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Summary Table

Category	Details
Risk Factors	Prematurity (<37 weeks), meconium-stained amniotic fluid (MSAF), maternal chorioamnionitis, prolonged rupture of membranes, placental abruption, cord prolapse, fetal bradycardia, maternal sedation/general anesthesia, oligohydramnios, multiple gestations, congenital anomalies
Etiology	Failure of fetal-to-neonatal cardiopulmonary transition. The underlying mechanism is nearly always respiratory failure (not primary cardiac arrest as in adults)
Patient Presentation	Apneic or gasping newborn, cyanosis, poor tone, HR <100 bpm, failure to cry at birth
Classic Physical Exam	Flaccid tone, absent or weak respiratory effort, central cyanosis, bradycardia (<100 bpm on auscultation or ECG), pale/mottled skin
Key Diagnostic Results	Pre-ductal $SpO_2$ below target range for minute of life; HR <100 bpm by pulse oximetry or ECG; cord or arterial pH <7.0, base deficit $\geq$ 12 mmol/L (indicates perinatal asphyxia); Apgar score $\leq$ 5 at 5 and 10 minutes
Management	Warm, dry, stimulate, position airway; positive-pressure ventilation (PPV) with T-piece resuscitator; MR SOPA corrective steps; chest compressions (3:1 ratio) if HR <60 bpm; epinephrine 0.01-0.03 mg/kg IV/IO (preferred) or 0.05-0.1 mg/kg ET; volume expansion with NS 10 mL/kg; post-resuscitation monitoring; therapeutic hypothermia if HIE criteria met
Keywords	"Golden Minute," "apneic at birth," "HR below 60 despite adequate ventilation," "MR SOPA," "3:1 compression-to-ventilation ratio," "deferred cord clamping," "T-piece resuscitator," "two-thumb encircling hands technique," "umbilical venous catheter"

1. Pathophysiology

The central concept in neonatal resuscitation is the understanding that neonatal cardiac arrest is almost always a consequence of respiratory failure, not a primary cardiac event. This is the single most important distinction from adult resuscitation and the reason why the entire algorithm prioritizes establishing effective ventilation above all else.

In utero, gas exchange occurs at the placenta. The fetal lungs are fluid-filled, pulmonary vascular resistance (PVR) is high, and most right ventricular output bypasses the lungs via the ductus arteriosus and the foramen ovale. At birth, a sequence of physiological events must occur for successful transition: the infant takes its first breath, the alveoli expand and clear fluid, PVR drops, pulmonary blood flow increases, left atrial pressure rises (closing the foramen ovale functionally), and the ductus arteriosus begins to constrict. Oxygen saturation rises gradually over the first 10 minutes of life.

When this transition fails, the alveoli remain fluid-filled or atelectatic, PVR stays elevated, and right-to-left shunting persists through fetal channels. The result is progressive hypoxemia and hypercapnia, leading to a period of primary apnea (responsive to stimulation), and if unresolved, secondary apnea (unresponsive to stimulation, requiring PPV). As hypoxia deepens, myocardial oxygen delivery falls, causing bradycardia and eventually asystole. This is why a rising heart rate is the single most reliable indicator that resuscitation efforts are working.

A key pathophysiological principle: because the problem originates in the lungs, effective ventilation alone resolves the vast majority of neonatal resuscitation scenarios. Approximately 85% of term newborns transition without any intervention, about 10% require some degree of stimulation and drying, roughly 5% need PPV, and fewer than 1% require chest compressions or medications.

2. Classification and Clinical Manifestation

Stage	Mechanism	Response to Stimulation	Heart Rate	Muscle Tone	Clinical Implication
Primary Apnea	Initial cessation of breathing after hypoxic insult; brainstem still functional	Responds to tactile stimulation	Decreased but usually >100 bpm initially	Decreased but present	Warming, drying, and gentle stimulation may be sufficient
Secondary Apnea	Prolonged hypoxia leads to brainstem depression; spontaneous breathing will not resume without intervention	Does NOT respond to stimulation	<100 bpm, falling toward <60 bpm	Flaccid	Requires PPV; will not recover spontaneously

At birth, you cannot reliably distinguish primary from secondary apnea. Therefore, if an infant does not respond to brief stimulation within the initial steps, you must assume secondary apnea and begin PPV immediately.

