Neonatal resuscitation and transition at birth

• Neonatal resuscitation is rarely about advanced life support. It is mostly about supporting the normal transition from placental to pulmonary gas exchange, and about recognising when that transition has failed.
• The commonest reason for delayed breathing is primary apnoea. The first job is therefore to open the airway, inflate the lungs with positive pressure, and assess the response.
• The neonatal algorithm splits into two phases: stabilisation (warmth, airway, breathing support, oxygen) and, only if needed, resuscitation (ventilation, then chest compressions, then vascular access and drugs).
• The heart rate decides what happens next. Over 100 beats per minute with regular breathing means normal transition. Under 100 means start ventilation. Under 60 after at least 30 seconds of effective ventilation means start chest compressions. ^[1]
• The guiding sources for this page are the Resuscitation Council UK 2025 Newborn Resuscitation guidelines (published 27 October 2025), the ILCOR Neonatal Life Support 2025 Consensus on Science, the AHA and AAP 2025 Part 5 Guidelines, and the WHO and AAP Helping Babies Breathe 2nd edition materials. They agree on the major sequence but differ on details such as inflation time and initial oxygen concentration, and those differences are stated where they matter. ^[6]

By the end of this page you should be able to:

1. Explain the physiological change that has to happen at birth and why some babies cannot make it.
2. List the risk factors that predict a need for stabilisation or resuscitation, and describe the preparation and briefing before delivery.
3. Perform the first minute assessment and give five inflation breaths with the right pressure and oxygen for gestational age.
4. Run the breathing, circulation and drug steps using heart-rate thresholds, knowing the dosing intervals and alternative routes.
5. Manage glucose, temperature and blood gas balance after return of spontaneous circulation or stable ventilation.
6. Adapt the approach for an unexpected out-of-hospital birth and for settings where equipment is limited.

Birth is a cardiorespiratory transition, not just an oxygen supply switch. In the uterus the lungs are fluid-filled and mostly unused, and the placenta provides oxygen. After birth the lungs must fill with air, clear much of the fluid, establish functional residual capacity, and take over gas exchange. At the same time the pulmonary vessels dilate, pulmonary vascular resistance falls, and the circulation changes so that the lungs receive blood in series rather than in parallel. The ductus arteriosus and foramen ovale begin to close, though they remain patent for variable periods.

When an infant cannot manage this transition, the problem is usually failure to establish regular breathing, not primary cardiac arrest. The baby's heart rate falls because hypoxia progressively deepens. That is why neonatal resuscitation starts with the lungs and only moves to compressions and drugs if ventilation does not restore the heart rate.

Most infants do establish breathing with drying, warmth and gentle stimulation. The educational programs that focus on the first minute, including Helping Babies Breathe (HBB), an AAP program that harmonises with the 2015 ILCOR consensus and the 2012 WHO Basic Newborn Resuscitation Guidelines, are built on that fact and aim to make every birth attendant competent at the initial steps. ^[1][6]

The 2025 AHA and AAP guidelines frame the whole approach as a gentle, physiology-based transition and present it as a "newborn chain of care" from antenatal planning through follow-up, rather than a stand-alone algorithm. ^[3] The Resuscitation Council UK (RCUK) 2025 newborn guideline covers the same physiology but adds extensive operational detail for hospital and out-of-hospital births. Its authors explicitly note that more evidence is needed in very preterm infants under 25 weeks, because most available evidence comes from slightly older gestational ages. ^[1]

Resuscitation or stabilisation is indicated when the initial assessment shows that the infant is not making the transition expected after birth. The RCUK guidance lists common antepartum risk factors (intrauterine growth restriction, gestation under 37 weeks, multiple pregnancy, serious congenital abnormality, oligo or polyhydramnios) and maternal factors (infection, gestational diabetes, pregnancy-induced hypertension, high body mass index, short stature, lack of antenatal steroids), plus intrapartum factors such as evidence of fetal compromise, meconium-stained amniotic fluid, breech, forceps or vacuum delivery, significant bleeding, emergency caesarean section and out-of-hospital birth. ^[1]

Although a plan for attendance should be proportionate to the expected risk, any infant can deteriorate without warning, so every birth should be attended by at least one person who is trained, equipped and assigned to initiate stabilisation. ^[1]

