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 [1-3]. 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 [4,5]. However, in the United States, 10 percent of all newborns need some intervention, and 1 percent will require extensive resuscitative measures at delivery . 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 .
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.
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 . Studies have demonstrated that NRP training improves the correct sequencing and timing of the resuscitative steps and procedures by health care providers , provider knowledge and comfort in performing neonatal resuscitation , five-minute Apgar scores , and the number of infants receiving chest compressions [4,8-10]. NRP is offered as a biennial training or as a self-directed learning program using short, quarterly learning and skills sessions designed to foster resuscitation preparedness .
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.
●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 :
●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) . 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 .
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 [17-20].
The following factors make the preterm infant more likely to require resuscitation and develop complications :
●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 "Spontaneous preterm birth: Pathogenesis", section on '#2 Inflammation'.)
●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 and intraventricular hemorrhage (GMH-IVH) in the newborn: Risk factors, clinical features, screening, and diagnosis" and "Bronchopulmonary dysplasia (BPD): Clinical features and diagnosis".)
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 "Respiratory distress syndrome (RDS) in preterm infants: Management".)
●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 'Oxygen concentration' 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.
COVID-19 precautions — A newborn in the delivery room is unlikely to transmit COVID-19, but a mother with confirmed or suspected COVID-19 can be a source of infection. All health care providers in the delivery room with a mother with suspected or confirmed COVID-19 should wear appropriate personal protective equipment (PPE) to decrease the risk of transmission to themselves or to the newborn . Appropriate PPE in this situation includes equipment for aerosol-generating procedures, such as an N95 respirator or positive pressure respirator, eye protection, gown, and gloves. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Aerosol-generating procedures/treatments'.)
ANTENATAL COUNSELING — Each birth institution should have a consistent approach to parental counseling which includes information regarding prognosis in cases where the fetal/neonatal outcome is a concern. Decisions about the extent of post-delivery care should be made collaboratively between the care team and the parents/caregivers in advance of delivery. 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) . (See "Periviable birth (limit of viability)".)
In some instances, the parents/caregivers may reasonably elect to limit interventions for the neonate after delivery, including resuscitation. These decisions are difficult and should be guided by a clear understanding of the prognosis of the fetus/neonate and the values and preferences of parents/caregivers. This most commonly occurs in pregnancies complicated by prenatal diagnosis of severe fetal conditions associated with high neonatal mortality or poor outcome (eg, severe chromosomal abnormalities such as trisomy 13 or 18) or by onset of preterm labor at the limit of viability (<25 weeks gestation). Ethical and clinical frameworks for decision-making in these circumstances are provided in a separate topic review. (See "Periviable birth (limit of viability)", section on 'Ethical framework' and "Periviable birth (limit of viability)", section on 'Our approach'.)
We agree with the following AAP guidelines :
●If there is no chance of survival, resuscitation should not be initiated.
●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.)
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 [1,2].
The following discussion and our own practice are in compliance with the American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) neonatal resuscitative guidelines for neonatal resuscitative care and the European Resuscitation Council (ERC) (algorithm 1) [1-3].
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. They are not used to guide resuscitation, but may be a useful measure of the newborn's overall status and response to resuscitation . (See 'Infants who qualify for routine care' below and "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 AHA/AAP/ILCOR guidelines recommend the following approach (algorithm 1) [1,2]:
●Initial stabilization (provide warmth, dry, stimulate, position and clear Airway if necessary)
●Breathing (ventilation and oxygenate)
●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 intervention based upon the respiratory effort and heart rate (HR) (algorithm 1).
●No further resuscitative actions are required if the infant responds to initial intervention with adequate spontaneous respirations and a HR >100 beats per minute (bpm).
●However, for infants who fail to respond adequately to initial interventions and who have continued gasping, apnea, labored breathing, cyanosis, or HR <100 bpm, further interventions are required. (See 'Infants requiring delivery room resuscitation' 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 AHA/AAP/ILCOR/ERC neonatal resuscitative guidelines (algorithm 1) [1-3].
Additional details of specific interventions are provided in the sections below. (See 'Interventions' below.)
