Neonatal resuscitation (NR) is a standardized, protocol-driven emergency medical procedure performed immediately after birth when a newborn does not begin or maintain breathing and circulation independently. This intervention is a series of timed actions designed to support the infant’s airway, breathing, and circulation during the transition from the womb to the outside world. Healthcare providers are trained to ensure a rapid and coordinated response when an infant requires assistance. The goal of this procedure is to prevent irreversible organ injury by quickly establishing adequate oxygenation and blood flow.
Why Immediate Intervention is Critical
A baby’s body must undergo a physiological shift at birth, moving from relying on the placenta for gas exchange to using its own lungs. Before birth, the fetal lungs are filled with fluid, and blood largely bypasses them through specialized connections. The placenta acts as the organ of respiration, supplying oxygen and removing carbon dioxide.
When a baby takes its first breaths, the lungs expand, the fluid is cleared, and the oxygen level in the blood rises, triggering a decrease in pulmonary vascular resistance. This drop in resistance redirects blood flow to the lungs, causing the fetal shunts to close and establishing the adult pattern of circulation. Failure to initiate effective breathing causes a rapid drop in oxygen and a build-up of acid in the blood, a condition known as asphyxia.
This oxygen deprivation quickly leads to a slowing heart rate, or bradycardia, which further impairs the delivery of oxygen to the brain and other organs. If this cycle of low oxygen and low heart rate is not broken immediately, it can cause severe, long-term damage or death. A standardized and time-sensitive resuscitation protocol is necessary for the approximately 10% of newborns who require some form of assistance to make this transition.
The Initial Steps of Newborn Stabilization
The first minute after birth is the timeframe for immediate and impactful interventions. The initial assessment of the newborn focuses on three rapid observations: whether the baby is breathing or crying, whether it has good muscle tone, and whether the heart rate is above 100 beats per minute. If the infant is not vigorous, the resuscitation team begins with a sequence of non-invasive steps under a radiant warmer.
The first action is providing warmth by placing the baby under a radiant heat source and immediately drying the infant thoroughly with warm towels. This prevents rapid heat loss, which can worsen respiratory distress and acidosis. Next, the airway is positioned, typically in a neutral or “sniffing” position, to ensure it is open. Suctioning is performed only if secretions are obstructing the airway or if the baby is gasping.
If the baby is not breathing spontaneously after these steps, the provider performs tactile stimulation, such as gently rubbing the baby’s back or flicking the soles of the feet. This stimulation is intended to encourage the baby to take a breath. If the infant remains apneic or has a heart rate below 100 beats per minute after these initial stabilization steps (which should take no more than 30 to 60 seconds), the next level of intervention is required.
Escalation to Advanced Life Support
If the initial steps fail to stabilize the newborn, the focus shifts to supporting ventilation and circulation through more advanced measures. The primary and most effective step in advanced resuscitation is initiating Positive Pressure Ventilation (PPV). PPV involves delivering controlled breaths using a mask connected to a ventilation device to inflate the lungs and introduce air or oxygen. This is started if the infant is not breathing adequately or if the heart rate remains below 100 beats per minute.
If the heart rate remains below 60 beats per minute despite 30 seconds of effective PPV that causes the chest to rise, the team must escalate care to include chest compressions. Chest compressions are coordinated with ventilation in a 3:1 ratio. The preferred technique is the two-thumb method, where the thumbs press down on the sternum while the fingers encircle the infant’s torso to provide support.
If the heart rate remains below 60 beats per minute after another 60 seconds of coordinated chest compressions and PPV, the medication epinephrine is administered. Epinephrine is a stimulant that helps increase the heart rate and improve the heart’s contractility. This medication is preferably given intravenously through an umbilical vein catheter, though it can be given via a tube placed in the trachea while intravenous access is being established.