Call for help earlier rather than later once the need for intervention is recognised. The RCUK guidance notes that telemedicine can be used to provide remote expert advice and that health systems should consider how to build this in. ^[1]

There are no absolute clinical contraindications to attempted stabilisation of a newborn at birth. The question is what is in the infant's and family's best interests, and this needs to be addressed before birth wherever possible. Where there is no time for discussion, resuscitation should usually be started. ^[1]

Where life-sustaining treatment is withheld or withdrawn, the RCUK criteria expect an extremely high predicted neonatal mortality (over 90%) with unacceptably high morbidity; resuscitation is usually appropriate in conditions associated with under 50% mortality and deemed acceptable morbidity. High mortality with substantial morbidity can be managed according to parental wishes, with full resuscitation, selective measures or comfort-focused care. For infants under 25 weeks, partial response to thermal, airway and breathing support versus failure to respond even with compressions and adrenaline is an important discriminator. ^[1]

In any setting where support is withdrawn, the infant must still receive careful comfort care, and the family supported throughout. Comfort care is the non-negotiable minimum even when resuscitation is not attempted. ^[1]

The newborn airway differs from the adult airway. The larynx is high and anterior, the epiglottis is long and floppy, and the trachea is narrow and easily compressed by hyperextension or flexion of the neck. A neutral position with a small shoulder roll or jaw thrust is therefore the starting point. Hyperextension collapses the pharyngeal airway and makes mask ventilation fail.

The umbilical cord provides rapid vascular access to the portal system via the umbilical vein. In an emergency the portal can be used for drugs and fluids while the infant is still newly born. The RCUK lists the umbilical vein as the preferred emergency route and intraosseous access as an alternative. ^[1]

The transitional circulation remains dependent on the foramen ovale and ductus arteriosus for the first hours to days. Persistent fetal circulation with pulmonary hypertension can therefore develop after a difficult transition, which is why significant hypoxia or shock can take time to recover even after the lungs have been ventilated.

Regular equipment checks, an easily accessible standardised layout and attention to human factors are all recommended. ^[1] For every birth at risk, or for a lone provider in the community, the following should be immediately available:

• A flat, well-illuminated, warm resuscitation surface that can support thermal care.
• A radiant warmer, preheated towels or hats, and, for infants under 32 weeks, a polyethene bag or wrap without drying, plus a hat.
• A fitted face mask and a T-piece resuscitator (or self-inflating bag with PEEP valve), with appropriate nasal interface sizes.
• A pulse oximeter and, where available, ECG monitoring. ECG is increasingly recognised because it gives more precise and continuous heart-rate data than other methods. ^[1]
• Suction under direct vision (per the ERC guidance) or when there is an obstructed airway.
• Airway adjuncts: appropriately sized supraglottic airways, nasopharyngeal or oropharyngeal airways, laryngeal mask airway (less useful in infants under 34 weeks) and tracheal tubes with video laryngoscopy where training allows.
• Drugs and fluids: 1:10000 adrenaline (epinephrine), 10% glucose, isotonic crystalloid and group O Rh-negative blood, plus emergency vascular access equipment (umbilical catheter or intraosseous device).

Briefing before birth is explicitly recommended: review available clinical information, assign roles, check equipment, consider and plan cord management, and prepare the family. A checklist or cognitive aid reduces mental load. ^[1] Communication continues through the resuscitation and into debrief.

Decisions to attempt resuscitation of an extremely preterm or clinically complex infant are taken in close consultation with parents and senior staff in advance of birth, and should be documented. ^[1]

Interprofessional teams proportionate to the expected risk should attend, with rapid mobilisation of extra skilled help. Training should be at least annually, ideally with booster sessions every 3 to 6 months, using standardised materials based on current national guidelines. ^[1]

Thermal control runs in parallel with every other step. Admission temperature is a prognostic and quality indicator. ^[1] Maintain temperature between 36.5 and 37.5 degrees C, avoid draughts, close windows, use warmers, and set room temperatures to 23 to 25 degrees in infants over 28 weeks and above 25 degrees in infants up to and including 28 weeks. ^[1]

