Newborn life-support principles

01Purpose and principlesWhat the treatment does and how it fits into care.

Newborn resuscitation differs from paediatric cardiac-arrest care because failure of lung aeration is usually the primary problem. Placental gas exchange stops and pulmonary blood flow rises only when the lungs inflate. Bradycardia is therefore generally hypoxic and responds to effective ventilation. Compressions and adrenaline given before lung inflation add little and distract from the decisive intervention.

Assess breathing, heart rate and tone while warming and gently stimulating. Auscultation gives an initial heart rate; ECG and pulse oximetry provide continuous information when intervention starts. Place the preductal oximeter on the right hand or wrist. Cyanosis by eye varies with lighting and skin pigmentation and must not determine oxygen alone.

If breathing is absent, gasping or ineffective, or the heart rate is below 100/min, open the airway and inflate the lungs. Support the head neutral and apply jaw thrust from behind the mandible; a two-person mask and jaw-thrust technique improves seal. Give 5 long inflations and look for chest movement. An increasing heart rate within 30 seconds is the most useful sign that ventilation works.

When the chest does not rise, reapply the mask, repeat the inflations and change one factor deliberately: head and jaw position, two-person seal, alternative interface, suction only for suspected obstructing material, supraglottic airway or tracheal tube, then pressure in 2–5 cm H2O increments. Pressures above 40 cm H2O are rarely needed. Reassess after each correction rather than cycling ineffectively.

Once the lungs have inflated but spontaneous breathing remains inadequate, give 15 breaths in 30 seconds using roughly 1-second inflations. Continue uninterrupted ventilation and reassess every 30 seconds until heart rate exceeds 100/min and breathing is effective. A T-piece with PEEP is preferred where available, especially for preterm babies; a self-inflating bag remains an essential backup.

Oxygen is a titrated medicine. Begin in air at 32 weeks or more and with at least 30% below 32 weeks, using a blender when possible. Follow heart rate and preductal saturations, recognising that normal transition takes minutes. Increase to 100% when compressions start, then reduce promptly once a reliable saturation and circulation recover to avoid hyperoxia.

Start chest compressions when heart rate remains below 60/min after at least 30 seconds of effective ventilation with visible chest movement. Encircle the chest with both hands and place adjacent or overlapping thumbs on the lower sternum. Coordinate three compressions to one ventilation, allowing full recoil. Stop compressions when heart rate exceeds 60/min but continue ventilation until breathing and heart rate are adequate.

If heart rate remains below 60/min despite ventilation and compressions, check equipment and airway, obtain emergency umbilical venous access or intraosseous access and give adrenaline. Consider blood loss, pneumothorax, congenital airway or lung anomaly and equipment failure. Tracheal adrenaline is a temporary bridge at a higher dose, not a substitute for vascular access.

When an infant has no detectable heart rate despite all recommended steps and reversible causes have been excluded, senior clinicians review gestation, antenatal information, effectiveness and duration of resuscitation and the family's views. The 2025 guideline advises considering stopping if the heart rate remains absent beyond 20 minutes; decisions are individual, and comfort-focused care and family support continue.

