Neonatal resuscitation: current evidence and guidelines

This article serves as a review of neonatal resuscitation guidelines which may be of interest to the obstetric anaesthetist involved in the care of newborns at the time of birth.

  • Cord management:
    • Deferred clamping for 1-2 minutes allows an increased blood volume to be transferred from the placenta to the newborn, with evidence for lower mortality rates in infants. It is therefore recommended when feasible, if no immediate resuscitation is required.
    • Timing of uterotonic drugs in relation to cord clamping has not been adequately studied, but does not appear to affect neonatal outcomes.


  • Initial assessment:
    • Dry newborns >32 weeks gestation, wrap newborns <32 weeks in plastic without drying
    • Gentle stimulation and warm theatre
    • Universal suctioning is not supported by evidence and may be harmful. Suction only when clearly excessive secretions present, or if mask ventilation is required and does not appear to result in effective ventilation as noted by chest rise.


  • Monitoring:
    • HR is the most important sign (via ECG/pulse oximetry/cord palpation/cardiac auscultation)


  • Positive pressure ventilation:
    • Initiate if apnoeic or gasping newborn, or HR <100, after period of drying and stimulation
    • Start with a PIP of 30 cmH20 for term newborns and 20-25 cmH20 for preterm newborns. First 5 inflations to be held for 2-3 seconds each.
    • Lower FiO2 (0.21-0.3) decreases short term mortality in term newborns. Set low then increase if HR not responding. Set at 1.0 if requiring compressions.


  • Compressions:
    • If HR <60 despite effective ventilation for 30 seconds.
    • Coordinated with breaths at 3:1 ratio, 2 thumb technique.


  • Medications:
    • Standardised adrenaline concentration to 0.1 mg/ml
    • IV or IO dose is 10-30 microg/kg (0.1-0.3 ml/kg)
    • Intra-tracheal dose is 50-100 microg/kg (0.5-1 ml/kg)


  • Other considerations:
    • If not responding to resuscitation efforts, consider a pneumothorax or congenital anomalies such as congenital diaphragmatic hernia.



Reviewed by Dr Natalie Akl