'Infants who require further management' above.)

● For infants who are apneic or gasping and have a heart rate < 100 beats/min (bpm), positive
pressure ventilation (PPV) provided by bag-mask ventilation (BMV) is initiated at a rate of 40 to
60 breaths/min. (See 'Apnea/gasping and heart rate <100 bpm' above and 'Positive pressure
ventilation' above.)

• Pulse oximetry is used to continuously monitor heart rate and oxygen saturation (SpO2).
(See 'Apnea/gasping and heart rate <100 bpm' above and 'Positive pressure ventilation'
above and 'Pulse oximetry' above.)

• Intubation or use of a laryngeal mask airway is needed if positive pressure ventilation is

ineffective or prolonged, or chest compressions are being performed. (See 'Endotracheal
intubation' above.)

• Chest compressions are required if the infant's heart rate remains <60 bpm despite
adequate ventilation for 30 seconds. Chest compressions must always be accompanied by
PPV using 100 percent oxygen. (See 'Chest compressions' above.)

• If the heart rate remains <60 bpm despite adequate ventilation and chest compressions,
intravenous administration of epinephrine is indicated (table 5). Cannulation of the umbilical
vein is the quickest means of obtaining intravenous access in the newborn. (See
'Epinephrine' above.)

● For infants with labored breathing or persistent cyanosis, and a heart rate ≥100 bpm, the airway
is optimally positioned and cleared of secretions, pulse oximetry is used to monitor SpO2, and
supplemental oxygen is provided to targeted preductal SpO2. (See 'Labored breathing or
persistent cyanosis and heart rate ≥100 bpm' above and 'Airway' above and 'Pulse oximetry'
above and 'Supplemental oxygen' above.)

● If supplemental oxygen is provided, we recommend that resuscitation begin with blended oxygen
or room air and the concentration of oxygen is adjusted based on targeted oxygen saturation
levels measured by pulse oximetry (Grade 1B). In our practice, we initiate resuscitation with room
air in infants greater than 30 weeks gestation, and use 30 percent oxygen concentration for those
≤30 weeks gestation. (See 'Supplemental oxygen' above and 'Pulse oximetry' above.)

● Resuscitation can be withheld if it is legally acceptable and there is complete agreement among
parents and care providers that the neonatal outcome is dismal. (See 'Withholding resuscitation'
above.)
 ● Resuscitation efforts may be discontinued after 10 minutes of resuscitation if the neonate has
demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes).
(See 'Discontinuing resuscitation' above.)

● Infants who required resuscitation are at risk of developing postresuscitative complications.

After successful resuscitation, they require placement in a setting in which close monitoring and
ongoing appropriate care can be provided. (See 'Postresuscitation' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation 2015; 132:S543.

2. Mitchell A, Niday P, Boulton J, et al. A prospective clinical audit of neonatal resuscitation

practices in Canada. Adv Neonatal Care 2002; 2:316.

3. Niles DE, Cines C, Insley E, et al. Incidence and characteristics of positive pressure ventilation
delivered to newborns in a US tertiary academic hospital. Resuscitation 2017; 115:102.

4. American Academy of Pediatrics. Textbook of Neonatal Resuscitation, 7th ed, Weiner GM (Ed),
American Academy of Pediatrics, 2016.

5. Jukkala AM, Henly SJ. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet
Gynecol Neonatal Nurs 2009; 38:443.

6. Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal resuscitation
training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001;
107:648.

7. de Almeida MF, Guinsburg R, da Costa JO, et al. Resuscitative procedures at birth in late preterm
infants. J Perinatol 2007; 27:761.

8. Spain JE, Tuuli MG, Macones GA, et al. Risk factors for serious morbidity in term nonanomalous
neonates. Am J Obstet Gynecol 2015; 212:799.e1.

9. Berazategui JP, Aguilar A, Escobedo M, et al. Risk factors for advanced resuscitation in term and
near-term infants: a case-control study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F44.
10. Soraisham AS, Lodha AK, Singhal N, et al. Neonatal outcomes following extensive
cardiopulmonary resuscitation in the delivery room for infants born at less than 33 weeks
gestational age. Resuscitation 2014; 85:238.

11. Bajaj M, Natarajan G, Shankaran S, et al. Delivery Room Resuscitation and Short-Term
Outcomes in Moderately Preterm Infants. J Pediatr 2018; 195:33.

12. Chien LY, Whyte R, Aziz K, et al. Improved outcome of preterm infants when delivered in tertiary
care centers. Obstet Gynecol 2001; 98:247.