Key points

Before birth brief the team, allocate roles, check warmer, gas supply, blender, suction, ventilation interfaces, oximeter, ECG, airway equipment, emergency access and drugs.
Aim for cord clamping after at least 60 seconds while warming, stimulating and assessing when safe; never delay necessary resuscitation that cannot be delivered with the cord intact.
Maintain 36.5–37.5°C. At less than 32 weeks, place the body in a polyethylene wrap without drying, dry and cover the head and use a preheated radiant warmer.
Initial assessment is breathing, heart rate and tone. Skin colour is not a reliable oxygen measure; use right-hand preductal pulse oximetry when support is required.
Open the airway in a neutral position with jaw thrust. Give 5 inflation breaths over 2–3 seconds each when apnoeic, gasping, ineffective or heart rate is below 100/min.
Starting inflation pressure is 30 cm H2O at 32 weeks or more and 25 cm H2O below 32 weeks; add PEEP about 6 cm H2O when possible and adjust to chest movement and response.
Start respiratory support in 21% oxygen at 32 weeks or more and at least 30% below 32 weeks, then titrate against preductal saturation and heart rate.
Acceptable right-hand saturations are approximately 70–75% at 3 minutes, 80–85% at 5 minutes and 85–95% at 10 minutes; avoid saturation below 80% with bradycardia at 5 minutes.
After successful lung inflation, give 15 ventilation breaths over 30 seconds and reassess. Continue about 30 breaths/min until regular breathing and heart rate above 100/min.
Start compressions only if heart rate remains below 60/min after 30 seconds of effective ventilation: use two thumbs, one-third chest depth and a 3:1 ratio for 90 compressions plus 30 breaths/min.
During compressions use 100% oxygen, secure an airway when skilled, seek umbilical venous or intraosseous access and reassess heart rate every 30 seconds.
If heart rate remains below 60/min after ventilation and compressions, give intravenous or intraosseous adrenaline 20 micrograms/kg and repeat every 4 minutes while correcting reversible causes.
Do not give routine bicarbonate or empirical glucose. Check glucose and give 10% glucose 2 mL/kg only when low; give 10 mL/kg blood or isotonic crystalloid when blood loss is suspected.
After recovery stabilise temperature, glucose, oxygenation and perfusion, assess HIE and other causes, document timings and support the family with an explanation and later debrief.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Normal transition

Regular breathing, rising heart rate, flexed tone and improving preductal saturation occur with warmth, skin contact and observation alone.

Primary respiratory compromise

Apnoea, gasping, shallow irregular breathing or heart rate below 100/min indicates inadequate lung aeration and need for inflation.

Ineffective ventilation

Absent chest rise and no heart-rate increase after inflations means the airway, seal, interface or delivered pressure remains inadequate.

Circulatory collapse

Heart rate below 60/min despite 30 seconds of visible-chest-movement ventilation signals severe hypoxia requiring coordinated compressions.

Possible hypovolaemia

Pallor, weak pulses and non-response with placental bleeding, cord accident or fetomaternal haemorrhage supports cautious emergency volume replacement.

Post-resuscitation encephalopathy

Altered consciousness, hypotonia, abnormal reflexes, seizures and multiorgan dysfunction after perinatal compromise prompts urgent HIE assessment.

Red flags requiring action

Absent or ineffective breathing, gasping, marked hypotonia or heart rate below 100/min requires immediate respiratory support rather than prolonged stimulation.
No chest movement and no heart-rate rise during inflation means ventilation is ineffective; correct airway, interface and pressure before starting compressions.
Heart rate below 60/min after at least 30 seconds of demonstrably effective ventilation requires 3:1 compressions, 100% oxygen and advanced help.
Pallor, poor response and a history of placental bleeding, cord rupture or fetomaternal haemorrhage suggests hypovolaemia and need for urgent volume replacement.
Unilateral breath sounds, sudden deterioration, poor ventilation pressure transmission or persistent cyanosis raises pneumothorax, airway obstruction or congenital anomaly.
Post-resuscitation seizures, encephalopathy, abnormal tone, persistent acidosis or multiorgan dysfunction requires urgent neonatal intensive care and therapeutic-hypothermia eligibility assessment.
Temperature outside 36.5–37.5°C, low glucose or wide glucose swings after resuscitation can worsen injury and require active correction and monitoring.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line monitoring: heart rate and breathingFirst stepFirst line
Why
Determine whether transition is adequate and measure the response to every ventilation or compression cycle.
Interpretation and limitations
Auscultate initially; continuous ECG and oximetry are preferred during intervention, but never delay ventilation while attaching monitors.
02
Preductal pulse oximetry
Why
Guide oxygen titration against time-from-birth transition targets using the right hand or wrist.
Interpretation and limitations
A poor waveform is unreliable; interpret alongside heart rate and ventilation, and reduce oxygen if saturation exceeds 95%.
03
Visible chest movement and respiratory function
Why
Confirm lung inflation and detect inadequate airway opening, mask leak or insufficient pressure.
Interpretation and limitations
Chest movement plus heart-rate rise supports effective ventilation; an expired tidal volume around 4–8 mL/kg may guide trained teams with a monitor.
04
Early blood glucose
Why
Detect hypoglycaemia after prolonged resuscitation, HIE risk or intravenous glucose treatment.
Interpretation and limitations
Treat a measured low result according to neonatal protocol and monitor repeatedly; avoid empirical boluses and wide swings.
05
Blood gas, lactate and targeted laboratory assessment
Why
Assess acidosis, ventilation, perfusion, anaemia, infection and multiorgan injury after stabilisation.
Interpretation and limitations
Cord gases describe the birth insult; postnatal trends inform recovery but do not replace neurological examination for cooling eligibility.
06
Targeted imaging and neurological monitoring
Why
Investigate pneumothorax, congenital anomaly, HIE or seizures once immediate ventilation and circulation are secure.
Interpretation and limitations
Use bedside transillumination or ultrasound only if it does not delay decompression of tension pneumothorax; use aEEG or EEG in suspected encephalopathy.

