Critical care Topic

Ventilate the newborn first.

Newborn resuscitation (2025 AHA/AAP): cord by gestational age, warmth, ventilation and corrective steps, starting oxygen, SpO₂ by minute, compressions, epinephrine and volume doses, cooling, stopping.

Reviewed October 2026 · verify against current guidelines

Newborn resuscitation · 1 of 6

Get ready before the baby arrives.

What matters most

Most newborns do not need resuscitation. They can be assessed during at least 60 seconds of deferred cord clamping and stay skin-to-skin with a parent. For the ones who do need help, the 2025 AHA/AAP guideline is blunt: effective ventilation of the lungs, shown by a rising heart rate, is the priority. Everything else supports that. For the clock, SpO₂ targets and an event log in the room, open the delivery-room companion.

Not a course — this is an independent summary in our own words. It is not an AHA or AAP product, is not endorsed by either, and does not replace certified AHA/AAP neonatal resuscitation training or your unit's protocols.

Before every birth (all Class 1)

One person for the baby	At least 1 person at every birth whose only job is the newborn (LOE B-NR).
Risk assessment	A standardized perinatal risk assessment, used to assemble a team matched to that risk (LOE B-NR).
Equipment check	A standardized checklist confirms that supplies and equipment are present and working (LOE C-LD).
Team briefing	When a high-risk birth is expected, brief the team before birth. Name the likely interventions and assign roles (LOE C-LD).

A 60-second briefing

Gestational age, fluid, and the risk factors that brought you here.
The cord plan: defer, milk, or clamp now. It depends on gestational age (section 2).
Starting oxygen concentration for this gestation (section 4).
Roles: who ventilates, who assesses heart rate and places the oximeter and monitor, who records, who gets vascular access.
The escalation line: who you call if you need an alternative airway or compressions.

Newborn resuscitation · 2 of 6

Manage the cord. Keep them warm.

Umbilical cord by gestational age

Term, no immediate resuscitation	Deferred clamping for at least 60 seconds can be beneficial compared with immediate clamping (Class 2a, LOE B-R).
Term, vigorous	Whether intact cord milking is better or worse than deferred clamping is uncertain (Class 2b, LOE C-LD).
Nonvigorous, 35 weeks or more	Intact cord milking may be reasonable compared with immediate clamping (Class 2b, LOE B-R). New in 2025.
Preterm (under 37 weeks), no immediate resuscitation	Deferred clamping for at least 60 seconds is recommended (Class 1, LOE A).
28⁺⁰ to 36⁺⁶ weeks	If deferred clamping can't be done, intact cord milking may be reasonable (Class 2b, LOE B-R).
Under 28⁺⁰ weeks	Do not milk the intact cord (Class 3: Harm, LOE B-R).

Changed — the 2025 guideline sets a 60-second minimum for deferred clamping at all gestations. The NRP 8th edition, as summarized by the Canadian Paediatric Society, taught at least 30 to 60 seconds for vigorous preterm infants.

Initial steps and temperature

First look	Quick look: born at term, moving with good tone, crying or breathing well? If so, the baby stays with the parent, skin-to-skin, kept warm and watched.
Otherwise	Otherwise, to the warmer: dry and warm, open the airway, stimulate. Clear the airway only if it needs it.
Target	36.5–37.5 °C from birth through admission and stabilization (Class 1, LOE B-NR).
Avoid both extremes	Prevent hypothermia (below 36 °C) and hyperthermia (above 38 °C). Both are Class 1, LOE B-NR.
Preterm warming	Radiant warmer, plastic bag or wrap with a cap, a warmer room, and warmed humidified inspired gases, alone or combined (Class 2a, LOE B-R). The evidence supports an ambient temperature of 23 °C or higher. An exothermic mattress may be considered (Class 2b, LOE B-R).
Stacking methods	Combining warming methods may be reasonable but can cause hyperthermia (Class 2b, LOE B-NR). Measure the temperature.
Skin-to-skin	Effective for keeping well newborns warm (Class 2a, LOE C-LD).
Stimulation	Tactile stimulation can help newborns with ineffective breathing effort (Class 2a, LOE C-LD).
Suction	No routine suctioning, whether the fluid is clear or meconium-stained (Class 3: No Benefit, LOE B-R). Suction the mouth and nose if ventilation is needed and the airway looks obstructed (Class 2a, LOE C-EO). Intubate and suction the trachea for evidence of tracheal obstruction (Class 2a, LOE C-EO).

