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Neonatal resuscitation
In a newborn almost every cardiac arrest starts as a breathing problem, so the step that saves most newborns is effective positive-pressure ventilation in the first minute; compressions and adrenaline are needed only when the heart rate stays below 60 despite effective ventilation.
Why it matters in the exam
Questions are built on heart-rate thresholds: below 100 per minute or apnoea and gasping → positive-pressure ventilation (PPV); below 60 after 30 seconds of ventilation that moves the chest → intubation, 100% oxygen and compressions at 3:1. Almost always a distractor offers to start compressions before effective ventilation is confirmed, or to give adrenaline before compressions.
A second point is oxygen: start with room air (21%) at 35 weeks' gestation or more and 21–30% in the preterm infant, and titrate to pre-ductal saturation from the right hand, which rises gradually from 60–65% at one minute to 85–95% at ten minutes. A non-vigorous newborn with meconium-stained fluid no longer gets routine intubation and suctioning — start with the initial steps and ventilation.
Also examined are waiting at least 30–60 seconds before clamping the cord when the newborn needs no resuscitation, prevention of hypothermia (plastic wrap for infants under 32 weeks, target 36.5–37.5°C), the adrenaline dose of 0.02 mg/kg IV (range 0.01–0.03) and fluid 10 mL/kg when hypovolaemia is suspected. In a newborn of 36 weeks or more with moderate to severe hypoxic-ischaemic encephalopathy, therapeutic hypothermia starts within 6 hours. The Apgar score does not decide when to start resuscitation.
Key points
- Effective ventilation in the first minute is the most important step.
- Heart rate below 100 → ventilate; below 60 despite effective ventilation → compressions at 3:1.
- Starting oxygen 21% in the term newborn and 21–30% in the preterm.
- Adrenaline 0.02 mg/kg IV when the heart rate stays below 60 after compressions.
- Therapeutic hypothermia for moderate to severe HIE from 36 weeks, within 6 hours.
Summary table
| Stage | When | What to do | Numbers |
|---|---|---|---|
| Initial steps | Every newborn who is not vigorous | Warm, dry, stimulate, open the airway; suction only for obstruction | Within the first minute (the golden minute) |
| Positive-pressure ventilation | Apnoea, gasping or heart rate below 100 | Mask and bag, saturation monitoring from the right hand | Rate 40–60 breaths per minute; starting oxygen 21% (21–30% preterm) |
| Corrective ventilation steps | The chest does not rise | Mask, head position, suction, open mouth, pressure, advanced airway | Before any further step |
| Compressions | Heart rate still under 60 despite 30 seconds of ventilation that moves the chest | Intubation, 100% oxygen, two thumbs on the lower third of the sternum | Ratio 3:1, 90 compressions and 30 breaths per minute |
| Drugs and fluids | Heart rate below 60 after 60 seconds of compressions | Adrenaline via umbilical vein or IO; fluids for suspected blood loss | Adrenaline 0.02 mg/kg IV; saline 10 mL/kg |
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Sources
- AHA/AAP Guidelines for Neonatal Resuscitation, 2020 (with ILCOR updates through 2025) — Initial steps, ventilation, compressions and medications
- Textbook of Neonatal Resuscitation (NRP), 8th edition (2021) — The NRP algorithm
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Delivery Room Emergencies
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.