04Treatment approachPreparation, options, escalation and aftercare.

01PreparationBrief, warm and checkFirst stepBirth is imminent or neonatal compromise is anticipated.

1Review gestation, fetal condition, maternal history and agreed extent of care and summon an appropriately skilled team.
2Allocate leadership, airway, monitoring, access, documentation and family support and check every item before birth.
3Prepare gestation-specific thermal measures and plan delayed cord clamping without delaying any necessary intervention.

02Airway and breathingInflate the lungs firstBreathing is absent or ineffective or heart rate is below 100/min.

1Place supine with neutral head, apply jaw thrust and an appropriately sized interface and give 5 inflations over 2–3 seconds each.
2AlternativeCheck chest movement and heart-rate response; if absent, correct seal and position, use a two-person or alternative airway and increase pressure incrementally.
3When chest rise is established, give 15 breaths over 30 seconds and reassess breathing and heart rate every 30 seconds.

03CirculationCompress only after effective ventilationHeart rate remains below 60/min after at least 30 seconds of effective ventilation.

1Use 100% oxygen, call advanced help and consider a supraglottic airway or tracheal tube while ventilation continues.
2Deliver two-thumb compressions to one-third chest depth at 3:1, aiming for 90 compressions and 30 ventilations each minute.
3Reassess every 30 seconds, stop compressions once heart rate exceeds 60/min and titrate oxygen after reliable recovery.

04Drugs and causesObtain access and correct reversible factorsHeart rate remains below 60/min despite ventilation and compressions.

1Obtain emergency umbilical venous access, or intraosseous access when UVC is unavailable, without interrupting effective ventilation and compressions.
2Give vascular adrenaline 20 micrograms/kg every 4 minutes if needed and use tracheal adrenaline only as a temporary bridge while access is obtained.
3Check glucose, blood loss, pneumothorax, airway obstruction, congenital anomaly and equipment failure and treat the identified cause.

05AftercareStabilise and reassess comprehensivelyBreathing and circulation recover after resuscitation.

1Maintain 36.5–37.5°C and stable oxygenation, glucose, ventilation and perfusion in an appropriately monitored neonatal setting.
2Assess neurological state, seizures, HIE cooling eligibility, infection, trauma and organ injury and arrange transfer when required.
3Record the complete timeline, explain events to parents, enable contact when safe and offer a later debrief and ongoing support.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Advanced NLS vasopressor after airway, lung inflation, ventilation and coordinated compressions have failed to restore heart rate.

Adrenaline 1:10,000, 0.1 mg/mL

If heart rate remains below 60/min after effective ventilation and 30 seconds of compressions, give 20 micrograms/kg, equivalent to 0.2 mL/kg, by umbilical venous or intraosseous route; repeat every 4 minutes while indicated. If intubated without vascular access, give 100 micrograms/kg, 1 mL/kg, intratracheally as a bridge.

