Newborn Care and Resuscitation

In depth

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Transition at birth

The fluid-filled fetal lungs have high vascular resistance and receive roughly 10–25% of combined ventricular output. Oxygenated umbilical venous blood bypasses the liver through the ductus venosus and the lungs through the foramen ovale and ductus arteriosus. Fetal arterial PO₂ is only about 20–30 mm Hg, but fetal hemoglobin (P50 near 19 mm Hg, adult about 27) still loads enough oxygen.

Labor hormones switch the airway epithelium to sodium absorption and the first breaths push lung liquid into the tissue, so cesarean birth without labor leaves more liquid and more transient tachypnea. Air, oxygen and nitric oxide relax the pulmonary vessels, pulmonary blood flow rises roughly 8- to 10-fold, and higher left atrial pressure closes the foramen ovale flap. Clamping removes the low-resistance placenta and systemic resistance rises; the ductus closes functionally over 1–3 days as oxygen rises and prostaglandin E₂ falls.

Until then, hypoxia, acidosis, hypercapnia or cold can restore right-to-left shunting (persistent pulmonary hypertension of the newborn, PPHN), seen as preductal SpO₂ above postductal. Umbilical venous return supplies much of left ventricular preload until the lungs aerate: in preterm lambs, clamping before ventilation cut heart rate by about 40% and right ventricular output by about two thirds, while ventilating first kept output stable (Bhatt 2013).

Asphyxia runs from rapid breathing to primary apnea, when stimulation still restarts breathing, then gasping and secondary apnea, when only ventilation helps. The two look alike at birth, so a baby still apneic after drying and stimulation is ventilated. Most babies breathe within 30–60 s (AHA 2025); healthy babies took a median of 7.9 minutes to pass 90% preductal SpO₂ (Dawson 2010).

Anticipation, initial steps and the NRP 9th changes

Every birth needs one person whose only job is the newborn and who can ventilate, a standardized risk assessment and an equipment checklist (AHA 2025, class 1); without risk screening, up to half of babies who need ventilation are not anticipated. NRP's prebirth questions: gestational age, amniotic fluid, other risk factors, cord plan.

Stimulation is drying and rubbing the back or soles and must not delay ventilation. Suction the mouth, then the nose, only for visible obstruction or a blocked airway during ventilation: routine suctioning, with clear or meconium-stained fluid, has no benefit (AHA 2025) and can cause vagal bradycardia, apnea and desaturation. A nonvigorous baby born through meconium is ventilated like any other; tracheal suction is reserved for tracheal obstruction during ventilation (2a).

Count heart rate with a stethoscope first (6 s × 10). ECG is fastest and most accurate (2a) and required during compressions (class 1); pulse oximetry took a median of 238 s to read in videos of 230 resuscitations (AHA 2025).

Temperature and the cord

Keep 36.5–37.5 °C from birth through admission; hypothermia below 36 °C and hyperthermia above 38 °C both harm (AHA 2025, class 1). A wet newborn loses heat mostly by evaporation and makes heat from brown fat at the cost of oxygen and glucose, so a cold baby turns hypoxemic, hypoglycemic and acidotic. In 5,277 very-low-birth-weight infants, mortality rose 28% for each 1 °C fall in admission temperature (Laptook 2007).

• Under 32 weeks: room 23 °C or warmer, radiant warmer, polyethylene wrap to the neck without drying, hat, thermal mattress, warmed humidified gas (2a–2b).
• Below 36 °C after stabilization, rewarm (class 1); faster (0.5 °C/h or more) and slower rates have had similar outcomes.

Deferred clamping gives a placental transfusion, classically about 80 mL by 1 minute and 100 mL by 3 minutes at term (Yao 1969). Under 37 weeks, if no immediate resuscitation is needed, deferring 60 s or more is class 1, level A: an ILCOR individual-participant meta-analysis (3,292 infants) found fewer deaths before discharge, number needed to treat 40, but more admission hypothermia under 32 weeks, so wrap during the delay. At term it raises hemoglobin and later ferritin without changing mortality (2a).

Milking strips about 20 cm of intact cord toward the baby 3–4 times. In nonvigorous babies at 35–42 weeks, MINVI (Katheria 2023, 1,730 infants) found no difference in NICU admission (23% vs 28%) but less delivery-room cardiorespiratory support, hypoxic-ischemic encephalopathy (HIE) and cooling than early clamping, so milking may be reasonable (2b). AHA allows it at 28–36+6 weeks only when deferral is impossible in a baby not needing immediate resuscitation (2b); NRP 9th finds too little evidence in nonvigorous babies at 28–34 weeks.

Ventilation, airway and oxygen

Start ventilation within 60 s for apnea, gasping or heart rate below 100 (AHA 2025, class 1); in 5,689 Tanzanian live births each 30 s of delay raised death or prolonged admission by 16% (Ersdal 2012). Excessive pressure gives tidal volumes that injure preterm lung and brain (3: Harm), so titrate it down as well as up.