Dry, stimulate gently (rub the soles of the feet or the back; avoid vigorous methods, especially in preterm infants), cover the head and body, and lay the infant on a warm surface. Assess with the cord intact if possible, and aim for at least 60 seconds of delayed cord clamping while resuscitation is performed. If resuscitation is needed and delayed clamping is not safe, clamp the cord in under 30 seconds to minimise delay. ^{[1] [3]}

The initial assessment should be as quick as it sounds. Assess three things: breathing (presence, rate, depth, symmetry and work), heart rate (by auscultation initially, then pulse oximetry or ECG when interventions are indicated) and muscle tone. Reassess breathing and heart rate every 30 seconds. ^[1]

Colour is deliberately de-emphasised in the 2025 guidance, because cyanosis is subjective and varies across skin tones. Use oxygen monitoring, not colour, to judge oxygenation. ^[1]

Do not wait for a specific time before acting. Breathing assessment, heart-rate assessment and the decision to support ventilation can all be completed within 60 seconds of birth. ^[3][5]

Infants who are term or near-term, breathing well, with a heart rate above 100 and reasonable tone, should remain with the mother, ideally skin-to-skin, covered and kept warm, with ongoing observation. In preterm infants, or those with extra support needs, thermal care is more active and delayed cord clamping should be prolonged. ^[1][3]

Until the airway is patent and the lungs are inflated, nothing else helps. ^[1] Place the infant supine, with the head in a neutral position, use a jaw thrust (two-person technique when staffing allows, because it is more effective), and clear obvious obstruction under direct vision. ^[1][4]

Suction is not longer and routine. Do not routinely suction meconium or amniotic fluid, because it delays ventilation. Suction only if there is an obstructed airway, and perform oropharyngeal suction under direct vision. Airway adjuncts can be used after the first opening attempts when available, including supraglottic airways and, for selected situations such as micrognathia, nasopharyngeal or oropharyngeal airways. ^[1]

If the infant is apnoeic, gasping or breathing ineffectively, or the heart rate is under 100, start positive pressure ventilation (PPV) within 60 seconds of birth. ^[1][3]

Inflation (recruitment) breaths. The RCUK approach is to give 5 inflation breaths, each with an inflation time of 2 to 3 seconds, looking for visible chest movement, using 30 cm H2O for infants over 32 weeks and 25 cm H2O for infants under 32 weeks, with PEEP of 6 cm H2O where possible. ^[1]

This follows the traditional ERC approach and differs from the AHA and AAP approach as described in the 2025 Part 5 guideline and algorithm: the AHA and AAP suggest starting ventilation at 30 to 60 breaths per minute with an inflation time of 0.5 to 1 second and a peak inspiratory pressure of 20 to 30 cm H2O. ^{[3][4][5] [1]}

Both fall within the ILCOR treatment recommendations' peak-pressure range, and the ILCOR 2025 chapter notes there has been no ILCOR systematic review of inflation time since 2010. Sustained inflations over 5 seconds have been associated with harm in extremely preterm infants, and the ERC guideline therefore explicitly advises against them. ^[2][4]

Decision points during inflation breaths. The RCUK guidance asks two questions. ^[1]

• Has chest movement been seen? If no, reapply the mask, repeat five inflations, and then use an alternative airway opening technique. If still unsuccessful, consider increasing inflation pressure.
• After inflation breaths, check the heart rate. An increase within 30 seconds or a stable rate over 100 confirms adequate ventilation; a rate under 100 usually means inadequate ventilation and poor chest movement.

Ventilation breaths. After successful inflation breaths, give 15 ventilation breaths over 30 seconds, with an inflation time of approximately 1 second, at 30 per minute. Continue uninterrupted PPV until the infant breathes adequately and the heart rate is over 100. ^[1]

Oxygen and monitoring. Use pulse oximetry and, where possible, ECG. Start at 21% oxygen for infants of 32 weeks or more and at 30% or higher for those under 32 weeks, titrating between the 25th and 75th centile targets. The guidance gives higher starting ranges and asks to avoid saturation under 80% or bradycardia at 5 minutes of age, and to reduce inspired oxygen when saturation exceeds 95%. ^[1]

Target saturation by time (from birth) according to the AHA 2025 neonatal resuscitation algorithm long description and the comparative review: ^[4][5] The AHA 2025 algorithm publishes this saturation table from 2 minutes of age; the ERC 2025 table begins at 3 minutes, although both agree on 70 to 75% at 3 minutes. ^[4][5]

A baby whose heart rate remains under 60 after 30 seconds of ventilation breaths moves to the circulation step, regardless of what else has been achieved.