Rapid Assessment at Birth (Three Questions)

Question	"Yes" to All Three	"No" to Any One
Term gestation?	Infant stays with mother for routine care: dry, skin-to-skin, cover with warm linen	Move to radiant warmer, begin initial resuscitation steps
Good muscle tone?
Breathing or crying?

Target Pre-ductal $SpO_2$ by Minute of Life

Minute of Life	Target $SpO_2$
1 minute	60-65%
2 minutes	65-70%
3 minutes	70-75%
4 minutes	75-80%
5 minutes	80-85%
10 minutes	85-95%

These values reflect the normal gradual rise in oxygen saturation after birth. Pulse oximetry is placed on the right hand or wrist (pre-ductal) to guide oxygen titration.

3. Diagnostic Workup

Assessment	Purpose	Timing	Notes
Rapid Assessment (3 questions)	Determines need for resuscitation vs. routine care	Immediately at birth	Screening step; drives the first decision point
Heart Rate (auscultation)	Initial HR assessment	Within first 30 seconds	Best initial method; stethoscope on precordium
Heart Rate (ECG)	Continuous, accurate HR monitoring	As soon as resuscitation is needed	2025 guidelines more strongly endorse early ECG use when resuscitation is required; faster and more accurate than pulse oximetry for HR
Pulse oximetry ($SpO_2$)	Guides oxygen titration	Applied as soon as PPV is initiated	Pre-ductal (right wrist); not reliable for HR in first minutes
Apgar Score	Retrospective assessment of transition	1 minute, 5 minutes, then every 5 minutes if score <7	Does NOT guide resuscitation decisions; it is a documentation tool
Arterial/cord blood gas	Assesses severity of acidosis post-event	Post-resuscitation	pH <7.0 and/or base deficit $\geq$ 12 help identify HIE candidates

The best initial assessment is the rapid evaluation using the three birth questions combined with auscultation of the heart rate. This determines whether the infant proceeds to routine care or to the radiant warmer for intervention.

The 2025 guidelines place greater emphasis on electrocardiography (ECG) as the preferred method for continuous heart rate monitoring during active resuscitation. Pulse oximetry remains valuable for oxygen saturation monitoring, but its heart rate readings can lag or be unreliable during the first minutes of life due to poor perfusion. ECG provides a faster, more accurate heart rate readout during the critical window when clinical decisions depend on knowing whether HR is above or below 60 bpm.

The Apgar score is a commonly tested concept, but it is important to understand that the Apgar score is not used to make real-time resuscitation decisions. It is recorded at 1 and 5 minutes and serves as a retrospective summary of the infant's condition. An Apgar score of 0-3 at 5 or 10 minutes correlates with poorer outcomes, but the resuscitation algorithm is driven by heart rate and respiratory effort, not by the Apgar score.

