Neonatal Resuscitation

Always see local and national guidelines, get appropriate training and have assistance from an experienced person when performing resuscitation. This is an overview for the purpose of understanding the underlying principles of neonatal resuscitation and not a guideline.



Hypoxia is central to neonatal resuscitation. Normal labour and birth leads to hypoxia. When contractions happen, the placenta is unable to carry out normal gaseous exchange, leading to hypoxia. Extended hypoxia will lead to anaerobic respiration and a subsequent drop in the fetal heart rate (bradycardia). Further hypoxia will lead to reduced consciousness and a drop in respiratory effort, in turn worsening hypoxia. Extended hypoxia to the brain leads to hypoxic-ischaemic encephalopathy (HIE), with potentially life-long consequences in the form of cerebral palsy.


Other Issues in Neonatal Resuscitations

  • Babies have a large surface area to weight ratio, and get cold very easily
  • Babies are born wet, so they loose heat rapidly
  • Babies that are born through meconium may have this in their mouth or airway


Principles of Neonatal Resuscitation

There is a very helpful neonatal life support algorithm from the UK resuscitation council, available on their website. It is worth learning this, as there may be questions on it in your exams. This section aims to help you understand the principles of this algorithm. When performing neonatal resuscitation always consider whether you need help.

Warm The Baby

  • Get the baby dry as quickly as possible. Vigorous drying also helps stimulate breathing.
  • Keep the baby warm with warm delivery rooms and management under a heat lamp
  • Babies under 28 weeks are placed in a plastic bag while still wet and managed under a heat lamp

Calculate the APGAR Score

  • This is done at 1, 5 and 10 minutes whilst resuscitation continues
  • This is used as an indicator of the progress over the first minutes after birth
  • It helps guide neonatal resuscitation efforts

Stimulate Breathing

  • Simulate the baby to prompt breathing, for example by drying vigorously with a towel
  • Place the baby’s head in a neutral position to keep airway open. A towel under the shoulders can help keep it neutral.
  • If gasping or unable to breath, check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation

Inflation Breaths

Inflation breaths are given when the neonate is gasping or not breathing despite adequate initial simulation.

  • Two cycles of five inflation breaths (lasting 3 seconds each) can be given to stimulate breathing and heart rate
  • If there is no response and the heart rate is low, 30 seconds of ventilation breaths can be used
  • If there is still no response, chest compressions can be used, coordinated with the ventilation breaths

Technique is very important in delivering effective inflation breaths. Get someone experienced to show you how to perform them. It is essential to maintain a neutral head position and get a good seal around the mouth and nose. Look for a rise and fall in the chest.

When performing inflation breaths, air should be used in term or near term babies, and a mix of air and oxygen should be used in pre-term babies. Oxygen saturations can be monitored throughout resuscitation if there are concerns about the breathing. Aim for a gradual rise in oxygen saturations, not exceeding 95%.

Chest Compressions

  • Start chest compressions if heart rate remains below 60 bpm despite resuscitation and inflation breaths (see protocol)
  • Chest compressions are performed at a 3:1 ratio with ventilation breaths

Severe Situations

Time is precious during neonatal resuscitation. Prolonged hypoxia increases the risk of hypoxic-ischaemic encephalopathy (HIE). In severe situations, IV drugs and intubation should be considered. Babies near or at term that have possible HIE may benefit from therapeutic hypothermia with active cooling.



The APGAR score is measured out of 10. The lowest score is 0 and the highest is 10.





Appearance (skin colour)

Blue / pale centrally

Blue extremities




< 100

> 100

Grimmace (response to stimulation)

No response

Little response

Good response

Activity (muslce tone)


Flexed arms and legs




Slow / irregular

Strong / crying


Delayed Umbilical Cord Clamping

After birth there is still a significant volume of fetal blood in the placenta. Delayed clamping of the umbilical cord provides time for this blood to enter the circulation of the baby. This is known as placental transfusion. Recent evidence indicates that in healthy babies, delaying cord clamping leads to improved haemoglobin, iron stores and blood pressure and a reduction in intraventricular haemorrhage and necrotising enterocolitis. The only apparent negative effect is an increase in neonatal jaundice, potentially requiring more phototherapy.

Current guidelines from the resuscitation council UK state that uncompromised neonates should have a delay of at least one minute in the clamping of the umbilical cord following birth.

Neonates that require neonatal resuscitation should have their umbilical cord clamped sooner to prevent delays in getting the baby to the resuscitation team. The priority will be resuscitation rather than delayed clamping.


Last updated January 2020
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