For term or preterm infants who do not require immediate resuscitation, delayed cord clamping is suggested for at least 30 to 60 seconds. This issue is discussed separately. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Early versus delayed cord clamping'.)
All newborn infants are initially assessed to determine the level of care needed and the following initial steps of stabilization are completed:
●Dry the infant, keep warm and maintain body temperature, preferably with skin-to-skin contact with mother, if the neonate’s condition permits. (See 'Temperature control' below.)
●Position airway and clear secretions if needed. (See 'Airway' below.)
●Stimulation – Tactile stimulation of the newborn is initiated promptly after birth to facilitate respiratory effort. 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 . However, unnecessary suction should be avoided as it may promote bradycardia. 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 — Term infants who at delivery have good tone and are crying or breathing without difficulty may stay with the mother and be cared for in the newborn nursery (level 1 newborn care). In addition, depending on the local hospital policy, late preterm neonates who are ≥35 weeks gestation who are vigorous with effective spontaneous respirations and normal HR may be admitted to the newborn nursery. (See "Overview of the routine management of the healthy newborn infant" and "Late preterm infants".)
Preterm neonates — Preterm infants born at <35 weeks gestation generally require higher levels of care (level 2 or 3 neonatal care unit). The final disposition is based upon their gestational age and clinical status. Preterm neonates who have inadequate respiratory effort and/or low HR after delivery are resuscitated according to the approach outlined in the algorithm (algorithm 1) and discussed in the sections below. (See 'Apnea/gasping and heart rate <100 bpm' below and 'Labored breathing or persistent cyanosis and heart rate ≥100 bpm' below.)
Additional detail on respiratory support for preterm neonates are provided separately. (See "Respiratory distress syndrome (RDS) in preterm infants: Management", section on 'Noninvasive positive airway pressure' and "Respiratory support, oxygen delivery, and oxygen monitoring in the newborn".)
Infants requiring delivery room resuscitation — Infants who fail to meet the criteria for routine care are reassessed for their respiratory effort, color, and HR.
Apnea/gasping and heart rate <100 bpm — For neonates who are apneic or gasping and/or have HR <100 beats per minute (bpm), the following interventions are performed within 30 seconds after delivery (algorithm 1) [1-3]:
●Begin positive pressure ventilation (PPV) with bag-mask ventilation (BMV) or T-piece resuscitator at a rate of 40 to 60 breaths per minute (see 'Positive pressure ventilation' below)
●Place the neonate on a monitor, including pulse oximetry and continuous ECG to monitor, which provide continuous assessment of HR and oxygen saturation (SpO2) during resuscitation (see 'Monitoring' below)
Further resuscitative efforts are based upon the neonate’s response after 15 to 30 seconds of BMV.
●Optimize PPV if HR is not increasing – If the HR is not increasing, evaluate for chest rise with assisted breaths. If the chest is not rising appropriately with administered breaths, optimize PPV as follows  (see 'Procedure' below):
•Adjust the mask to improve the seal
•Reposition airway to ensure correct head position (figure 1)
•Suction mouth and nose
•Open the mouth and tilt the jaw forward
•Increase the pressure administered using increments of 5 to 10 cm H2O to maximum of 40 cm H2O
●Start chest compressions if HR is <60 bpm despite adequate PPV for 30 seconds (see 'Chest compressions' below)
●If the HR remains <60 bpm after 60 seconds of chest compressions and PPV:
•Secure the airway (if not already done) (see 'Endotracheal intubation' below)
•Obtain venous access (typically by inserting an umbilical venous catheter (figure 2) (see "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'Umbilical vein access'))
•Address any other potential causes (eg, hypovolemic, pneumothorax) (see 'Volume expansion' below and "Pulmonary air leak in the newborn", section on 'Thoracentesis' and 'Failure of initial resuscitation' below)
●If the HR has increased to ≥100 bpm and neonate has effective spontaneous respirations:
•Monitor the neonate closely (including HR and SpO2) to determine whether the spontaneous respiratory effort is adequate without need for further intervention (see 'Monitoring' below)
Labored breathing or persistent cyanosis and heart rate ≥100 bpm — For infants who have labored breathing or persistent cyanosis and HR ≥100 bpm, the following interventions are performed within one minute after delivery.