4. Management and Treatment

Step	Intervention	Trigger/Indication	Key Details
Step 0	Pre-delivery team huddle	All high-risk deliveries	Assign roles: airway, compressions, medications, documentation. Equipment check.
Step 1	Initial steps	"No" to any rapid assessment question	Warm (radiant warmer), position airway (neutral/sniffing), dry, stimulate, clear secretions only if copious/obstructive. Complete within 30-60 seconds.
Step 2	Positive-Pressure Ventilation (PPV)	Apneic/gasping OR HR <100 bpm after initial steps	T-piece resuscitator preferred (2025). Rate 40-60 breaths/min. Initial PIP 20-25 cm $H_2O$ (term). Look for chest rise.
Step 3	MR SOPA corrective steps	Chest not rising with PPV	M: Mask adjustment; R: Reposition airway; S: Suction; O: Open mouth; P: Pressure increase; A: Alternative airway (supraglottic device or ETT)
Step 4	Alternative airway	PPV via mask fails after MR SOPA	Supraglottic airway (laryngeal mask) for infants $\geq$ 34 weeks; endotracheal intubation if supraglottic fails or infant <34 weeks
Step 5	Chest compressions	HR <60 bpm despite adequate ventilation (preferably via ETT/alternative airway)	Two-thumb encircling hands technique. Depth: 1/3 AP diameter of chest. 3:1 compression-to-ventilation ratio (90 compressions + 30 breaths = 120 events/min). Increase $FiO_2$ to 100% when compressions start.
Step 6	Epinephrine	HR <60 bpm despite adequate ventilation + chest compressions	IV/IO (preferred): 0.01-0.03 mg/kg of 1:10,000 solution. ET (while obtaining access): 0.05-0.1 mg/kg. Administer via low-lying UVC, flush with 0.5-1 mL NS. May repeat every 3-5 minutes.
Step 7	Volume expansion	Suspected hypovolemia (pale, poor perfusion, weak pulses, no response to resuscitation)	Normal saline 10 mL/kg IV over 5-10 minutes via UVC. May repeat.
Step 8	Post-resuscitation care	After ROSC or stabilization	Monitor glucose, temperature, cardiorespiratory status. Maintain normothermia. Consider therapeutic hypothermia if HIE criteria met.

Pre-Delivery Preparation (2025 Update). The 2025 guidelines introduce the concept of a Newborn Chain of Care and emphasize a mandatory pre-delivery team briefing ("huddle") before every high-risk delivery. This includes reviewing anticipated risk factors (prematurity, MSAF, fetal distress, maternal conditions), assigning team roles explicitly (who manages the airway, who does compressions, who draws up medications, who documents), and checking all equipment including the T-piece resuscitator, suction, oxygen blender, pulse oximetry, and ECG leads.

Delayed Cord Clamping. Deferred cord clamping for at least 60 seconds is recommended for term and preterm infants who do not require immediate resuscitation. Intact cord milking may be reasonable for infants at 28 to 36+6 weeks when delayed clamping is not possible, but should not be performed in infants under 28 weeks due to increased risk of intraventricular hemorrhage.

Initial Steps (The First 30-60 Seconds). Place the infant under a radiant warmer, position the head in a neutral or slight "sniffing" position, dry thoroughly with warm towels, provide brief tactile stimulation (flicking soles of feet or rubbing the back), and clear the airway only if secretions are copious or visibly obstructing. Routine suctioning is no longer recommended. Reassess after initial steps: is the infant breathing? What is the heart rate?

Positive-Pressure Ventilation. If the infant remains apneic, is gasping, or has HR <100 bpm, begin PPV immediately. The 2025 guidelines recommend the T-piece resuscitator as the preferred device for delivering PPV, replacing the self-inflating bag as the device of choice. T-piece resuscitators provide more consistent and precise pressure delivery with the ability to set both PIP and PEEP. Initial settings for a term infant are typically PIP 20-25 cm $H_2O$ with PEEP of 5 cm $H_2O$, at a rate of 40-60 breaths per minute.

Oxygen administration: For term infants ($\geq$ 35 weeks), begin PPV with 21% $FiO_2$ (room air) and titrate based on pre-ductal $SpO_2$ targets. For preterm infants (<35 weeks), start with 21-30% $FiO_2$ and titrate accordingly. If chest compressions are initiated, increase $FiO_2$ to 100% and wean after HR recovers.