A size 1 laryngeal mask is a rescue airway (2a) or a first interface (2b) at 34 weeks or more; most are labeled for 2 kg or more.

If heart rate is not rising within 15–30 s and the chest is not moving, use MR SOPA in the order most likely to help (NRP 9th; Canada's CPS keeps the fixed order). Once the chest moves, ventilate 30 s and recheck: 100 or more, continue and wean; 60–99, keep optimizing; below 60, intubate or place a laryngeal mask and start compressions.

Use a Miller 1 blade at term and 0 in preterm babies, limit attempts to about 30 s (NRP), and use video laryngoscopy where trained (2a; higher first-attempt success). Confirm with exhaled CO₂, rising heart rate, chest movement and equal breath sounds; with almost no pulmonary blood flow, a tracheal tube can show no CO₂. The tip belongs in the midtrachea, near the clavicles on film.

Place the oximeter on the right hand or wrist as soon as support starts (class 1) and titrate to the minute targets, drawn from healthy term babies born vaginally at sea level. Air rather than 100% oxygen lowered short-term mortality at 35 weeks or more. Under 32 weeks, 21–30% often misses the targets, an individual-patient meta-analysis linked 90–100% starts to lower mortality, and missing 80% by 5 minutes is associated with death, hence 30% or more (AHA 2025). European guidance (2022): 30% under 28 weeks, 21–30% at 28–31, 21% from 32.

Compressions, UVC, epinephrine and volume

Start compressions when heart rate stays below 60 after 30 s of ventilation that moves the chest, preferably through an endotracheal tube (class 1) or a laryngeal mask at 34 weeks or more (2b), because compressions compete with ventilation.

• Thumbs above the xiphoid, compressing from the head of the bed so the umbilicus stays free; full recoil (2b).
• Cadence for 3:1: 'One-and-Two-and-Three-and-Breathe-and', 2 s per cycle.
• 100% oxygen and ECG; recheck after 60 s and stop at 60 or more. An ECG rate above 60 needs a pulse or heart sounds to exclude PEA.
• Rotate the compressor every 2–5 minutes, at a heart rate check.

The umbilical vein is the preferred emergency route (class 1); IO is reasonable when it fails or is not feasible (2a), although neonatal IO succeeded on the first attempt in only 50–86%, with complications in 10–35% (AHA 2025). Emergency UVC steps (NRP):

1. Fill a 3.5 or 5 Fr single-lumen catheter with saline via a stopcock; keep it closed to the baby.
2. Clean the cord, tie umbilical tape loosely at the base, cut 1–2 cm above the skin.
3. Find the single large thin-walled vein; the two arteries are small and thick-walled.
4. Advance 2–4 cm at term, less if preterm, until blood draws back freely; stop there, give the drug and a 3 mL flush.
5. For longer use, image or replace it: tip at the IVC–right atrial junction (about T8–T9), never in the liver.

In a registry of 93,656 deliveries, 32% of babies given tracheal epinephrine achieved ROSC, against 77% with UVC doses after the tracheal dose failed (AHA 2025). A 3 kg baby gets 0.6 mL IV (0.06 mg) or 3 mL by tube (0.3 mg); label the tracheal syringe.

Give volume for suspected blood loss (pallor, weak pulses, abruption, previa, cord or fetomaternal bleeding) when heart rate stays below 60 despite epinephrine: normal saline, or uncrossmatched O Rh-negative blood when loss is substantial, 10–20 mL/kg over 5–10 minutes, repeated if needed (2b). Infuse slowly in preterm babies, in whom rapid volume shifts are linked to IVH. Naloxone is not in the algorithm; a baby depressed by maternal opioids is ventilated.

When the heart rate will not rise

Preterm babies: CPAP, surfactant and oxygen

Preterm lungs are stiff and surfactant-poor, the germinal matrix bleeds easily before about 32 weeks, and brown fat is scarce. A preterm baby who breathes but needs support right after birth can be managed with CPAP rather than intubation (AHA 2025, 2a, level A). In SUPPORT (2010, 1,316 infants at 24–27 weeks), early CPAP matched intubation and surfactant for death or bronchopulmonary dysplasia (BPD; 47.8% vs 51.0%) with fewer intubations; pooled trials showed CPAP reduced death or BPD, number needed to treat 25 (Schmölzer 2013). Traditional starting CPAP was about 5–6 cm H₂O; the European consensus (2022) uses 6–8.

Give surfactant when oxygen need rises on CPAP: the European consensus treats at FiO₂ above 0.30 on at least 6 cm H₂O, preferably by thin catheter (LISA), otherwise by brief intubation (INSURE). In OPTIMIST-A (2021, 485 infants at 25–28 weeks), thin-catheter surfactant did not significantly cut death or BPD (43.6% vs 49.6%) but lowered BPD in survivors. Doses: poractant alfa 2.5 mL/kg (200 mg/kg), beractant 4 mL/kg, calfactant 3 mL/kg. Compliance improves within minutes, so lower pressure and FiO₂ promptly.

