The decision to begin cardiopulmonary resuscitation (CPR) on a newborn is a time-sensitive process guided by specific physiological markers. This process is distinct from CPR performed on older children or adults because the cause of collapse in a newborn is almost always a respiratory problem, not a primary cardiac event. A newborn refers to an infant typically within the first 28 days of life, although resuscitation principles apply to any baby suffering a sudden collapse due to respiratory failure near the time of birth. Understanding the sequential steps of assessment and intervention is important, as early and correct action improves the chances of a positive outcome. This guidance provides a framework for emergency response but should be supplemented with hands-on, certified training.
Recognizing the Newborn Emergency
The first moments of assessment focus on observing clear signs that a newborn is in distress and unable to sustain life functions independently. A healthy newborn should be crying vigorously, have strong muscle tone, and display a pink color. Conversely, a newborn needing intervention will show a lack of responsiveness to stimulation, demonstrating a flaccid or limp body posture.
A visual assessment often reveals cyanosis, a blue or pale discoloration of the skin, which signals inadequate oxygenation. A baby in distress may exhibit extremely shallow or absent breathing (apnea) or only an irregular, gasping effort. These initial observations indicate the immediate necessity of opening the airway and assisting ventilation. The absence of normal breathing or a weak, slow heart rate are the most telling signs that active resuscitation must begin.
The Protocol: When to Initiate Chest Compressions
The decision to start chest compressions is a sequential process that prioritizes establishing effective breathing first, as respiratory failure is the primary issue. The initial step is to provide gentle tactile stimulation, such as flicking the soles of the feet or gently rubbing the baby’s back, for no more than 5 to 10 seconds. If the newborn remains unresponsive, apneic, or has a heart rate less than 100 beats per minute (BPM), the rescuer must immediately provide rescue breathing, also known as positive pressure ventilation (PPV).
Effective ventilation is the most important action in newborn resuscitation because it addresses the root cause of the cardiac compromise. The rescuer must deliver effective breaths for a full 30 seconds, ensuring the chest rises visibly with each breath. The definitive trigger for initiating chest compressions occurs only if the newborn’s heart rate remains below 60 BPM after this 30-second period of effective ventilation.
To check the heart rate, the preferred method outside of a healthcare setting is to check the pulse at the brachial artery, located on the inside of the upper arm, for 5 to 10 seconds. If the heart rate is less than 60 BPM after the initial 30 seconds of assisted breathing, chest compressions must be started immediately while continuing ventilation. This specific heart rate threshold confirms the need to mechanically support both breathing and circulation.
Key Differences in Newborn CPR Technique
Newborn CPR technique is specialized and differs from the standard adult or older child protocol, primarily due to the respiratory origin of the collapse. The compression-to-ventilation ratio for newborns is a strict 3:1, meaning three chest compressions are delivered for every single breath. This ratio is maintained to ensure adequate oxygenation through frequent ventilation, achieving approximately 90 compressions and 30 breaths per minute.
Compression technique is tailored to the newborn’s anatomy and size. The compression site is on the lower third of the sternum, just below the imaginary line connecting the nipples. The depth of compression should be approximately one-third of the anterior-posterior diameter of the chest, typically about 1.5 inches (4 centimeters).
The preferred method for delivering compressions, especially when two rescuers are present, is the two-thumb encircling hands technique. This method involves wrapping both hands around the newborn’s torso and using both thumbs to press the sternum, providing better compression depth and quality. When a rescuer is alone, the two-finger technique, using the index and middle fingers, may be used, though the two-thumb method is superior for generating blood flow.
Immediate Next Steps and Seeking Professional Help
Once chest compressions have begun, the resuscitation effort must be coordinated with the immediate activation of emergency medical services (EMS). If two rescuers are present, one should immediately call 911 or the local emergency number while the other begins CPR. If the rescuer is alone, the sequence dictates performing CPR for approximately one minute, or five cycles of the 3:1 ratio, before pausing briefly to call for help.
CPR should continue without interruption until one of three conditions is met: the heart rate recovers to 60 BPM or higher, the newborn shows clear signs of revival (such as spontaneous breathing and movement), or emergency medical personnel arrive and take over care. The rescuer should never stop the effort out of fear of causing injury, as the risk of brain damage or death from inadequate circulation far outweighs the risk of injury from correct compressions. Maintaining the newborn’s body temperature is important, as hypothermia can complicate resuscitation efforts and worsen outcomes.