13. Cifuentes J, Bronstein J, Phibbs CS, et al. Mortality in low birth weight infants according to level
of neonatal care at hospital of birth. Pediatrics 2002; 109:745.

14. Batton DG, Committee on Fetus and Newborn. Clinical report--Antenatal counseling regarding
resuscitation at an extremely low gestational age. Pediatrics 2009; 124:422.

15. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal Resuscitation: 2015 International
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Circulation 2015; 132:S204.

16. AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON FETUS AND NEWBORN, AMERICAN

COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE.
The Apgar Score. Pediatrics 2015; 136:819.

17. Mizumoto H, Tomotaki S, Shibata H, et al. Electrocardiogram shows reliable heart rates much
earlier than pulse oximetry during neonatal resuscitation. Pediatr Int 2012; 54:205.

18. Kamlin CO, Dawson JA, O'Donnell CP, et al. Accuracy of pulse oximetry measurement of heart
rate of newborn infants in the delivery room. J Pediatr 2008; 152:756.

19. Watkinson M. Temperature control of premature infants in the delivery room. Clin Perinatol
2006; 33:43.

20. da Mota Silveira SM, Gonçalves de Mello MJ, de Arruda Vidal S, et al. Hypothermia on
admission: a risk factor for death in newborns referred to the Pernambuco Institute of Mother
and Child Health. J Trop Pediatr 2003; 49:115.

21. te Pas AB, Lopriore E, Dito I, et al. Humidified and heated air during stabilization at birth
improves temperature in preterm infants. Pediatrics 2010; 125:e1427.
22. Perlman JM. Hyperthermia in the delivery: potential impact on neonatal mortality and morbidity.
Clin Perinatol 2006; 33:55.

23. Kelleher J, Bhat R, Salas AA, et al. Oronasopharyngeal suction versus wiping of the mouth and
nose at birth: a randomised equivalency trial. Lancet 2013; 382:326.

24. Noori S, Wlodaver A, Gottipati V, et al. Transitional changes in cardiac and cerebral
hemodynamics in term neonates at birth. J Pediatr 2012; 160:943.

25. Higgins RD, Bancalari E, Willinger M, Raju TN. Executive summary of the workshop on oxygen in
neonatal therapies: controversies and opportunities for research. Pediatrics 2007; 119:790.

26. Vento M, Asensi M, Sastre J, et al. Oxidative stress in asphyxiated term infants resuscitated with
100% oxygen. J Pediatr 2003; 142:240.

27. Vento M, Sastre J, Asensi MA, Viña J. Room-air resuscitation causes less damage to heart and
kidney than 100% oxygen. Am J Respir Crit Care Med 2005; 172:1393.

28. Welsford M, Nishiyama C, Shortt C, et al. Room Air for Initiating Term Newborn Resuscitation: A
Systematic Review With Meta-analysis. Pediatrics 2019; 143.

29. Saugstad OD, Aune D, Aguar M, et al. Systematic review and meta-analysis of optimal initial
fraction of oxygen levels in the delivery room at ≤32 weeks. Acta Paediatr 2014; 103:744.

30. Oei JL, Vento M, Rabi Y, et al. Higher or lower oxygen for delivery room resuscitation of preterm
infants below 28 completed weeks gestation: a meta-analysis. Arch Dis Child Fetal Neonatal Ed
2017; 102:F24.

31. Lui K, Jones LJ, Foster JP, et al. Lower versus higher oxygen concentrations titrated to target
oxygen saturations during resuscitation of preterm infants at birth. Cochrane Database Syst Rev
2018; 5:CD010239.

32. Welsford M, Nishiyama C, Shortt C, et al. Initial Oxygen Use for Preterm Newborn Resuscitation:
A Systematic Review With Meta-analysis. Pediatrics 2019; 143.

33. Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterm infants with different inspired
oxygen fractions. J Pediatr 2014; 164:1322.

34. Boronat N, Aguar M, Rook D, et al. Survival and Neurodevelopmental Outcomes of Preterms
Resuscitated With Different Oxygen Fractions. Pediatrics 2016; 138.
35. Soraisham AS, Rabi Y, Shah PS, et al. Neurodevelopmental outcomes of preterm infants
resuscitated with different oxygen concentration at birth. J Perinatol 2017; 37:1141.

36. Thamrin V, Saugstad OD, Tarnow-Mordi W, et al. Preterm Infant Outcomes after Randomization
to Initial Resuscitation with FiO2 0.21 or 1.0. J Pediatr 2018; 201:55.

37. Thió M, Bhatia R, Dawson JA, Davis PG. Oxygen delivery using neonatal self-inflating
resuscitation bags without a reservoir. Arch Dis Child Fetal Neonatal Ed 2010; 95:F315.