●Position and clear airway (see 'Airway' below)
●Monitor SpO2 using pulse oximetry (see 'Pulse oximetry' below)
●Consider the use of continuous positive airway pressure (CPAP) (see 'Continuous positive airway pressure (CPAP)' below)
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 [25-28]. After delivery, temperature should be measured and recorded. Temperature should be maintained between 36.5°C and 37.5°C [1,2]. 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. For healthy neonates, "skin-to-skin" contact with mother is the preferred method to maintain normal temperature as it also promotes bonding and breastfeeding [1,2]. 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 :
●Swaddle after drying.
●Polyurethane bags or wraps in infants with birth weights (BW) less than 1500 g.
●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) .
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 [1,2,30]. 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.
●Positioning – 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 – Suctioning immediately after birth is reserved for babies with obvious obstruction due to secretions and those who require positive pressure ventilation (PPV). 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. Unnecessary suctioning or 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 .
●Meconium stained amniotic fluid – In the presence of meconium-stained amniotic fluid (MSAF), routine intrapartum nasopharyngeal suctioning and/or endotracheal suctioning post-delivery are not recommended [1-3]. Care of these infants should be guided by the same general principles as for neonates without MSAF and the need for resuscitation and other interventions are based upon the neonate’s respiratory effort and heart rate (HR) (algorithm 1). A more detailed discussion of the management of an infant with MSAF is presented separately. (See "Meconium aspiration syndrome: Management and outcome".)
Pulse oximetry — Pulse oximetry is used to monitor oxygen saturation (SpO2) in the following settings because skin color (cyanosis) is a poor indicator of oxygenation immediately after birth [1-3]:
●When resuscitation is anticipated
●When PPV is used for more than a few breaths
●When supplemental oxygen is administered
●When the neonate is persistently cyanotic
The oximeter probe should be placed in a preductal location (ie, on the right upper extremity, usually the wrist or medial surface of the palm).
Immediately following birth, the neonate’s oxygen saturation normally remains in the range of 70 to 80 percent for several minutes [1-3].
●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
These targets were derived from data on term infants born at sea level. Although data for preterm infants and infants born at higher altitudes are lacking, the above levels are thought to be reasonable for these patients.
Oxygen targets for preterm neonates beyond the initial resuscitation are discussed in greater detail separately. (See "Neonatal target oxygen levels for preterm infants".)
Heart rate — HR monitoring is used to evaluate the effectiveness of the neonate's respiratory efforts and to assess the response to interventions. Auscultation of the precordium is the initial preferred physical assessment of HR. However, continuous electrocardiography (ECG) monitoring provides the most rapid and accurate estimation of neonatal HR in the delivery room and during resuscitation, and should be used to confirm HR prior to initiation of chest compressions for bradycardia [1,2]. The ECG monitor should be used in conjunction with the pulse oximeter because it is faster and more accurate in detecting changes in HR compared with pulse oximetry alone. (See 'Pulse oximetry' above.)
At our center, initial ECG monitoring is used for infants who require further intervention after delivery based on the judgement of the pediatric team, and for infants with antenatally diagnosed cardiac lesions.
Oxygen concentration — When providing respiratory support during neonatal resuscitation, the goal is to prevent hypoxemia while avoiding hyperoxemia, since both can have adverse effects in the neonate. Hyperoxemia can be harmful especially in preterm infants as it is associated with increased risk of bronchopulmonary dysplasia and retinopathy of prematurity. (See "Bronchopulmonary dysplasia (BPD): Clinical features and diagnosis", section on 'Oxygen toxicity' and "Retinopathy of prematurity: Pathogenesis, epidemiology, classification, and screening", section on 'Risk factors'.)
Our suggested approach is as follows:
●For neonates born at >30 weeks gestation, we initiate resuscitation with room air ([RA], ie, fraction of inspired oxygen [FiO2] of 0.21).
●For neonates ≤30 weeks gestation, we initiate resuscitation with an FiO2 of 0.3 using a blender.
