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Neonatal resuscitation in the delivery room

Caraciolo J Fernandes, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD


The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90 percent), these changes are successfully completed at delivery without requiring any special assistance. However, about 10 percent of infants will need some intervention, and 1 percent will require extensive resuscitative measures at birth [1].

The indications and principles of neonatal resuscitation will be reviewed here. The physiological changes that occur in the transition from intrauterine to extrauterine life are discussed separately. (See "Physiologic transition from intrauterine to extrauterine life".)


Being prepared is the first and most important step in delivering effective neonatal resuscitation [1]. However, most newborns are healthy and do not require additional special assistance and the need for resuscitation is often not anticipated even in tertiary birth centers [2,3]. As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated [1].

In all instances, at least one healthcare provider is assigned primary responsibility for the newborn infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures such as positive pressure ventilation and chest compressions. In addition, either this person or another who is immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications.

Equipment needed for resuscitation should be available at every delivery area (table 1), and routinely checked to ensure the equipment is functioning properly [1,4].


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Literature review current through: May 2017. | This topic last updated: Jun 07, 2017.
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  1. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S543.
  2. Mitchell A, Niday P, Boulton J, et al. A prospective clinical audit of neonatal resuscitation practices in Canada. Adv Neonatal Care 2002; 2:316.
  3. Niles DE, Cines C, Insley E, et al. Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation 2017; 115:102.
  4. American Academy of Pediatrics. Overview and principles of resuscitation. In: Textbook of Neonatal Resuscitation, 6th ed, Kattwinkel J (Ed), American Academy of Pediatrics, 2011.
  5. Jukkala AM, Henly SJ. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet Gynecol Neonatal Nurs 2009; 38:443.
  6. Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001; 107:648.
  7. Lockyer J, Singhal N, Fidler H, et al. The development and testing of a performance checklist to assess neonatal resuscitation megacode skill. Pediatrics 2006; 118:e1739.
  8. de Almeida MF, Guinsburg R, da Costa JO, et al. Resuscitative procedures at birth in late preterm infants. J Perinatol 2007; 27:761.
  9. Spain JE, Tuuli MG, Macones GA, et al. Risk factors for serious morbidity in term nonanomalous neonates. Am J Obstet Gynecol 2015; 212:799.e1.
  10. Berazategui JP, Aguilar A, Escobedo M, et al. Risk factors for advanced resuscitation in term and near-term infants: a case-control study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F44.
  11. Soraisham AS, Lodha AK, Singhal N, et al. Neonatal outcomes following extensive cardiopulmonary resuscitation in the delivery room for infants born at less than 33 weeks gestational age. Resuscitation 2014; 85:238.
  12. Chien LY, Whyte R, Aziz K, et al. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol 2001; 98:247.
  13. Cifuentes J, Bronstein J, Phibbs CS, et al. Mortality in low birth weight infants according to level of neonatal care at hospital of birth. Pediatrics 2002; 109:745.
  14. O'Donovan DJ, Fernandes CJ. Free radicals and diseases in premature infants. Antioxid Redox Signal 2004; 6:169.
  15. Saugstad OD, Ramji S, Vento M. Oxygen for newborn resuscitation: how much is enough? Pediatrics 2006; 118:789.
  16. Batton DG, Committee on Fetus and Newborn. Clinical report--Antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 2009; 124:422.
  17. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2015; 132:S204.
  19. Iliodromiti S, Mackay DF, Smith GC, et al. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. Lancet 2014; 384:1749.