38. Thio M, van Kempen L, Rafferty AR, et al. Neonatal resuscitation in resource-limited settings:
titrating oxygen delivery without an oxygen blender. J Pediatr 2014; 165:256.

39. Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for newborn ventilation in the
delivery room. J Pediatr 2014; 165:234.

40. Thakur A, Saluja S, Modi M, et al. T-piece or self inflating bag for positive pressure ventilation
during delivery room resuscitation: an RCT. Resuscitation 2015; 90:21.

41. International Liaison Committee on Resuscitation. 2005 International Consensus on

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment
Recommendations. Part 7: Neonatal resuscitation. Resuscitation 2005; 67:293.

42. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 2010; 122:S909.

43. Gandini D, Brimacombe JR. Neonatal resuscitation with the laryngeal mask airway in normal
and low birth weight infants. Anesth Analg 1999; 89:642.

44. O'Shea JE, Thio M, Owen LS, et al. Measurements from preterm infants to guide face mask size.
Arch Dis Child Fetal Neonatal Ed 2016; 101:F294.

45. Schmölzer GM, Te Pas AB, Davis PG, Morley CJ. Reducing lung injury during neonatal
resuscitation of preterm infants. J Pediatr 2008; 153:741.

46. Roberts WA, Maniscalco WM, Cohen AR, et al. The use of capnography for recognition of
esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995; 19:262.

47. Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide detector role in
endotracheal intubation in newborns. J Perinatol 1999; 19:110.
48. Hosono S, Inami I, Fujita H, et al. A role of end-tidal CO(2) monitoring for assessment of tracheal
intubations in very low birth weight infants during neonatal resuscitation at birth. J Perinat Med
2009; 37:79.

49. Repetto JE, Donohue PA-C PK, Baker SF, et al. Use of capnography in the delivery room for
assessment of endotracheal tube placement. J Perinatol 2001; 21:284.

50. Wang TC, Kuo LL, Lee CY. Utilizing nasal-tragus length to estimate optimal endotracheal tube
depth for neonates in Taiwan. Indian J Pediatr 2011; 78:296.

51. Menegazzi JJ, Auble TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression
during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 1993; 22:240.

52. THALER MM, STOBIE GH. AN IMPROVED TECHNIC OF EXTERNAL CARDIAC COMPRESSION IN
INFANTS AND YOUNG CHILDREN. N Engl J Med 1963; 269:606.

53. Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized, controlled trial of two-thumb vs two-
finger chest compression in a swine infant model of cardiac arrest [see comment]. Prehosp
Emerg Care 1997; 1:65.

54. Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb is superior to the two-
finger method for administering chest compressions in a manikin model of neonatal
resuscitation. Arch Dis Child Fetal Neonatal Ed 2011; 96:F99.

55. Saini SS, Gupta N, Kumar P, et al. A comparison of two-fingers technique and two-thumbs
encircling hands technique of chest compression in neonates. J Perinatol 2012; 32:690.

56. Hemway RJ, Christman C, Perlman J. The 3:1 is superior to a 15:2 ratio in a newborn manikin
model in terms of quality of chest compressions and number of ventilations. Arch Dis Child
Fetal Neonatal Ed 2013; 98:F42.

57. Ziino AJ, Davies MW, Davis PG. Epinephrine for the resuscitation of apparently stillborn or
extremely bradycardic newborn infants. Cochrane Database Syst Rev 2003; :CD003849.

58. Halling C, Sparks JE, Christie L, Wyckoff MH. Efficacy of Intravenous and Endotracheal
Epinephrine during Neonatal Cardiopulmonary Resuscitation in the Delivery Room. J Pediatr
2017; 185:232.

59. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine
during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006; 118:1028.
 60. Guinsburg R, Wyckoff MH. Naloxone during neonatal resuscitation: acknowledging the
unknown. Clin Perinatol 2006; 33:121.

61. Wyckoff MH, Perlman JM. Use of high-dose epinephrine and sodium bicarbonate during
neonatal resuscitation: is there proven benefit? Clin Perinatol 2006; 33:141.

62. Beveridge CJ, Wilkinson AR. Sodium bicarbonate infusion during resuscitation of infants at
birth. Cochrane Database Syst Rev 2006; :CD004864.

63. Aschner JL, Poland RL. Sodium bicarbonate: basically useless therapy. Pediatrics 2008;
122:831.

64. Jain L, Ferre C, Vidyasagar D, et al. Cardiopulmonary resuscitation of apparently stillborn

infants: survival and long-term outcome. J Pediatr 1991; 118:778.