Our approach is generally consistent with the guidelines of the American Heart Association/American Academy of Pediatrics/International Liaison Committee Resuscitation (AHA/AAP/ILCOR), with the exception that we extend use of RA for resuscitation to a lower gestational age range (ie, the guidelines suggest using RA in neonates ≥35 weeks gestation) [1,2].
The practice of using lower FiO2 (ie, 0.21 to 0.3) for neonatal resuscitation is supported by randomized trials and meta-analyses [33-41]:
●Term and late preterm infants – In a meta-analysis of seven trials involving 1469 neonates ≥35 weeks gestation requiring respiratory support at birth, use of RA was associated with reduced mortality compared with using 100 percent oxygen (risk ratio [RR] 0.73, 95% CI 0.57-0.94); rates of hypoxic ischemic encephalopathy were similar in both groups .
●Preterm infants – In a meta-analysis of 10 trials involving 968 neonates <35 weeks gestation who were assigned to lower or higher FiO2 for initial resuscitation, mortality rates were similar in both groups (RR 0.83, 95% CI 0.50-1.37) . Rates of neurodevelopmental impairment and other key preterm morbidities were also similar in both groups. There was considerable variability in the FiO2 used in these trials with “low FiO2” ranging from 0.21 to 0.5 and “high FiO2” ranging from 0.6 to 1.0.
Positive pressure ventilation — For neonates who are apneic or gasping and/or have HR <100 beats per minute (bpm), PPV should be provided with bag mask ventilation (BMV) or T-piece resuscitator at a rate of 40 to 60 breaths per minute [1-3]. (See 'Apnea/gasping and heart rate <100 bpm' above.)
Equipment — During neonatal resuscitation, PPV can be administered by a T-piece resuscitator, self-inflating bag, or flow-inflating bag. The choice among these depends upon availability of a gas supply, the skills of the resuscitator, and whether delivery of positive end expiratory pressure (PEEP) is desired. In our center, we use all three devices because we have a diverse group of providers, including many trainees. More experienced clinicians prefer either the T-piece resuscitator or a flow-inflating bag for their advantages of providing a continuous flow of supplemental oxygen and if needed, PEEP. We generally agree with the guidance of the International Liaison Committee on Resuscitation (ILCOR), which suggests using a T-piece resuscitator rather than a self-inflating bag if resources permit and clinical staff have adequate training and experience using this method . However, a self-inflating bag is the most effective method in resource-limited settings, as it does not require a gas supply.
●T-piece resuscitator – The T-piece resuscitator is the only device that maintains constant positive inspiratory pressure (PIP) and PEEP. The device consists of a lightweight resuscitator unit with an adjustable flow-control valve that controls PIP. It connects via tubing to a facemask to provide PPV to the neonate. Though the device does not actually have a bag, it is considered a form of BMV because it functions similarly. The T-piece resuscitator requires a compressed gas source, so a self-inflating bag should be available as a backup device in case of gas-supply failure.
The efficacy of the T-piece resuscitator is supported by clinical trials and meta-analyses [42-45]. In a meta-analysis of four trials (1247 infants) comparing T-piece resuscitator with self-inflating bags, in-hospital mortality rates were similar for both groups (2.8 versus 3.8 percent, relative risk [RR] 0.74, 95% CI 0.4-1.34) . Rates of BPD were lower in the T-piece resuscitator group (5.8 versus 8.9 percent, RR 0.64, 95% CI 0.43-0.95). In two trials, the T-piece resuscitator reduced intubation rates compared with self-inflating bags [44,45].
●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 . 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 .
●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.
Procedure — The following steps are required to effectively and safely provide PPV:
●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 . 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).
●Breath rate and inflation pressure – PPV should be given at a rate of 40 to 60 breaths per minute. Term neonates usually require an inflation pressure of approximately 30 cm H2O initially to adequately inflate the lungs. In preterm infants, an initial inflation pressure of 20 to 25 cm H2O is usually adequate. In some cases, higher inflation pressures may be needed. Adequacy of PPV is demonstrated by improvement in SpO2 and HR and by visible chest wall movement.