  20. Freeman JM, Nelson KB. Intrapartum asphyxia and cerebral palsy. Pediatrics 1988; 82:240.
  21. Watkinson M. Temperature control of premature infants in the delivery room. Clin Perinatol 2006; 33:43.
  22. da Mota Silveira SM, Gonçalves de Mello MJ, de Arruda Vidal S, et al. Hypothermia on admission: a risk factor for death in newborns referred to the Pernambuco Institute of Mother and Child Health. J Trop Pediatr 2003; 49:115.
  23. Perlman JM. Hyperthermia in the delivery: potential impact on neonatal mortality and morbidity. Clin Perinatol 2006; 33:55.
  24. te Pas AB, Lopriore E, Dito I, et al. Humidified and heated air during stabilization at birth improves temperature in preterm infants. Pediatrics 2010; 125:e1427.
  25. Kelleher J, Bhat R, Salas AA, et al. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. Lancet 2013; 382:326.
  26. Noori S, Wlodaver A, Gottipati V, et al. Transitional changes in cardiac and cerebral hemodynamics in term neonates at birth. J Pediatr 2012; 160:943.
  27. Higgins RD, Bancalari E, Willinger M, Raju TN. Executive summary of the workshop on oxygen in neonatal therapies: controversies and opportunities for research. Pediatrics 2007; 119:790.
  28. Vento M, Asensi M, Sastre J, et al. Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen. J Pediatr 2003; 142:240.
  29. Vento M, Sastre J, Asensi MA, Viña J. Room-air resuscitation causes less damage to heart and kidney than 100% oxygen. Am J Respir Crit Care Med 2005; 172:1393.
  30. Sola A, Rogido MR, Deulofeut R. Oxygen as a neonatal health hazard: call for détente in clinical practice. Acta Paediatr 2007; 96:801.
  31. Tan A, Schulze A, O'Donnell CP, Davis PG. Air versus oxygen for resuscitation of infants at birth. Cochrane Database Syst Rev 2005; :CD002273.
  32. Rabi Y, Rabi D, Yee W. Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 2007; 72:353.
  33. Vento M, Asensi M, Sastre J, et al. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics 2001; 107:642.
  34. Hellström-Westas L, Forsblad K, Sjörs G, et al. Earlier Apgar score increase in severely depressed term infants cared for in Swedish level III units with 40% oxygen versus 100% oxygen resuscitation strategies: a population-based register study. Pediatrics 2006; 118:e1798.
  35. Saugstad OD, Aune D, Aguar M, et al. Systematic review and meta-analysis of optimal initial fraction of oxygen levels in the delivery room at ≤32 weeks. Acta Paediatr 2014; 103:744.
  36. Oei JL, Vento M, Rabi Y, et al. Higher or lower oxygen for delivery room resuscitation of preterm infants below 28 completed weeks gestation: a meta-analysis. Arch Dis Child Fetal Neonatal Ed 2017; 102:F24.
  37. Oei JL, Saugstad OD, Lui K, et al. Targeted Oxygen in the Resuscitation of Preterm Infants, a Randomized Clinical Trial. Pediatrics 2017; 139.
  38. Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterm infants with different inspired oxygen fractions. J Pediatr 2014; 164:1322.
  39. Boronat N, Aguar M, Rook D, et al. Survival and Neurodevelopmental Outcomes of Preterms Resuscitated With Different Oxygen Fractions. Pediatrics 2016; 138.
  40. Oei JL, Ghadge A, Coates E, et al. Clinicians in 25 countries prefer to use lower levels of oxygen to resuscitate preterm infants at birth. Acta Paediatr 2016; 105:1061.
  41. Thió M, Bhatia R, Dawson JA, Davis PG. Oxygen delivery using neonatal self-inflating resuscitation bags without a reservoir. Arch Dis Child Fetal Neonatal Ed 2010; 95:F315.
  42. Thio M, van Kempen L, Rafferty AR, et al. Neonatal resuscitation in resource-limited settings: titrating oxygen delivery without an oxygen blender. J Pediatr 2014; 165:256.
  43. Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for newborn ventilation in the delivery room. J Pediatr 2014; 165:234.
  44. Thakur A, Saluja S, Modi M, et al. T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT. Resuscitation 2015; 90:21.
  45. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 7: Neonatal resuscitation. Resuscitation 2005; 67:293.
  46. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S909.
  47. Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2005; :CD003314.
  48. Gandini D, Brimacombe JR. Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anesth Analg 1999; 89:642.