65. Haddad B, Mercer BM, Livingston JC, et al. Outcome after successful resuscitation of babies
born with apgar scores of 0 at both 1 and 5 minutes. Am J Obstet Gynecol 2000; 182:1210.

66. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving
infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based
cohort. Am J Obstet Gynecol 2007; 196:463.e1.

67. Kasdorf E, Laptook A, Azzopardi D, et al. Improving infant outcome with a 10 min Apgar of 0.
Arch Dis Child Fetal Neonatal Ed 2015; 100:F102.

68. American Academy of Pediatrics Committee on Fetus and Newborn, Bell EF. Noninitiation or
withdrawal of intensive care for high-risk newborns. Pediatrics 2007; 119:401.

69. Frazier MD, Werthammer J. Post-resuscitation complications in term neonates. J Perinatol

2007; 27:82.

70. Akinloye O, O'Connell C, Allen AC, El-Naggar W. Post-resuscitation care for neonates receiving
positive pressure ventilation at birth. Pediatrics 2014; 134:e1057.

Topic 5015 Version 60.0

GRAPHICS

Neonatal resuscitation supplies and equipment

Suction equipment
Bulb syringe

Mechanical suction, tubing, and catheters

Meconium aspirator

8F feeding tube and 20 cc syringe

Intubation equipment
Laryngoscope with straight blades (number 0 and 1 for preterm and term infants, respectively)

Face masks (preterm and term infant sizes)

Oxygen source with flowmeter

Medications
Dextrose solution 10 percent

Epinephrine (0.1 mg/mL)

Isotonic solution

Naloxone hydrochloride (0.4 mg/mL)

Needles

Syringes

Umbilical vessel catheterization supplies

Sterile gloves, scalpel, antiseptic prep solution, umbilical catheter, tape, three-way stopcock

Miscellaneous
Radiant warmer

Warm towels

Cardiac monitor

Pulse oximeter and probe

Oropharyngeal airways

Additional equipment for delivery of preterm infants

Compressed air source

Oxygen blender

Plastic wrap

Transport incubator

Reproduced with permission from: Kattwinkel J. Textbook of neonatal resuscitation, 5th ed, American Academy of Pediatrics, 2006. Copyright ©
2006 American Academy of Pediatrics.

Graphic 69486 Version 14.0

Factors associated with a high-risk delivery

Antepartum
Maternal conditions

Age (>40 years, <16 years)

Poor socioeconomic status (poverty, malnutrition)

Detrimental habits (smoking, drug and/or alcohol abuse)

Medical conditions
• Diabetes mellitus
• Hypertension
• Chronic heart and/or lung diseases
• Kidney diseases/urinary tract infections
• Blood disorders (thrombocytopenia, anemia, blood group incompatibilities)

Obstetric conditions
• Prior stillbirth/fetal loss/early neonatal death
• Prior birth of a high-risk infant
• Antepartum hemorrhage
• Premature rupture of membranes
• Serious infection during pregnancy
• Placental anomalies: praevia, polyhydramnios or oligohydramnios, pregnancy-induced hypertension, group B streptococcus carrier

Fetal conditions

Prematurity

Postmaturity

Intrauterine growth retardation

Macrosomia

Multiple gestation

Congenital anomalies

Hydrops

During birth
Complications of maternal medical disease

Preterm labor

Prolapsed cord

Utero-placental bleeding

Abnormalities of presentation (transverse lie, breech, etc)

Chorioamnionitis or systemic maternal infection

Foul-smelling or meconium-stained amniotic fluid

Abnormal fetal heart rate patterns

Instrumented delivery (forceps or vacuum deliveries)

Cesarean delivery for maternal or fetal compromise

Narcotic administered to mother within four hours of birth

Reproduced with permission from: Fernandes CJ. Care of the High-Risk Neonate. In: Conn's Current Therapy 2005, 57th ed, Rakel RE, Bope ET (Eds),
WB Saunders, Philadelphia 2005. Copyright © 2005 Elsevier Science, Inc.

Graphic 58639 Version 5.0

Head position for neonatal resuscitation

The top panel demonstrates the correct head position with the baby positioned on the back with
the neck slightly extended resulting in alignment of the posterior pharynx, larynx, and trachea,
which allows unrestricted air entry.

