20.9 Neonatal Resuscitation
The goal of neonatal care at birth is to support their transition from the uterus to extrauterine life. According to the American Heart Association, the most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Newborns who cannot breathe on their own require urgent interventions, ranging from suctioning and administering oxygen therapy to full resuscitation.[1]
Risk factors associated with neonates requiring resuscitation include the following[2]:
- Limited or no prenatal care
- Gestational age < 36 weeks or ≥ 41 weeks
- Multiple gestation
- Forceps- or vacuum-assisted delivery
- Emergency cesarean delivery
- Meconium-stained amniotic fluid
- Shoulder dystocia, breech, or other abnormal presentation
- Abnormal fetal heart rate
- Infection (maternal or fetal)
- Maternal substance use
A quick visual assessment immediately after delivery allows the nurse to identify newborns who need resuscitation. Newborns who are breathing and/or crying can be placed skin-to-skin with their mother or other parent. These infants do not require routine tactile stimulation or suctioning, even if the amniotic fluid was notable for meconium. Although suctioning and intubation were previously considered a routine practice for newborns with meconium staining, current evidence indicates suctioning should only be performed to clear the airway because it can cause bradycardia.[3]
If the newborn is not breathing, not crying, or does not have good muscle tone, immediate interventions are required. The nurse provides tactile stimulation by drying the newborn, rubbing their back, and flicking the soles of their feet, while also keeping them warm. If visible fluid is obstructing the airway or there is a concern about obstructed breathing, the mouth and nose may be suctioned. The airway is positioned in an open position (i.e., slightly extending the infant’s neck.) If these interventions are unsuccessful, the nurse calls for assistance and begins resuscitation steps, as outlined in the following box.[4]
Neonatal resuscitation involves a series of systematic steps to assess and support newborns who require help with breathing and circulation immediately after birth. The steps follow the Neonatal Resuscitation Program (NRP) guidelines and are typically structured around the initial assessment and the ABC approach (Airway, Breathing, Circulation).
- Initial Assessment (within the first 30 seconds): Evaluate the newborn based on the following three questions:
- Is the baby full-term gestation?
- Is the baby crying or making efforts to breathe?
- Does the baby have good muscle tone and is it actively moving?
If all three questions can be answered YES, routine neonatal care is provided. If any question is answered NO, the following resuscitation steps are initiated.
- Provide Initial Resuscitation Steps (the first 30–60 seconds): Use the mnemonic TABC for Temperature, Airway, Breathing, and Circulation:
- Temperature control: Dry the baby thoroughly, remove wet linens, and place them under a radiant warmer to prevent hypothermia.
- Airway: Position the baby’s head in a neutral position (i.e., with slight neck extension). Suction the mouth first and then the nose if visible fluid is noted or there is a concern about obstruction (but avoid excessive suctioning).
- Breathing: Provide gentle stimulation by rubbing the baby’s back and flicking the soles of their feet. If the baby does not breathe or gasp, proceed to positive pressure ventilation (PPV).
- Circulation: Assess heart rate by auscultating the chest or palpating the umbilical cord.
- Provide Positive Pressure Ventilation (PPV) if the baby is not breathing or has a heart rate <100 bpm, use a bag-mask device with room air or 21% oxygen initially for term infants, or 30% oxygen for preterm infants. Ventilate at a rate of 40-60 breaths per minute. Assess chest rise, heart rate, and oxygen saturation.
- If heart rate is less than 100 bpm after 30 seconds of effective PPV, reassess technique (i.e., check mask seal, airway position, etc.) and consider increasing oxygen concentration. If there is no improvement, proceed to advanced steps.
- Provide Chest Compressions if the heart rate is less than 60 bpm after 30 seconds of PPV. Use the two-thumb technique with fingers encircling the baby’s chest. The compression-to-ventilation ratio is 3:1 (i.e., 90 compressions and 30 breaths per minute). Continue for 30 seconds and reassess.
- Provide Advanced Resuscitation Steps: If the baby remains unresponsive despite PPV and chest compressions, the multidisciplinary team provides advanced resuscitation, including the following:
- Endotracheal Intubation
- Epinephrine is administered if the heart rate remains <60 bpm despite effective resuscitation. Dose is typically 0.01–0.03 mg/kg IV or via endotracheal tube.
- If blood loss or shock is suspected, intravenous normal saline and/or blood product transfusion is initiated.
- Post-Resuscitation Care: After resuscitation is successful, closely monitor the baby’s heart rate, respiratory rate, and oxygen saturation. Maintain normothermia (36.5–37.5°C). Consider transferring to NICU if ongoing support is needed.
Nurses and multidisciplinary teams participate in regular training on neonatal resuscitation. See an image of a multidisciplinary team practicing neonatal resuscitation with infant CPR and bag mask ventilation in Figure 20.13.[6]
View more information about recommendations from the American Heart Association about neonatal resuscitation.
View a supplementary YouTube video[7] on neonatal resuscitation: Neonatal Resuscitation Education for Essential Providers
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal-newborn nursing. OpenStax. https://openstax.org/details/books/maternal-newborn-nursing ↵
- Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal-newborn nursing. OpenStax. https://openstax.org/details/books/maternal-newborn-nursing ↵
- American Heart Association. (2025) Part 5: Neonatal resuscitation. American Heart Association. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation ↵
- American Heart Association. (2025) Part 5: Neonatal resuscitation. American Heart Association. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation ↵
- American Heart Association. (2025) Part 5: Neonatal Resuscitation. American Heart Association. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation ↵
- “Nursing Skills Fair helps keep Blanchfield nurses ready [Image 3 of 3]” by Maria Christina Yager, U.S. Army is in the Public Domain. The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement. ↵
- TexSun NeoEd. (2023, June 29). Neonatal resuscitation education for essential providers [Video]. YouTube. All rights reserved. https://youtu.be/GpUINL0m7wA?si=8Djb5KuyLR7DVjvs ↵
A series of systematic steps to assess and support newborns who require help with breathing and circulation immediately after birth.
Temperature, Airway, Breathing, and Circulation
A method used to provide positive pressure ventilation to an infant during neonatal resuscitation, where both thumbs are placed on the infant's chest to compress the sternum, aiding in heart function when traditional chest compressions are needed.