MR SOPA Corrective Steps. If chest rise is not observed during PPV, systematically apply the MR SOPA sequence before escalating to an alternative airway:

Letter	Step	Action
M	Mask adjustment	Reapply mask, ensure proper size and seal (consider two-hand technique)
R	Reposition airway	Neutral or slight extension ("sniffing" position)
S	Suction	Suction mouth then nose (only if secretions are present)
O	Open mouth	Open the mouth and lift the jaw forward
P	Pressure increase	Increase PIP in increments of 5-10 cm $H_2O$ (max 40 cm $H_2O$)
A	Alternative airway	Supraglottic airway device ($\geq$ 34 weeks) or endotracheal intubation

Chest Compressions. If the heart rate remains <60 bpm after at least 30 seconds of effective ventilation (preferably via a secured airway such as ETT or supraglottic device), begin chest compressions. The recommended technique is the two-thumb encircling hands method, compressing the lower third of the sternum to a depth of one-third the anterior-posterior chest diameter. The ratio is 3 compressions to 1 ventilation breath (3:1), yielding approximately 90 compressions and 30 breaths per minute (120 total events/min). Increase $FiO_2$ to 100% when compressions begin.

Epinephrine. If HR remains <60 bpm despite effective ventilation and chest compressions, epinephrine is indicated. The umbilical venous route is the preferred intravascular access for epinephrine administration in the newborn. The IV/IO dose is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 concentration), followed by a normal saline flush of 0.5-1 mL. The endotracheal dose (used only while IV access is being established) is 0.05-0.1 mg/kg (0.5-1 mL/kg of 1:10,000). The dose may be repeated every 3-5 minutes. The intraosseous (IO) route may be considered when IV access is not feasible.

Volume Expansion. If the infant is not responding to resuscitation and hypovolemia is suspected (history of placental abruption, fetal-maternal hemorrhage, cord avulsion, pale skin, poor perfusion, weak pulses), administer isotonic crystalloid (normal saline) 10 mL/kg over 5-10 minutes via the umbilical venous catheter. Repeat if needed. O-negative packed RBCs may be used if blood loss is confirmed.

Post-Resuscitation Care. After successful resuscitation, monitor the infant closely for secondary deterioration. Key components include glucose monitoring (neonates post-asphyxia are at high risk for hypoglycemia), temperature management (maintain normothermia at 36.5-37.5 degrees Celsius), and cardiorespiratory monitoring. The 2025 guidelines provide greater emphasis on post-resuscitation care, including monitoring for hypoglycemia, neurologic injury, and respiratory instability, and appropriate use of therapeutic hypothermia in eligible infants.

Therapeutic Hypothermia. For term or near-term infants ($\geq$ 36 weeks) with moderate-to-severe hypoxic-ischemic encephalopathy (HIE), therapeutic hypothermia (target core temperature 33.5 degrees Celsius for 72 hours) should be initiated within 6 hours of birth. Cooling should begin under controlled NICU conditions, not during active resuscitation. Eligibility criteria typically include evidence of perinatal asphyxia (Apgar $\leq$ 5 at 10 minutes, cord pH <7.0, base deficit $\geq$ 12 mmol/L, or need for continued resuscitation at 10 minutes) plus clinical evidence of moderate or severe encephalopathy.