Newborn resuscitation · 3 of 6

Ventilate within 60 seconds.

Heart rate and breathing

Start ventilation	Within 60 seconds of birth if the baby is gasping or apneic, or if the heart rate stays below 100/min despite initial steps (Class 1, LOE B-NR).
Heart rate, routine	ECG is useful for fast, accurate heart rate (Class 2a, LOE B-NR). Listening with a stethoscope and pulse oximetry are reasonable alternatives (Class 2a, LOE C-LD).
Heart rate during compressions	Use ECG (Class 1, LOE C-EO).
Is it working?	A rising heart rate is the sign of effective ventilation. Watch for chest movement with each breath.

Ventilation settings

Peak inflation pressure	Start at 20–30 cm H₂O, then adjust to what ventilates (Class 2a, LOE C-LD). Avoid excessive pressure and high tidal volumes (Class 3: Harm, LOE C-LD).
PEEP	May be reasonable (Class 2b, LOE C-LD). The guideline gives no number.
Rate	30–60 inflations/min (Class 2a, LOE C-LD).
Inflation time	Start with 0.5–1 second (Class 2a, LOE C-LD).
Sustained inflation	Do not routinely use inflations longer than 5 seconds under 28 weeks (Class 3: Harm, LOE B-R).
Device	A T-piece resuscitator can be better than a self-inflating bag, especially for preterm infants (Class 2a, LOE B-R).

Heart rate not rising? Corrective steps (Class 2a, LOE C-LD)

Reposition	Reposition the airway.
Mask	Adjust the mask, or switch to a 2-handed hold.
Suction	Clear the mouth and nose.
Pressure	Raise the peak inflation pressure.
Alternative airway	Laryngeal mask or endotracheal tube. Video laryngoscopy can help with intubation (Class 2a, LOE B-R). New in 2025.

Airway and breathing support

Laryngeal mask, rescue	Reasonable instead of intubation when face-mask ventilation fails, at 34⁺⁰ weeks or more (Class 2a, LOE C-LD). New in 2025.
Laryngeal mask, first choice	May be reasonable instead of a face mask, at 34⁺⁰ weeks or more (Class 2b, LOE C-LD). New in 2025.
CPAP, preterm under 34 weeks	For spontaneously breathing preterm infants who need support, CPAP is reasonable instead of intubation and mechanical ventilation (Class 2a, LOE A). High-flow nasal cannula versus CPAP is unproven (Class 2b). At 34 weeks or more, see the next row.
CPAP, 34 weeks or more	Its usefulness for spontaneously breathing infants with or at risk of respiratory distress is not well established (Class 2b, LOE C-LD).

Changed — the 2025 guideline widened the rate to 30–60/min and the starting pressure to 20–30 cm H₂O. The NRP 8th edition, as summarized by the Canadian Paediatric Society, used 40–60 breaths/min and 20–25 cm H₂O.

Newborn resuscitation · 4 of 6

Titrate oxygen to the minute.

Starting oxygen by gestational age (all Class 2b, LOE C-LD)

35 weeks or more	21% (air).
32⁺⁰ to 34⁺⁶ weeks	21–30%.
Under 32 weeks	30–100%. Updated in 2025: in the pooled evidence, starting at 90–100% was linked to lower mortality than 21–30%. Titrate down as targets are reached.
For everyone	Titrate to the SpO₂ targets (Class 1, LOE C-EO). Place a pulse oximeter as soon as possible on any newborn receiving respiratory support (Class 1, LOE C-LD; new). Put the probe preductal, on the right hand or wrist.