• Use a T-piece with PEEP. Sustained inflations over 5 s are harmful under 28 weeks: in SAIL (2019) death within 48 hours was 7.4% against 1.4%.
• In the NICU, NeOProM (2018, 4,965 infants under 28 weeks) found 85–89% targets raised death (19.9% vs 17.1%) but lowered ROP treatment compared with 91–95%; European guidance aims for 90–94%.
• Protect the brain: midline head, gentle handling, no rapid boluses, no wide swings in CO₂ or blood pressure.

After resuscitation, the Apgar and when to stop

After prolonged ventilation or advanced resuscitation, monitor in a NICU or similar area (AHA 2025): oxygenation, heart rate, temperature, blood pressure, acid-base, urine output, seizures and infection. In paired umbilical gases, an arterial pH below 7.0 or a base deficit of 12 mmol/L or more marks metabolic acidemia (ACOG–AAP 2014). Debrief and update the family.

Check glucose early and until it stays normal (class 1); hypoglycemia is common after advanced resuscitation, especially under 32 weeks, and both low and high values worsen hypoxic-ischemic injury. AAP 2011 acts below 25 mg/dL in the first 4 hours and below 35 at 4–24 hours (goal 45 or more before feeds); the Pediatric Endocrine Society (2015) aims above 50 for 48 hours, then above 60. IV: D10W 2 mL/kg, then about 4–6 mg/kg/min (D10W at 60–80 mL/kg/day).

Cooling to 33.5–34.5 °C started within 6 hours (class 1, level A) cut death or major disability at 18 months (Cochrane 2013: 8 trials, 1,344 infants, RR 0.75, number needed to treat 7). The recommendation says 'greater than 36 weeks'; its supportive text and the trials use 36 weeks or more. Below 36 weeks cooling showed no benefit and possible harm (Faix 2025, 33–35 weeks). Avoid hyperthermia; passive cooling for transport needs continuous core temperature monitoring and the cooling center's direction, because it can overshoot below 33 °C.

The Apgar describes condition and response (ACOG Committee Opinion 644). Prematurity, maternal drugs, anomalies and ongoing resuscitation all change it, color is the least reliable sign, and ACOG recommends the expanded form that records interventions. It does not diagnose asphyxia or predict one baby's outcome, though in term infants a 5-minute score of 0–3 carried a neonatal mortality of 244 per 1,000 against 0.2 for 7–10 (Casey 2001).

With no detectable heart rate after every step, discuss stopping with the team and family at about 20 minutes after birth (AHA 2025, class 1; 2010 guidance said 10); an Apgar of 0 at 10 minutes alone did not predict death or impairment in the Optimizing Cooling trial. Not starting and stopping are ethically equivalent (class 1). For conditions likely to cause early death or severe morbidity, including birth at the margin of viability (22–24 weeks), withholding or limiting resuscitation is planned with parents, ideally before birth (2a).

Evidence and controversies

After routine tracheal suction stopped, one before-and-after study (231 nonvigorous babies) found more NICU admissions for respiratory problems (40% vs 22%) but no more MAS (Chiruvolu 2018); 4 RCTs still show no benefit from tracheal suction, so ventilation comes first.

Open questions in AHA 2025: cord management when resuscitation is needed, preterm deferral time, ventilation rate and interface, laryngeal masks below 34 weeks or 2 kg, oxygen during compressions (no human data), epinephrine timing and dose, passive cooling, cooling for mild HIE, and glucose monitoring.

Exam pearls

NBRC items stress equipment and numbers (bags, T-piece settings, FiO₂ and SpO₂ targets, ETT size and depth, CPAP and surfactant thresholds, transillumination, ductal SpO₂ differences); NCLEX and NREMT stress sequence and Apgar; transport exams add UVC or IO dosing and cooling.

• Ventilate within 60 s for apnea, gasping or HR below 100; HR not rising and chest not moving after 15–30 s means MR SOPA.
• Rate 30–60/min, inflation 0.5–1 s, PIP 25 cm H₂O (20–25 under 32 wk, 25–30 at 32 wk+), PEEP about 5.
• Starting FiO₂ 21% at 35 wk+, 21–30% at 32–34 wk, 30%+ under 32 wk; right-hand SpO₂ 65–70% at 2 min up to 85–95% at 10.
• Compressions for HR below 60 after 30 s of chest-moving ventilation, ideally through an ETT: 3:1, 90 + 30/min, two thumbs, 100% O₂, ECG.
• Epinephrine 0.1 mg/mL: IV/IO 0.01–0.03 mg/kg every 3–5 min; ETT 0.05–0.1 mg/kg only until access; volume 10–20 mL/kg for blood loss.
• No routine suction, even with meconium; defer clamping 60 s or more; never milk under 28 wk; keep 36.5–37.5 °C.
• Cooling: 36 wk or more, moderate or severe HIE, within 6 h, 33.5–34.5 °C for 72 h; with no HR, discuss stopping at about 20 min.