When to Stop. If all steps of resuscitation have been effectively completed and there is no detectable heart rate by 20 minutes, redirection of care may be discussed with the team and family.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Transient Tachypnea of the Newborn (TTN)	Respiratory distress at birth, tachypnea, may appear cyanotic	TTN presents with tachypnea (>60 breaths/min) in a term infant born by C-section with GOOD tone and adequate HR. Infant is breathing but tachypneic, not apneic. Self-resolves within 24-72 hours. CXR shows perihilar streaking and fluid in fissures.
Meconium Aspiration Syndrome (MAS)	Respiratory distress at birth, history of MSAF, may require PPV	MAS presents in a term/post-term infant with MSAF history who develops respiratory distress with barrel chest, coarse crackles. CXR shows patchy infiltrates and hyperinflation. The 2025 guidelines no longer recommend routine intubation and suctioning of non-vigorous infants born through MSAF; instead, begin PPV and suction only if airway is obstructed.
Congenital Diaphragmatic Hernia (CDH)	Respiratory distress at birth, cyanosis, may not respond to PPV	Scaphoid (flat/concave) abdomen, absent breath sounds on affected side (usually left), bowel sounds in chest, barrel chest contralaterally. Do NOT bag-mask ventilate (inflates the bowel in the chest); intubate immediately.
Pneumothorax	Cyanosis, poor response to PPV, bradycardia	Sudden deterioration during PPV, unilateral decreased breath sounds, distended hemithorax. Transillumination positive. Requires needle decompression.
Congenital Heart Disease (CHD)	Central cyanosis, may not improve with oxygen	Persistent cyanosis despite 100% $FiO_2$ (failed hyperoxia test, $PaO_2$ <100 mmHg on 100% $FiO_2$). May have murmur, differential saturations between pre- and post-ductal sites. Needs echocardiography. Responds to prostaglandin E1, not to more aggressive ventilation.
Neonatal Sepsis/Pneumonia	Poor tone, respiratory distress, apnea, cyanosis at birth	Risk factors include maternal GBS colonization, PROM >18 hours, maternal fever. CXR may show bilateral infiltrates. WBC count abnormal. Responds to antibiotics, not just ventilation alone.
Persistent Pulmonary Hypertension of the Newborn (PPHN)	Severe cyanosis, poor response to oxygen, pre-post ductal $SpO_2$ gradient	Pre-ductal to post-ductal $SpO_2$ difference >5-10%. Echo shows right-to-left shunting at PDA/PFO level. Responds to inhaled nitric oxide (iNO), not to epinephrine or more PPV.

6. Traps and High-Yield Pearls

The most common way students get questions on neonatal resuscitation wrong is by jumping to chest compressions or epinephrine before ensuring effective ventilation. The algorithm is designed sequentially, and the test rewards you for understanding that ventilation is the cornerstone of neonatal resuscitation. The majority of questions will test whether you can identify the correct next step when PPV is not working. The answer is almost never "start compressions" or "give epinephrine." The answer is to fix the ventilation first using MR SOPA corrective steps and then consider an alternative airway.

Another frequently tested trap involves the 3:1 compression-to-ventilation ratio. Students conditioned by adult ACLS (30:2) or pediatric BLS (15:2) often select the wrong ratio for neonates. The neonatal ratio is 3:1 because the underlying problem is respiratory, and the newborn myocardium recovers when oxygenation is restored.

The initial oxygen concentration is also a trap. Students may instinctively choose 100% $FiO_2$ for a distressed newborn, but the correct initial concentration is 21% (room air) for term infants and 21-30% for preterm infants. The only time 100% oxygen is used is when chest compressions are initiated.

The Apgar score is another point of confusion. Students sometimes believe a low Apgar score triggers a change in management. It does not. Resuscitation decisions are driven by heart rate and respiratory effort assessed in real time, not by the Apgar. The Apgar score is a retrospective documentation tool.

Watch for vignettes describing a newborn with a scaphoid abdomen and respiratory distress. This is congenital diaphragmatic hernia, and the critical teaching point is that bag-mask ventilation is contraindicated because it inflates the herniated bowel and worsens lung compression. The correct answer is immediate intubation and gastric decompression with an orogastric tube.

Finally, understand the epinephrine route hierarchy. The preferred route is IV via a low-lying umbilical venous catheter, not endotracheal. Endotracheal epinephrine has lower and delayed peak plasma concentrations and is used only as a temporizing measure while vascular access is being established. If a vignette asks for the best route, the answer is IV/UVC.

The core competency being tested across all neonatal resuscitation questions is the ability to execute a stepwise algorithm in the correct order: assess, warm/dry/stimulate, ventilate, fix ventilation if it is not working, compress, then medicate. Every step depends on the one before it having been performed correctly. Skipping ahead is the error the exam is designed to catch.

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