Preductal SpO₂ targets after birth

2 min	65–70%
3 min	70–75%
4 min	75–80%
5 min	80–85%
10 min	85–95%

Changed — the 2025 table starts at 2 minutes. The AHA notes that a reading at 1 minute won't routinely be available. The NRP 8th edition table, as summarized by the Canadian Paediatric Society, also listed 60–65% at 1 minute. Not reaching 80% by 5 minutes has been associated with death.

SpO₂ oxygen saturation by pulse oximetryPEEP positive end-expiratory pressureCPAP continuous positive airway pressureCOR / LOE class of recommendation / level of evidence

Newborn resuscitation · 5 of 6

Compress only after ventilation fails.

Chest compressions

Trigger	Heart rate below 60/min despite 30 seconds of ventilation (Class 1, LOE C-EO). The guideline's summary describes that ventilation as moving the chest, preferably through an alternative airway (endotracheal tube or laryngeal mask). Its take-home message adds that the corrective steps should preferably include intubation.
Airway	Ventilate through an endotracheal tube during compressions (Class 1, LOE C-EO). A laryngeal mask may be reasonable at 34 weeks or more if a tube can't be placed (Class 2b, LOE C-EO).
Oxygen	100% during compressions may be reasonable (Class 2b, LOE C-EO).
Ratio	3 compressions to 1 inflation, coordinated: about 90 compressions and 30 inflations each minute (Class 2b, LOE C-LD).
Technique	Two thumbs with hands encircling the chest (Class 2b, LOE C-LD).
Where and how deep	Over the lower third of the sternum, above the xiphoid (new), to one third of the chest's front-to-back depth. Both are Class 2b, LOE C-LD.
Rotate	Change compressors every 2–5 minutes (Class 2b, LOE C-LD). New in 2025.
Monitor	ECG for heart rate (Class 1, LOE C-EO).

Access and epinephrine (§14–15)

When	Heart rate still below 60/min after ventilation with 100% oxygen (preferably through an alternative airway) and compressions. The guideline's summary puts it at 60 seconds of compressions with adequate ventilation.
Access	Umbilical venous catheter (Class 1, LOE C-LD). Intraosseous if IV access fails or isn't feasible (Class 2a, LOE C-LD). IO devices can cause fractures, extravasation with compartment syndrome, and tissue necrosis.
IV/IO dose	0.01–0.03 mg/kg (Class 1, LOE B-NR), then a 3 mL normal saline flush at any birth weight.
Endotracheal dose	0.05–0.1 mg/kg, while vascular access is being obtained, not as a substitute for it (Class 2a, LOE C-LD).
After an ET dose	If the response is inadequate, give intravascular epinephrine as soon as access is obtained, regardless of the dosing interval (Class 2a, LOE B-NR).
Repeat	Every 3–5 minutes, preferably intravascularly, while the heart rate stays below 60/min (Class 2b, LOE C-LD). Repeated ET doses or higher IV doses can produce harmful plasma levels, with hypertension and tachycardia.

Volume expansion (§16, both Class 2b, LOE C-EO)

Who	Evidence of hypovolemia on history and exam (pale, weak pulses) and heart rate still below 60/min despite ventilation, compressions and epinephrine.
What and how much	Normal saline (0.9% sodium chloride) or blood, 10–20 mL/kg. Give it as a steady infusion over 5–10 minutes, and repeat if the response is inadequate.
Blood	For major blood loss, give O Rh-negative blood without waiting for a crossmatch, or crossmatched blood if it's already on hand.
Route	Umbilical line; intraosseous is the alternative.
Also think	Tension pneumothorax needing needle drainage.

Doses are in mg/kg, not mL — Part 5 names no epinephrine concentration. Check the concentration you have before converting to mL, and have the dose drawn up by weight before the birth when you can. The companion shows mg only.

Newborn resuscitation · 6 of 6

After the code, and when to stop.