The concordance review makes clear that the current guidelines' peak-pressure advice is based mostly on historical studies and manikin data. It suggests targeting exhaled tidal volume (typically 4 to 8 mL per kg) using a respiratory function monitor when available. Neither guideline requires this routine equipment. ^{[4] [1]}

Start chest compressions when the heart rate is under 60 after at least 30 seconds of effective ventilation. ^[1] Before starting: increase oxygen to 100%, call for experienced help, consider securing the airway and establishing vascular access. ^[1]

Use a 3 to 1 compression to ventilation ratio, 90 compressions and 30 ventilations per minute, two-thumb hand-encircling technique or the most practical variation, compress to one third of the anteroposterior chest diameter, allow full recoil, and reassess the heart rate every 30 seconds. ^[1]

If the heart rate remains under 60, secure the airway with a supraglottic airway or tracheal tube and continue the 3 to 1 ratio. Once a reliable saturation is available, titrate oxygen against it. Stop compressions when the heart rate exceeds 60 and confirm output by auscultation, pulse and signs of life. ^[1]

Umbilical venous access is the preferred route, with intraosseous access as an alternative. ^[1] Drug doses are simple, but intervals have been simplified in the 2025 guideline. ^[1]

• Adrenaline (epinephrine). 20 micrograms per kg (0.2 mL per kg of 1:10000 adrenaline) via umbilical vein or intraosseous access, then every 4 minutes if the heart rate stays under 60 (RCUK 2025 and ERC 2025 use 4 minutes; the AHA 2025 algorithm gives adrenaline every 3 to 5 minutes). If the baby is intubated but no umbilical or intraosseous access exists yet, give 100 micrograms per kg (1 mL per kg of 1:10000 adrenaline) into the tracheal tube; as soon as access is achieved give a dose through it, irrespective of when the tracheal dose was given. ^[1][5]
• Glucose. Check glucose if possible, and give 200 mg per kg (2 mL per kg of 10% glucose) if low, with 2.6 mmol per litre commonly used as the threshold. ^[1]
• Volume. Give 10 mL per kg of group O Rh-negative blood or isotonic crystalloid if suspected blood loss, or if the infant is unresponsive to the other measures. ^[1]
• Sodium bicarbonate. No longer recommended in resuscitation, and is reserved for post-resuscitation care under local protocols. ^[1][4]

When the response remains poor, remember reversible factors: hypovolaemia, pneumothorax, congenital abnormality and equipment failure. ^[1]

Record a time-based heart rate and breathing log, Apgar scores with individual components, all conversations with the parents and the interventions given. ^[1]

After breathing and circulation stabilise, the work is not finished. Temperature, glucose, oxygen and carbon dioxide all need active management.

• Temperature. Monitor frequently or continuously, and keep 36.5 to 37.5 degrees C. Hypothermia in the newly born is a strong predictor of poor outcome. ^[1]
• Glucose. Check early and regularly and avoid both hypoglycaemia and hyperglycaemia and wide swings. A commonly used threshold is 2.6 mmol per litre for treatment, and the RCUK recommends 200 mg per kg of 10% glucose as a bolus. ^[1]
• Oxygenation and ventilation. Avoid both hypoxia and hyperoxia. Monitor pre- and post-ductal saturations where possible, to detect pulmonary hypertension. Avoid inadvertent hypocapnia during mechanical ventilation. ^[1]
• Therapeutic hypothermia. In eligible term infants with clinical, biochemical and neurophysiological evidence of hypoxic-ischaemic encephalopathy, cooling to 33 to 34 degrees should be considered, with careful eligibility criteria, transfer to an appropriately equipped facility, and transport monitoring. ^[1]
• Parents and team. Involve and support parents before, during and after the resuscitation. A performance-focused interdisciplinary debrief should follow significant events, including review of equipment and systems. ^[1][4]

Complications during neonatal transition follow the degree and duration of hypoxia and the interventions needed. Those explicitly named in the source guidelines include:

• Failed transition. Hypoxic-ischaemic encephalopathy, seizures and organ dysfunction in survivors if hypoxia is prolonged.
• Airway and lung trauma. Pneumothorax, particularly if ventilation pressures are high or the airway is closed, and pulmonary interstitial emphysema in preterm infants.
• Circulatory failure. Persistent pulmonary hypertension, shock, and, late after ductal closure, left heart loading failure if residual left-to-right shunt.
• Drug and fluid complications. Hyperglycaemia with high glucose, extravasation with intraosseous access, and the recognised pharmacological actions of adrenaline on blood pressure and peripheral perfusion.
• Hypothermia. A common and dangerous complication, especially for preterm and out-of-hospital infants. ^[1]
• Outcomes of prolonged resuscitation. The AHA and AAP Part 5 and RCUK summaries consider 20 minutes of full resuscitation without any sign of improvement a reasonable point at which to reconsider goals of care, with earlier consideration in very preterm infants. ^[1][4]

Sodium bicarbonate is deliberately not recommended during resuscitation, because of the lack of benefit and potential for harm. ^[1][4]

Helping Babies Breathe (HBB) is the educational programme designed for basic newborn resuscitation in settings where staff, equipment and intensive care may be limited. Its 2nd edition aligns with the 2015 ILCOR consensus and the 2012 WHO Basic Newborn Resuscitation Guidelines and teaches the initial steps to be completed within "The Golden Minute" (the first minute after birth). It has been associated with reductions in neonatal mortality of up to 47% and fresh stillbirths of up to 24% in the settings studied. ^[6] The same sequence is now often taught through the WHO/AAP Essential Newborn Care Course 2nd edition, which incorporates Helping Babies Breathe; the 47% and 24% figures above still come from HBB studies.

The practical message for low-resource settings is identical in sequence if not in detail: keep the baby warm, assess breathing and heart rate, help the baby breathe within the first minute, and, where possible, give oxygen and advanced support according to local protocol and skill level. ^[4][6]

For babies born unexpectedly outside hospital, the RCUK guidance emphasises thermal care as the first priority, early supraglottic airway use when staffing is thin, respiratory support in air unless compressions are needed and 100% oxygen then, intraosseous access (unless clinicians can site an umbilical catheter), and mandatory transfer to hospital of every baby that needed resuscitation. ^[1]

• Most newborns transition to extrauterine life without intervention; resuscitation is about supporting that physiology, not restarting a heart.
• Delayed cord clamping for at least 60 seconds should be used in all births unless resuscitation is needed and it cannot be done safely, in which case clamp in under 30 seconds. ^[1]
• Temperature must be kept between 36.5 and 37.5 degrees C throughout; room temperature targets are 23 to 25 degrees above 28 weeks and above 25 degrees at or under 28 weeks. ^[1]
• Airway comes first. Neutral position, mouth and nose cleared only if obstructed, and jaw thrust, before any ventilation or drug step.
• Inflation breaths are 5 of 2 to 3 seconds, 30 cm H2O at 32 weeks or more, 25 cm H2O below, with PEEP 6 cm H2O. AHA guidance differs (20 to 30 cm H2O, inflation time 0.5 to 1 second); both are within the ILCOR range. ^{[1][4] [5]}
• Positive pressure ventilation starts within 60 seconds, then 15 breaths in 30 seconds at 30 per minute; aim for heart rate above 100.
• Heart rate is the single most reliable endpoint. Under 100, ventilate. Under 60 after 30 seconds of ventilation, compress at 3 to 1 with 100% oxygen.
• Adrenaline is 20 micrograms per kg every 4 minutes via umbilical vein or intraosseous route; intra-tracheal dose is 100 micrograms per kg. ^[1]
• Glucose is 200 mg per kg when low, volume is 10 mL per kg, and bicarbonate is no longer used in resuscitation.
• Consider goals of care after 20 minutes without improvement, earlier in very preterm infants. ^[1][4]
• The two most common remediable causes of poor response are failure to inflate the lungs and hypothermia.

Plain text only here: delayed cord clamping, ventilation of the newborn, therapeutic hypothermia, persistent pulmonary hypertension of the newborn, neonatal hypoglycaemia, antenatal counselling for extremely preterm birth, neonatal resuscitation program education. (No links were made because no verified topic list was supplied in this brief.)