  49. O'Shea JE, Thio M, Owen LS, et al. Measurements from preterm infants to guide face mask size. Arch Dis Child Fetal Neonatal Ed 2016; 101:F294.
  50. Schmölzer GM, Te Pas AB, Davis PG, Morley CJ. Reducing lung injury during neonatal resuscitation of preterm infants. J Pediatr 2008; 153:741.
  51. Luten R, Kahn N, Wears R, Kissoon N. Predicting endotracheal tube size by length in newborns. J Emerg Med 2007; 32:343.
  52. Roberts WA, Maniscalco WM, Cohen AR, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995; 19:262.
  53. Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol 1999; 19:110.
  54. Hosono S, Inami I, Fujita H, et al. A role of end-tidal CO(2) monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth. J Perinat Med 2009; 37:79.
  55. Repetto JE, Donohue PA-C PK, Baker SF, et al. Use of capnography in the delivery room for assessment of endotracheal tube placement. J Perinatol 2001; 21:284.
  56. Peterson J, Johnson N, Deakins K, et al. Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate. J Perinatol 2006; 26:333.
  57. Amarilyo G, Mimouni FB, Oren A, et al. Orotracheal tube insertion in extremely low birth weight infants. J Pediatr 2009; 154:764.
  58. Menegazzi JJ, Auble TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 1993; 22:240.
  60. Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized, controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest [see comment]. Prehosp Emerg Care 1997; 1:65.
  61. Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb is superior to the two-finger method for administering chest compressions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 2011; 96:F99.
  62. Saini SS, Gupta N, Kumar P, et al. A comparison of two-fingers technique and two-thumbs encircling hands technique of chest compression in neonates. J Perinatol 2012; 32:690.
  63. Hemway RJ, Christman C, Perlman J. The 3:1 is superior to a 15:2 ratio in a newborn manikin model in terms of quality of chest compressions and number of ventilations. Arch Dis Child Fetal Neonatal Ed 2013; 98:F42.
  64. Ziino AJ, Davies MW, Davis PG. Epinephrine for the resuscitation of apparently stillborn or extremely bradycardic newborn infants. Cochrane Database Syst Rev 2003; :CD003849.
  65. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006; 118:1028.
  66. So KW, Fok TF, Ng PC, et al. Randomised controlled trial of colloid or crystalloid in hypotensive preterm infants. Arch Dis Child Fetal Neonatal Ed 1997; 76:F43.
  67. Oca MJ, Nelson M, Donn SM. Randomized trial of normal saline versus 5% albumin for the treatment of neonatal hypotension. J Perinatol 2003; 23:473.
  68. Niermeyer S. Volume resuscitation: crystalloid versus colloid. Clin Perinatol 2006; 33:133.
  69. Guinsburg R, Wyckoff MH. Naloxone during neonatal resuscitation: acknowledging the unknown. Clin Perinatol 2006; 33:121.
  70. Wyckoff MH, Perlman JM. Use of high-dose epinephrine and sodium bicarbonate during neonatal resuscitation: is there proven benefit? Clin Perinatol 2006; 33:141.
  71. Beveridge CJ, Wilkinson AR. Sodium bicarbonate infusion during resuscitation of infants at birth. Cochrane Database Syst Rev 2006; :CD004864.
  72. Aschner JL, Poland RL. Sodium bicarbonate: basically useless therapy. Pediatrics 2008; 122:831.
  73. American Academy of Pediatrics Committee on Fetus and Newborn, Bell EF. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics 2007; 119:401.
  74. Jain L, Ferre C, Vidyasagar D, et al. Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome. J Pediatr 1991; 118:778.
  75. Haddad B, Mercer BM, Livingston JC, et al. Outcome after successful resuscitation of babies born with apgar scores of 0 at both 1 and 5 minutes. Am J Obstet Gynecol 2000; 182:1210.
  76. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort. Am J Obstet Gynecol 2007; 196:463.e1.
  77. Kasdorf E, Laptook A, Azzopardi D, et al. Improving infant outcome with a 10 min Apgar of 0. Arch Dis Child Fetal Neonatal Ed 2015; 100:F102.
  78. Frazier MD, Werthammer J. Post-resuscitation complications in term neonates. J Perinatol 2007; 27:82.
  79. Akinloye O, O'Connell C, Allen AC, El-Naggar W. Post-resuscitation care for neonates receiving positive pressure ventilation at birth. Pediatrics 2014; 134:e1057.