Over 4 million infants are born each year in the United States. Approximately 10% of these newly born infants require active intervention in the delivery room, and approximately 1% require extensive resuscitation to sustain life. National guidelines have been developed to provide health-care workers with the necessary training for competency and uniformity in neonatal resuscitation.^1–3 They address a sequential increase in assistance based on the physiologic response of the infant to each intervention along an algorithm.

Initial Assessment: At least one appropriately trained medical person should be present to perform a rapid assessment of an infant after delivery. This assessment determines the infant’s overall maturity, presence of meconium, quality of respirations, and degree of muscle tone. If transition to extrauterine life is uneventful, the infant receives routine care that comprises drying, warming, positioning, and possibly suctioning to clear the airway. In the event that extrauterine transition is delayed or inadequate, resuscitation is begun. Further intervention is administered based on an “evaluation-decision-action” assessment of the infant’s respirations, heart rate, and color at 30-second intervals. An Apgar score is assigned to the infant at 1 minute and 5 minutes after birth. The Apgar score is a mechanism by which one can assess and summarize the condition of the newborn after childbirth and allows caregivers to understand the condition of the infant after birth. The Apgar score comprises five components: skin color, heart rate, reflex irritability, muscle tone, and respirations. Each component can be scored from 0 to 2 points, allowing the cumulative score to be between 0 and 10 points total.

Assisted Ventilation: Effective ventilation is the most crucial step in any resuscitation. Free-flow oxygen is administered to any infant who appears cyanotic but otherwise has adequate respiratory effort and heart rate. Supplemental oxygen may be gradually removed as the cyanosis resolves. However, if the cyanosis persists despite the administration of 100% oxygen, a trial of positive-pressure ventilation may be administered with bag and mask. Positive-pressure ventilation is also indicated for infants with persistent apnea or gasping respirations, despite brief tactile stimulation and for bradycardic infants whose heart rate is less than 100 beats per minute. The initial positive-pressure breaths often require higher inflation pressures to establish functional residual capacity. Subsequent breaths are delivered so that the infant receives the lowest inflation pressures necessary to produce adequate chest rise. Signs of effective ventilation are good chest movement, audible breath sounds, and rapid improvement in heart rate and color. Once positive-pressure ventilation is initiated, resuscitation should proceed with the use of 100% oxygen. A notable exception is the premature infant, for whom use of variable oxygen concentration between 21% and 100% may be used to maintain adequate oxygen saturation. If no appreciable improvement is observed within 90 seconds of initiating resuscitation with room air, supplemental oxygen should be provided.

Endotracheal Intubation: Endotracheal intubation is indicated when positive-pressure ventilation with bag and mask is ineffective or required for prolonged duration. Other indications include tracheal suctioning for meconium, continued chest compressions, endotracheal administration of medications, and special situations such as congenital diaphragmatic hernia and extreme prematurity. The infant should receive free-flow oxygen throughout the intubation in order to minimize hypoxia, and each attempt should be limited to less than 20 seconds duration. The best indication of successful endotracheal intubation is a prompt improvement in vital signs. Endotracheal placement should be confirmed by exhaled carbon dioxide (CO₂) detection. The most commonly used CO₂ detector is a colorimetric device that confirms placement by demonstrating a rapid change in detector color from violet to yellow. A false-negative result may occur in infants with decreased pulmonary blood flow or low cardiac output. Other clinical indicators such as condensed humidified gas within the endotracheal tube during exhalation and equal breath sounds on auscultation may be helpful but are not as reliable alone.

Meconium-Stained Amniotic Fluid: Meconium-stained amniotic fluid (MSAF) occurs in approximately 10% to 15% of all deliveries with increasing incidence as pregnancies extend beyond 42 weeks gestation. Of those infants born through MSAF, only 3% to 12% exhibit respiratory distress consistent with meconium aspiration syndrome (MAS). Up to 50% of infants who develop MAS will require intubation and mechanical ventilation. Evidence from multicenter, randomized controlled studies altered long-standing obstetric and neonatal practices, and now routine intrapartum oropharyngeal and nasopharyngeal suctioning of the hypopharynx before delivery of the infant’s shoulders is no longer advised because these practices did not reduce the incidence of MAS. Endotracheal intubation and direct tracheal suctioning of meconium is still recommended in the infant who appears depressed at birth or who subsequently develops respiratory distress after initial assessment. Visible meconium is removed by bulb suction or large-bore catheter suction. If endotracheal intubation is indicated, continuous suctioning by means of a meconium aspirator should be applied as the tube is gradually removed. Repeat intubation and suctioning is recommended until no further meconium is recovered or until “significant bradycardia” indicates that resuscitation must proceed.

Chest Compressions: Chest compressions are indicated in any infant whose heart rate remains less than 60 beats per minute despite a minimum of 30 seconds of adequate ventilation. The lower third of the sternum is compressed a relative depth of approximately one-third of the anterior-posterior diameter of the chest with two-thumb encircling hand technique. Alternatively, a two-finger technique may be preferable during attempts at umbilical catheterization for intravenous access. Chest compressions are coordinated with assisted ventilation in a 3 : 1 ratio so that the infant receives 90 compressions for every 30 breaths. The heart rate is periodically reassessed by either palpating pulsations at the base of the umbilical cord or by auscultation of the infant’s precordium. Once the heart rate exceeds 60 beats per minute, chest compressions may be discontinued. Positive-pressure ventilation then continues at a faster rate of 40 to 60 breaths per minute until the infant’s heart rate exceeds 100 beats per minute and spontaneous respirations occur. If the heart rate remains less than 60 beats per minute despite coordinated ventilation–chest compression, administration of epinephrine is indicated.

Resuscitative Medications: Only a small minority of infants require resuscitative medications. The medications available for use in the delivery room are epinephrine, volume expanders, naloxone, and sodium bicarbonate. Although the intratracheal route is the most accessible route, intravenous administration via the umbilical vein is the preferred route of drug administration. Alternatively, peripheral venous cannulation may be attempted. If intravenous access cannot be obtained, intraosseous administration is an acceptable alternative.

Epinephrine should be administered if the infant’s heart rate remains less than 60 beats per minute despite adequate coordinated ventilation and chest compressions of at least 30 seconds’ duration. The recommended dose is 0.01 to 0.03 mg/kg of a 1 : 10,000 solution infused intravenously as quickly as possible followed by a 0.5 to 1 mL flush of normal saline. A larger dose (0.05 to 0.1 mg/kg) may be given via the intratracheal route while intravenous access is attempted. Repeat doses of epinephrine should be administered intravenously as necessary on a 3- to 5-minute interval.

In the setting of acute blood loss or shock, isotonic crystalloid solution (i.e., normal saline or Ringer’s lactate) is indicated for volume expansion. Albumin should not be used as a volume expander because equally efficacious alternatives are available. The recommended dose is 10 mL/kg infused intravenously or intraosseously over 5 to 10 minutes duration. However, rapid infusions of volume expanders should be avoided in premature infants given its association with intraventricular hemorrhage. Additional doses may be necessary depending on degree of suspected blood loss. If large blood loss is anticipated, O Rh-negative packed red blood cells may also be considered.

Rarely, other medications such as a narcotic antagonist, buffer, or vasopressor may be useful following initial resuscitation. However, these medications are not recommended for use in the delivery room.