When providing BMV, the provider should try to avoid excess volume or pressure (ie, volutrauma and barotrauma), which can cause lung injury or pulmonary air leak, especially in the preterm infant . (See "Pulmonary air leak in the newborn" and "Bronchopulmonary dysplasia (BPD): Prevention", section on 'Ventilation strategies to minimize lung injury'.)
Sustained lung inflation may be harmful and should be avoided, as discussed below. (See 'Sustained inflation' below.)
●PEEP – If using a device that provides PEEP (eg, T-piece resuscitator or flow-inflating bag), PEEP is initially set to of 4 to 5 cm H2O to prevent atelectasis . The self-inflating bag does not provide PEEP.
Continuous positive airway pressure (CPAP) — In preterm neonates, CPAP is routinely used in the delivery room for management of neonatal respiratory distress syndrome (RDS), as discussed separately. (See "Respiratory distress syndrome (RDS) in preterm infants: Management", section on 'Nasal continuous positive airway pressure (nCPAP)'.)
In addition, CPAP may be considered for respiratory support in spontaneously breathing neonates with labored breathing or persistent cyanosis, regardless of gestational age (GA). However, CPAP may increase the risk of pneumothorax term and late preterm infants (GA ≥35 weeks) [50-53]. (See "Pulmonary air leak in the newborn", section on 'Risk factors'.)
In a large single center retrospective study of term and late preterm (GA ≥35 weeks) neonates born between 2001 and 2015, infants who received CPAP in the delivery room had an increased risk of pneumothorax compared with those who did not receive CPAP (16.9 versus 3.7 percent, odds ratio [OR] 4.6, 95% CI 3.6-6.0) . This study reported an increased incidence of pneumothorax following publication of the 2011 Neonatal Resuscitation Program (NRP) guidelines, which included a conditional recommendation for using CPAP in neonates with ongoing respiratory distress. These results, while concerning, need to be confirmed, ideally in a prospective randomized trial evaluating the benefits and risks of CPAP in term and late preterm infants. In our center, recognizing the benefits and risks associated with the use of CPAP, we are judicious in our use of CPAP in infants with respiratory distress, regardless of GA until further data are available.
Laryngeal mask airway (LMA) — In term and preterm infants with birth weight >1500 g (≥34 weeks gestation), LMAs may be considered as an alternative to endotracheal intubation if BMV is unsuccessful in providing adequate ventilation, or if endotracheal intubation is unsuccessful or not feasible [3,54-57]. An LMA is a soft mask with an inflatable cuff attached to a silicone rubber airway. The inflated cuff covers the laryngeal opening and its rim conforms to the contours of the hypopharynx, occluding the esophagus with a low-pressure seal.
The LMA is inserted through the mouth using the index finger to guide "blind" insertion along the hard palate. The technique is summarized in the figure and described in greater detail separately (figure 4). In neonates, a size 1 LMA should be used. (See "Supraglottic airway devices in children with difficult airways", section on 'Laryngeal mask airway (LMA)'.)
LMAs have been proposed for initial airway management in neonatal resuscitation instead of BMV, particularly for nonphysician providers in low-resource settings. However, trials have shown advantages to using an LMA for initial neonatal resuscitation in more general settings. A meta-analysis of six trials found that for term and late preterm infants (GA ≥34 weeks), using an LMA versus a face mask for BMV decreased the probability of failure to improve (ie, increasing heart rate and other clinical signs of improvement), (risk ratio [RR] 0.24, 95% CI 0.17 to 0.36) . In the same meta-analysis, four trials found that BMV with an LMA decreased the probability of intubation compared to BMV with a face mask (RR 0.34, 95% CI 0.2 to 0.56).
In a clinical trial not included in the above meta-analysis in which neonates requiring PPV after delivery were randomly assigned to LMA (placed by a trained midwife) or BMV, the incidence of hypoxic-ischemic encephalopathy was similar in both groups (11 versus 10 percent, respectively; adjusted RR 1.27, 95% CI 0.84-1.93) . There were more deaths among infants assigned to LMA (22 versus 18 percent), but this finding was not statistically significant (adjusted RR 1.21, 95% CI 0.90-1.63).