Graphic 50607 Version 2.0

Umbilical vein catheterization

The steps for passage of an umbilical vein catheter (UVC) are as follows:

A. After preparing the stump with antiseptic solution, place umbilical tie firmly around the base of the
umbilicus with a half knot that will control bleeding from the stump but permit passage of the UVC. Cut the
residual umbilical cord about 2 cm above the skin.
B. Locate the umbilical vein (thin-walled, typically cephalad in the 12 o’clock position, and, in newborns, bleeds
after cutting). For patients undergoing resuscitation outside of the delivery room, identify and remove any
blood clot from the umbilical vein using a small, curved hemostat.
B and C. While holding the base of the umbilicus with the non-dominant hand, insert the pre-flushed UVC into
the vein approximately 3 to 5 cm in a full-term infant (2 to 4 cm in a premature infant) and check for blood
return.
D. Once blood return is confirmed, secure the catheter manually or with adhesive tape and administer
medications. Because emergency UVCs can frequently become misplaced during resuscitation, check for
blood return prior to each use.

For further information, refer to UpToDate topics on vascular access for pediatric resuscitation and other
pediatric emergencies.
Graphic 115073 Version 1.0
E-C clamp technique for a neonate

The hand is positioned so that the little, ring, and middle fingers are spread over the mandible from the angle
of the jaw forward towards the chin in the configuration of the letter "E". The jaw is then lifted, pulling the face
into the mask. The thumb and forefinger are placed over the mask in the shape of the letter "C". The mask is
squeezed onto the face and a seal is formed between the mask and the face.

Graphic 114184 Version 1.0

Endotracheal tube sizes for neonatal resuscitation

Tube size, mm, inside diameter Gestational age, weeks Weight, grams

2.5 <28 <1000

3 28 to 34 1000 to 2000

3.5 34 to 38 2000 to 3000

3.5 to 4 >38 >3000

Use No. 0 laryngoscope blade for preterm infants, and No. 1 for term infants.

Graphic 71813 Version 3.0

Initial endotracheal tube insertion depth ("tip to lip") for orotracheal intubation

Endotracheal tube insertion depth

Gestation (weeks) Baby's weight (g)
at lips (cm)

23 to 24 5.5 500 to 600

25 to 26 6.0 700 to 800

27 to 29 6.5 900 to 1000

30 to 32 7.0 1100 to 1400

33 to 34 7.5 1500 to 1800

35 to 37 8.0 1900 to 2400

38 to 40 8.5 2500 to 3100

41 to 43 9.0 3200 to 4200

Reproduced from: Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal intubation. Resuscitation 2008; 77:369. Table used
with the permission of Elsevier Inc. All rights reserved.

Graphic 116373 Version 1.0

Chest compression for infant resuscitation: Two thumb technique

The thorax is encircled with the hands and cardiac compressions are performed with both
thumbs. The compression site is approximately one finger's breadth below the
intermammary line. The area over the xiphoid process should be avoided to prevent injury to
the liver, spleen, or stomach.

Graphic 77050 Version 2.0

Chest compression for infant resuscitation: Two finger technique

Chest compressions for infants (under one year) may be performed with two fingers placed
on the sternum just below the nipples. This picture shows the site of compressions. When
compressions are performed the two fingers used should be perpendicular to the chest and
straight.

Graphic 73038 Version 5.0

Medications used in neonatal resuscitation

Medication Action Indication Dose and route

Epinephrine Increases cardiac output by
increasing the heart rate and
myocardial contractility, increases
blood pressure by causing peripheral
vasoconstriction
Heart rate <60 per minute despite 0.1 to 0.3 mL/kg IV using 0.1 mg/mL
adequate ventilation and chest epinephrine (also labeled 1:10,000)
compressions 0.3 to 1 mL/kg ET using 0.1 mg/mL
epinephrine (also labeled 1:10,000)

Isotonic saline Increases intravascular volume Suspected hypovolemia 10 mL/kg of 0.9 percent saline
solution IV over 5 to 10 minutes

Sodium Corrects metabolic acidosis Not recommended for routine use. 1 or 2 mEq/kg slow IV administration
bicarbonate Has been used in cases of at a rate no faster than 1 mEq/kg per
metabolic acidosis, and should only minute
be given after adequate ventilation
and circulation have been
established.

IV: intravenous; ET: endotracheal.

Graphic 55367 Version 6.0

Contributor Disclosures
Caraciolo J Fernandes, MD Nothing to disclose Leonard E Weisman, MD Grant/Research/Clinical Trial Support:
Vax-Immune [Ureaplasma diagnosis, vaccines, antibodies, other medical diagnostics and pre-analytical devices].
Patent Holder: Baylor College of Medicine [Ureaplasma diagnosis, vaccines, antibodies, process for preparing
biological samples]. Equity Ownership/Stock Options: Vax-Immune [Ureaplasma diagnosis, vaccines, antibodies,
other medical diagnostics and pre-analytical devices]. Melanie S Kim, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy