Neonatal resuscitation is the standardized sequence of interventions designed to help a newborn transition to life outside the womb when they do not begin breathing spontaneously. Unlike adult or child CPR, problems in newborns usually stem from a failure to establish adequate breathing, making ventilation the primary focus of initial efforts. This distinct protocol is based on the unique physiology of an infant’s transition from reliance on the placenta to independent respiratory function. A rapid, structured response is necessary in the immediate minutes following birth to prevent long-term injury.
Initial Assessment and Stabilization Sequence
Upon delivery, a rapid evaluation assesses three main factors: whether the baby is term, whether they have good muscle tone, and whether they are crying or breathing spontaneously. If any of these conditions are not met, the infant requires immediate assistance beyond routine care. Initial steps focus on preparing the infant for breathing, including providing warmth, drying the baby thoroughly, and positioning the head and neck to open the airway.
Drying and gentle stimulation, such as rubbing the back, often encourages a healthy baby to take their first effective breaths. If the infant remains apneic (not breathing) or gasping, or if the heart rate falls below 100 beats per minute, the next step is to initiate positive pressure ventilation (PPV). PPV, typically delivered via a bag-mask device, involves giving controlled breaths to inflate the lungs and introduce oxygen.
This assisted ventilation should be delivered at a rate of 40 to 60 inflations per minute and is the most effective action in newborn resuscitation. The goal is to see the chest rise and the heart rate climb above 100 beats per minute, indicating successful lung inflation and oxygen delivery. After the first 15 seconds of PPV, the provider checks for chest movement, and if present, continues PPV for a total of 30 seconds before reassessing the heart rate.
Defining the Threshold for Chest Compressions
Chest compressions are not initiated until ventilation alone proves insufficient to support the heart. The decision to begin compressions is only made after 30 seconds of effective positive pressure ventilation (PPV) have been administered. This threshold is defined as a heart rate remaining below 60 beats per minute (bpm).
The reason for this sequence is that profound bradycardia (slow heart rate) in a newborn is usually the result of inadequate oxygenation, not a primary cardiac issue. Effective PPV for 30 seconds maximizes oxygen delivery to the heart muscle. If the heart rate still does not rise above 60 bpm after this targeted ventilation, it signifies a failure of oxygen delivery to restore cardiac function.
At this point, the resuscitation sequence escalates to include chest compressions to manually circulate blood, combined with continued ventilation. The initiation of compressions signals a severe cardiopulmonary compromise. Once compressions begin, the inspired oxygen concentration is increased to 100%, and preparations are made to establish vascular access for potential medication administration.
Key Technical Differences in Neonatal CPR
The mechanical performance of CPR on a newborn differs significantly from techniques used for older children or adults. The internationally recommended method is the two-thumb encircling technique. The thumbs are placed on the lower third of the sternum, just below the nipple line, while the encircling fingers support the baby’s back. This technique helps generate better compression depth and pressure.
The two-thumb technique is preferred over the two-finger technique because it is associated with better blood flow and less rescuer fatigue. Compressions should be delivered to a depth of approximately one-third of the chest’s anterior-posterior diameter. Compressions must be performed smoothly, allowing the chest to fully recoil between each press so the heart can refill with blood.
A primary difference is the required compression-to-ventilation ratio of 3:1. This ratio prioritizes ventilation over circulation, delivering approximately 90 compressions and 30 breaths every minute. Compressions and ventilations must be carefully coordinated to avoid simultaneous delivery, which impedes effective lung inflation. Chest compressions continue until the heart rate recovers to 60 bpm or greater, with reassessment occurring every 30 seconds.