Endotracheal intubation — Endotracheal intubation allows direct access to the upper trachea for delivery of invasive PPV. Intubation is a skill that must be learned and takes practice to become proficient. While BMV suffices for most neonates who require resuscitation, there are instances when intubation may be preferred. Thus, when a high-risk delivery is anticipated, at least two trained providers should be present for the birth to assist with neonatal resuscitation, one of whom should be skilled in neonatal intubation.
●Indications – Endotracheal intubation may be indicated if:
•BMV is ineffective or prolonged
•Chest compressions are being performed
In addition, elective intubation may be performed 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. (See "Congenital diaphragmatic hernia in the neonate", section on 'Postnatal management' and "Respiratory distress syndrome (RDS) in preterm infants: Management", section on 'Surfactant therapy'.)
Indications for intubation outside of the delivery room setting (ie, in preterm neonates who have persistent of progressive RDS despite management with noninvasive respiratory support) are discussed separately. (See "Approach to mechanical ventilation in very preterm neonates", section on 'Indications for invasive MV'.)
●Procedure – Two care providers are required for endotracheal intubation, one to perform the procedure and the other to assist and monitor the status of the neonate during the procedure. 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 endotracheal tubes (ETT). The ETT size is determined based upon birth weight or gestational age, as summarized in the table (table 4A) .
A suction device should be available to remove secretions 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 torque the laryngoscope forward 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 passed through them with the right hand until the vocal cord guide mark (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.
Although it is not widely used in the delivery room, video laryngoscopy (VL) is another technique for neonatal endotracheal intubation. In contrast to the procedure described here (ie, direct laryngoscopy), VL allows for visualization of the vocal cords on a video screen. The choice to use VL versus standard laryngoscopy is discussed in detail separately. (See "Airway management for pediatric anesthesia", section on 'Choice of intubation technique'.)
•Assessment of successful intubation – Successful endotracheal intubation is confirmed with all of the following while providing PPV through the ETT:
-Prompt increase in HR (if the HR was low at time of intubation)
-Adequate oxygenation as demonstrated by pulse oximetry (see 'Pulse oximetry' above)
-Audible breath sounds over both lung fields
-Symmetrical chest movement
-Detection of exhaled carbon dioxide (CO2) using a colorimetric device or capnography [59-62]
-Vapor condensation inside the ETT during exhalation
In addition, chest radiography is needed to confirm that the ETT is correctly placed above the carina of the trachea.
•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 4B) [6,63,64]. Since there is evidence to support each technique, the exact method of determining depth of ETT insertion is less important than choosing one technique and using it consistently. 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.
Chest compressions — Chest compressions are initiated if the infant's HR remains <60 bpm despite adequate ventilation for 30 seconds [1,3].
●Technique – Chest compressions apply pressure to the lower one-third of the sternum visualized as an imaginary line between the nipples and the xiphoid process. In neonates, chest compressions can be applied using the two-thumb or two-finger technique. We generally prefer the two thumb technique because it generates higher systolic and coronary perfusion pressure, and it allows better access for umbilical line insertion [1,2,65-70].
•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 5). 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 6).
With both techniques, 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.
●Compression rate and coordination with PPV – Chest compressions are always accompanied by PPV. During neonatal resuscitation, the chest compression rate is 90 per minute accompanied by 30 breaths per minute in a 3 to 1 ratio (ie, one breath interposed after every third compression). Thus, the ventilation rate is reduced from the 40 to 60 breaths per minute in the absence of chest compressions to 30 breaths in the presence of chest compressions.
●Supplemental oxygen – Whenever chest compressions are provided, the oxygen concentration is increased to 100 percent, but it should be weaned rapidly when the HR recovers and chest compression is no longer needed based on targeted SpO2 levels, which are monitored by pulse oximetry (table 3) [1,3,54]. (See 'Oxygen concentration' above.)
●Reassessment – After 60 seconds of chest compressions and PPV, the infant's HR, color, and respiratory effort should be reassessed to determine whether further interventions are required (eg, intubation or administration epinephrine).