After stabilization (§17)

Monitor	Watch breathing effort and oxygenation, heart rate, temperature and blood glucose. The guideline names respiratory compromise, hypoglycemia and hypothermia among the transitional problems to expect.
Glucose	After prolonged ventilation or advanced resuscitation (intubation, compressions or epinephrine), check glucose early and keep checking until it stays in the normal range (Class 1, LOE B-NR).
Cooling	Over 36 weeks with moderate-to-severe HIE: offer therapeutic hypothermia under clearly defined protocols (Class 1, LOE A). The target is 33.5–34.5 °C, started within 6 hours of birth, for 72 hours. Under 36 weeks it has not shown benefit and may cause harm.
Rewarming	Unintentionally below 36 °C after resuscitation: rewarm (Class 1, LOE C-LD). The best rate is unknown; fast (0.5 °C/h) and slow rewarming had similar outcomes.
Temperature	Otherwise keep 36.5–37.5 °C through admission and stabilization.
People	Talk with the family, and debrief the team.

Withholding and stopping (§18)

No heart rate	If there is no heart rate and all the steps of resuscitation have been performed, discuss stopping with the team and the family. Around 20 minutes after birth is a reasonable time frame for that change in goals (Class 1, LOE C-LD).
Ethics	Not starting resuscitation and stopping life-sustaining treatment during or after it are ethically equivalent (Class 1, LOE C-EO).
Before birth	For a condition likely to cause early death or severe morbidity, not starting or limiting resuscitation is reasonable after consultation and shared decision-making with the family (Class 2a, LOE C-EO).
Check first	Were the steps truly done? Chest moving, alternative airway, 100% oxygen, coordinated compressions, intravascular epinephrine, hypovolemia and pneumothorax considered.

Common errors

Starting compressions before ventilation works. The trigger is 30 seconds of ventilation that moves the chest.
Treating a slow heart rate with oxygen instead of ventilation.
Starting a term baby on 100% oxygen. Start on air, then titrate.
Chasing 90s at 3 minutes. The target then is 70–75%.
Routine suctioning, including for meconium.
Repeating endotracheal epinephrine instead of getting umbilical venous access.
Converting mg to mL without checking the concentration in your hand.
Milking the intact cord under 28 weeks.
Sustained inflations over 5 seconds in a baby under 28 weeks, or too much pressure at any age.
Letting the temperature drift, or stacking warmers until the baby overheats.
Relying on auscultation during compressions. Put on ECG leads.

What's new or updated in 2025

Cord	60-second minimum for deferred clamping. Intact cord milking for nonvigorous babies at 35 weeks or more.
Ventilation	Pressure 20–30 cm H₂O. Rate 30–60/min. Video laryngoscopy. Laryngeal mask as rescue or first interface at 34⁺⁰ weeks or more.
Oxygen	30–100% to start under 32 weeks. Oximeter on as soon as possible. SpO₂ table starts at 2 minutes.
Compressions	Lower third of the sternum. Rotate compressors every 2–5 minutes.

ECG electrocardiogramIV / IO intravenous / intraosseousAHA / AAP American Heart Association / American Academy of PediatricsNRP Neonatal Resuscitation Program (AAP)HIE hypoxic-ischemic encephalopathy

Educational reference only — not medical advice. Verify against current AHA/AAP guidelines and local protocol.

Sources

Verify against current guidelines and local protocol before acting.

Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2025;152(16 Suppl 2):S385-S423. Published October 22, 2025. doi:10.1161/CIR.0000000000001367. Co-published in Pediatrics 2026;157(1):e2025074352. doi:10.1542/peds.2025-074352. Online text: cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation (§7 anticipation, §8 cord, §9 initial steps, §10 heart rate, §11 ventilation, §12 oxygen, §13 compressions, §14 vascular access, §15 epinephrine, §16 volume expansion, §17 postresuscitation care, §18 withholding and discontinuing).
American Heart Association and American Academy of Pediatrics. 2025 Neonatal Resuscitation Algorithm (cpr.heart.org, 2025). Source for the SpO₂ target table.
American Heart Association. Highlights of the 2025 American Heart Association Guidelines for CPR and ECC (cpr.heart.org, 2025). Source for which neonatal recommendations are new or updated.
Canadian Paediatric Society. NRP 9th Edition: Canadian Practice Changes (July 2026). Used only for the earlier (8th edition) values quoted in the “changed from 2020” notes.
Equipment sizes and epinephrine concentration: use your unit's current neonatal references, checked before the birth.