Confirm concentration and weight calculation aloud. Intratracheal absorption is unreliable and vascular adrenaline should follow immediately when access is achieved. Do not give before effective ventilation, and look continuously for hypovolaemia, pneumothorax, obstruction or equipment failure.

Measured hypoglycaemia correction during or after advanced newborn resuscitation; empirical administration is no longer recommended.

Glucose 10%

Check blood glucose during prolonged resuscitation where possible. If it is low, give 200 mg/kg, equivalent to 2 mL/kg of 10% glucose, intravenously or intraosseously, then provide gestation-appropriate infusion and repeat measurement under the neonatal protocol.

Secure intravascular placement and avoid extravasation. Monitor for rebound hypoglycaemia, hyperglycaemia and rapid glucose swings. Do not confuse the 2025 NLS bolus with older 2.5 mL/kg protocols.

Restore circulating volume when placental or fetal blood loss is suspected or the infant remains unresponsive despite otherwise effective resuscitation.

Emergency intravascular volume

Give 10 mL/kg of group O Rh-negative blood when acute blood loss is likely, or isotonic crystalloid when blood is unavailable, reassessing perfusion and response after each cautious aliquot.

Routine volume can worsen overload when blood loss is absent. Use warmed fluid, watch heart rate, perfusion and lung signs, and obtain compatible blood and neonatal intensive-care support as soon as possible.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Reassess breathing and heart rate every 30 seconds during active support and document the response to each airway correction, ventilation cycle, compression cycle and drug.
Monitor preductal saturation continuously when respiratory support is used, titrating oxygen to the transition range and reducing it promptly after recovery.
Measure temperature frequently or continuously, record admission temperature and adjust heat sources to remain within 36.5–37.5°C without overshoot.
Check glucose early and serially after prolonged resuscitation, HIE risk or treatment and avoid both low and high concentrations and abrupt fluctuation.
After stabilisation follow blood gas, perfusion, urine output, respiratory status and neurological examination and investigate organ injury or infection from the clinical pattern.
Use continuous aEEG or EEG where encephalopathy or seizures are suspected and complete therapeutic-hypothermia eligibility assessment within the first 6 hours.
Undertake a structured team review of equipment, human factors, timing and guideline adherence and arrange a clear family explanation and follow-up plan.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Heart-rate rise proves ventilation

The most persuasive response to lung inflation is an increasing heart rate, not merely a displayed pressure or mask movement.

Compressions are a late step

Most newborn bradycardia reverses when the lungs inflate; premature compressions interrupt the treatment that matters most.

Oxygen targets change by minute

Healthy transition is not immediately pink, so oxygen is titrated against preductal time-based ranges rather than adult saturation expectations.

Very preterm babies are not dried

Below 32 weeks the wet body goes directly into polyethylene wrapping while the head is dried and covered.

Tracheal adrenaline is temporary

Its higher dose and variable absorption make it a bridge while umbilical venous or intraosseous access is secured.

Family support is clinical care

A named professional, contemporaneous explanation, facilitated contact and later debrief reduce avoidable trauma after resuscitation.

08Common pitfallsFrequent interpretation and management errors.

01
Do not delay ventilation while attaching ECG leads or obtaining a perfect saturation trace.
02
Do not assess oxygenation by skin colour alone.
03
Do not start compressions before confirming effective ventilation and visible chest movement.
04
Do not keep repeating ineffective mask inflations without changing airway, seal, interface or pressure.
05
Do not use 100% oxygen from the outset unless compressions are required.
06
Do not give routine sodium bicarbonate or empirical glucose during newborn resuscitation.
07
Do not milk the umbilical cord in an infant below 28 weeks.
08
Do not begin unsupervised therapeutic hypothermia outside a controlled neonatal pathway.
09
Do not overlook blood loss, pneumothorax or congenital anomaly when ventilation appears effective but recovery fails.
10
Do not finish the event without post-resuscitation glucose, temperature, neurological review, documentation and family support.