Epinephrine can be administered intravenously (IV) or endotracheally; IV administration is preferred because it is more efficacious [71,72]. However, the endotracheal route can be used while IV access is being obtained:
●IV administration – IV epinephrine is given at a dose of 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of a 0.1 mg/mL solution [may be labeled 1:10,000]).
The dose may be repeated every three to five minutes if the HR remains <60 bpm. If the initial dose was given endotracheally, subsequent doses can be given IV once access is obtained.
Epinephrine is universally accepted as an intervention in neonatal resuscitation, though it has never been prospectively studied and validated in placebo-controlled clinical trials [1,2,73]. In particular, 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 . 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 .
If there is no response to administration of epinephrine, the clinician should reassess earlier resuscitative steps to ensure that they have been performed optimally (algorithm 1). In addition, other factors that may be contributing to ongoing bradycardia should be addressed (eg, hypovolemia, pneumothorax). (See 'Volume expansion' below and "Pulmonary air leak in the newborn", section on 'Thoracentesis'.)
Volume expansion — In the delivery room, neonatal hypovolemia requiring volume expansion is rarely encountered, and volume resuscitation should only be considered if the HR remains <60 bpm despite adequate ventilation and administration of epinephrine (algorithm 1). 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 HR, such as pallor, poor perfusion, and weak pulses. (See "Neonatal shock: Etiology, clinical manifestations, and evaluation", section on 'Clinical manifestations'.)
We agree with the current guidelines to administer a 10 mL/kg bolus of normal saline over 5 to 10 minutes to correct hypovolemia . This dose can be repeated if necessary, based upon the response to the initial bolus. (See "Neonatal shock: Management", section on 'Fluid resuscitation'.)
Other acceptable solutions include Ringer's lactate or uncrossed O Rh-negative blood. The latter is preferred if available and severe blood loss and/or anemia is suspected or documented [1,2].
Sustained inflation — For preterm neonates, it has been postulated that the use of sustained inflation (defined as a positive pressure breath held at full inflation pressure for 10 to 20 seconds), in the delivery room during neonatal resuscitation may improve outcomes compared with standard PPV [74-76]. However, published data do not show a benefit of sustained inflation at delivery in improving survival or reducing risk of BPD and there is concern that it may increase risk of mortality [77-81]. In a meta-analysis of nine trials involving 1406 preterm infants who required resuscitation, there was a nonsignificant trend towards increased in-hospital mortality associated with sustained inflation compared with standard PPV (12 versus 9 percent, adjusted risk difference [aRD] 3.6 percent, 95% CI -0.7 to 7.9 percent) . Of note, the largest trial was stopped early after enrolling 426 infants because of early death within 48 hours of age associated with sustained versus standard PPV (7 versus 1 percent, aRD 5.6 percent, 95% CI 2.1-9.1%) . Thus, in the delivery room, we continue to use standard PPV for preterm infants who require resuscitation. (See 'Positive pressure ventilation' above.)
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 [82,83]. 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 [6,84,85]. Although theoretically sodium bicarbonate should be beneficial to correct acidosis, there is also evidence that sodium bicarbonate adversely affects myocardial and cerebral function . 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.
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 20 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 >20 minutes) [1-3]. During this time period, the redirected goals of care are discussed with members of the healthcare team and family.
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.
POSTRESUSCITATION — Infants who required resuscitation are at risk of developing postresuscitative complications . The longer and the greater the extent of resuscitation, the more likely that there will be subsequent and serious complications. Infants should be observed closely in either a neonatal intensive care unit or a monitored triage order for signs of further deterioration and possible complications including [1-3,88]:
●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 and disorders of transition")
●Hypotension (see "Neonatal shock: Etiology, clinical manifestations, and evaluation")
●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")
SUMMARY AND RECOMMENDATIONS
●Anticipation of resuscitation need – In the United States, approximately 10 percent of all newborns need some intervention at deliver, and 1 percent require extensive resuscitation. Personnel who are adequately trained personnel and appropriate resuscitation equipment should be readily available at every birthing location whether or not problems are anticipated (table 1). (See 'Anticipation of resuscitation need' above.)
