Neonatal chest compressions are an emergency procedure performed on newborn infants when their heart is not beating effectively. This intervention involves rhythmically pressing on a baby’s chest to manually circulate oxygenated blood to the brain and other organs. While a dramatic event, this intervention is rare. Approximately 10% of newborns require some assistance to begin breathing at birth, but only about 1 in 1,000 need chest compressions. This procedure is a component of a larger response known as neonatal resuscitation.
Indications for Chest Compressions
The primary indicator for starting compressions is a newborn’s heart rate that remains below 60 beats per minute (bpm) after at least 30 seconds of effective positive-pressure ventilation (PPV) has proven insufficient. PPV involves using a specialized bag and mask to deliver air into the baby’s lungs. This sequence is followed because circulatory collapse in a newborn is secondary to a respiratory issue.
In most cases, if a newborn is not breathing adequately, their heart rate will drop from a lack of oxygen. Establishing ventilation is the first action. If it does not prompt the heart rate to rise above 60 bpm, manual circulatory support is required.
The Neonatal Resuscitation Algorithm
Chest compressions are an advanced step within the neonatal resuscitation algorithm. This process is visualized as an inverted pyramid, where common interventions form the wide base at the top, and the least common, most intensive interventions form the narrow tip. This structure ensures clinicians perform the most likely needed actions first before escalating.
For nearly all newborns, the initial steps involve basic care: drying the infant, providing warmth, clearing the airway if necessary, and stimulating them to breathe. If a baby does not begin breathing or has a heart rate below 100 bpm, the team moves to positive-pressure ventilation to support the lungs. This step resolves the issue for the majority of infants who need help.
Only when a newborn’s heart rate remains persistently below 60 bpm despite effective ventilation does the team proceed to chest compressions. This places compressions further down the inverted pyramid, highlighting that they are part of a broader response and never the first action taken.
Technique for Performing Compressions
The recommended and most effective method is the two-thumb encircling-hands technique. The rescuer places both thumbs on the lower third of the infant’s sternum (breastbone), with their fingers encircling the baby’s torso to support the back. This technique is preferred because it generates better pressure to perfuse the coronary arteries and is less tiring for the rescuer.
An alternative method is the two-finger technique, where the tips of the middle and index fingers are used to compress the sternum. Regardless of the method, the location for compressions is on the lower third of the sternum, just below the nipple line. Compressions should be delivered to a depth of approximately one-third of the front-to-back diameter of the chest.
A defining feature of neonatal resuscitation is the coordination between compressions and ventilation. The standard is a 3:1 ratio of three compressions followed by one ventilation. This cycle achieves a rate of 90 compressions and 30 breaths per minute, totaling 120 “events” per minute. This synchronized rhythm optimizes the delivery of oxygenated blood.
Associated Risks and Prognosis
Performing chest compressions on a newborn carries risks. The physical force can lead to injuries such as rib or sternal fractures and, in rare cases, damage to underlying organs like the liver or lungs.
The need for chest compressions indicates a serious crisis, and the infant’s prognosis is guarded. Survival rates are directly linked to the underlying cause of the arrest and the infant’s gestational age. Studies have shown that while many infants who receive compressions survive to hospital discharge, the odds decrease significantly for more premature infants. For those who survive, there is a heightened risk of long-term adverse outcomes, including neurodevelopmental impairment.
The duration of resuscitation also plays a role in the prognosis. Infants who require ongoing compressions for more than 10 minutes are at a high risk for mortality or significant neurodevelopmental disability. The outcome is influenced by how quickly the infant responds and whether a stable heart rate and circulation can be restored.