•High-risk delivery – Infants who are more likely to require resuscitation can be identified by maternal risk factors, pregnancy complications, fetal conditions, and perinatal complications (table 2). Preterm infants are more likely to require resuscitation compared with term infants. Care providers skilled in neonatal resuscitation should be present and equipment should be prepared prior to the birth of a high-risk infant (table 1). (See 'High-risk delivery' above and 'Preterm infants' above.)
•Antenatal counseling and withholding of resuscitation – Decisions about the extent of post-delivery care should be made collaboratively between the care team and the parents/caregivers in advance of delivery. In some instances, the parents/caregivers may reasonably elect to limit interventions for the neonate after delivery, including resuscitation. These decisions are difficult and should be guided by a clear understanding of the prognosis and the values and preferences of parents/caregivers. (See 'Antenatal counseling' above.)
●Resuscitation – Initial routine care includes warming the infant, clearing his/her airway, and drying and stimulating the infant. (See 'Initial steps' above.)
-Positive pressure ventilation (PPV) – PPV is provided at a rate of 40 to 60 breaths/min using a T-piece resuscitator, self-inflating bag, or flow-inflating bag. For most neonates, we suggest a T-piece resuscitator rather than a self-inflating bag if resources permit and clinical staff have adequate training (Grade 2C). A self-inflating bag should be available as a backup device in case of gas-supply failure. (See 'Positive pressure ventilation' above.)
When providing PPV, we recommend a low fraction of inspired oxygen (FiO2) (eg, 0.21 to 0.3) rather than 100 percent oxygen (Grade 1B). In our practice, we initiate resuscitation with room air (FiO2 0.21) in infants >30 weeks gestation and use an FiO2 of 0.3 for infants ≤30 weeks gestation. The exception is neonates receiving chest compressions, for whom PPV is initially provided with an FiO2 of 1.0. The FiO2 is subsequently adjusted as needed to maintain the target preductal oxygen saturation on pulse oximetry (table 3). (See 'Oxygen concentration' above and 'Pulse oximetry' above.)
-Chest compressions – Chest compressions are required if the infant's HR remains <60 bpm despite adequate ventilation for 30 seconds. (See 'Chest compressions' above.)
-Epinephrine – If the HR remains <60 bpm despite adequate PPV and chest compressions, intravenous administration of epinephrine is indicated (table 5). Cannulation of the umbilical vein is the quickest means of obtaining venous access in the newborn (figure 2). (See 'Epinephrine' above and "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'Umbilical vein access'.)
-Endotracheal intubation – More definitive airway management (ie, endotracheal intubation (table 4A-B) or placement of a laryngeal mask airway (figure 4)) is necessary when PPV is ineffective or prolonged, or if chest compressions are being performed. (See 'Endotracheal intubation' above and 'Laryngeal mask airway (LMA)' above.)
•Infants with labored breathing or persistent cyanosis and HR ≥100 bpm – Supportive measures for these infants include (see 'Labored breathing or persistent cyanosis and heart rate ≥100 bpm' above):
-Position the airway optimally and clear secretions (see 'Airway' above)
•Infants who are vigorous and well appearing – Infants born at ≥35 weeks gestation who have good tone and are crying or breathing without difficulty may stay with the mother and be cared for in the newborn nursery. (See "Overview of the routine management of the healthy newborn infant".)
Preterm infants born at <35 weeks gestation require a higher level of care (ie, level 2 or 3 neonatal care unit) and final disposition is based on their gestational age and clinical status. Respiratory support for preterm neonates is discussed in detail separately. (See "Respiratory distress syndrome (RDS) in preterm infants: Management", section on 'Noninvasive positive airway pressure' and "Respiratory support, oxygen delivery, and oxygen monitoring in the newborn".)
●Discontinuing resuscitation – Resuscitation efforts may be discontinued after 20 minutes of resuscitation if the neonate has demonstrated no signs of life (no heartbeat or no respiratory effort for >10 minutes). (See 'Discontinuing resuscitation' above.)
●Postresuscitation care – Infants who required resuscitation are at risk of developing postresuscitative complications. After successful resuscitation, they should be cared for in a setting that can provide close monitoring and appropriate ongoing care. (See 'Postresuscitation' above.)
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