Neonatal Resuscitation (NRP 9th Edition)

Most newborns start breathing on their own. The ones who need help usually are not breathing, are gasping, or are breathing ineffectively. The NRP sequence runs on one rule: fix ventilation first. Add compressions next, then drugs, and only if the heart rate stays low. The 2025 AHA Guidelines for CPR and ECC, Part 5 follows the same sequence. Every dose on this page is for the neonatal period.

Care starts before birth. The 2025 AHA-AAP newborn chain of care covers antenatal risk recognition, team and family preparation and follow-up. The delivery room is only part of it.

Why Newborns Are Different

• Heart rate is the main escalation signal: an awake term neonate normally runs 100–205/min. Under 100/min after the first steps means PPV. Under 60/min after effective ventilation means compressions. Blood pressure does not trigger anything in the delivery room.
• Low SpO₂ is expected early: saturations climb over the first 10 minutes. Use the pre-ductal (right-hand) probe and the minute-by-minute targets in High-Quality CPR.
• The airway is small and short: the trachea is about 4 cm long in term neonates. A small movement changes tube depth.
• Doses are per kilogram and concentration-sensitive: epinephrine for IV/UVC use is 0.1 mg/mL. The intramuscular product is 1 mg/mL, tenfold stronger.
• Access is limited: the intravascular route is an umbilical venous catheter (UVC) or an intraosseous (IO) line. UVC placement is limited to trained staff.

Recognition answers two questions. Does this newborn need help right now? Is it responding? Use measured values, and the same heart-rate threshold at every step.

Assessment Points

• Weight: the measured birth weight is the one to use. No scale reading? Use the NRP weight chart by gestational age. Write the weight you used on every dose.
• Gestation: gestational age sets the starting oxygen concentration, the PIP range and the tube size. See High-Quality CPR and Equipment and Special Populations.
• Heart rate: watch it continuously with ECG or pulse oximetry whenever you intervene and whenever you stabilize a preterm infant.
• Response: reassess heart rate, chest rise and SpO₂ after each intervention. Don't wait for a fixed number of steps.

In a newborn the order is ventilation, then oxygenation, then compressions. Compressions come in only when the heart rate stays low after effective ventilation.

Initial Care and Ventilation

1. Cord management: wait at least 60 seconds before clamping in most newborns, and keep the baby warm while the cord is still attached. For preterm cord care and cord milking, follow the neonatal team's guidance.
2. Warm, dry and stimulate: keep the newborn warm and dry, and open the airway (position; suction only if it is obstructed). Skip routine oral, nasal or tracheal suctioning, whether the fluid is clear or meconium-stained (2025 AHA Guidelines for CPR and ECC, Part 5, COR 3: No Benefit, LOE B-R). Infants under 32 weeks: place in a plastic bag or wrap.
3. Start PPV for apnea, gasping or a heart rate under 100/min after the first steps, within the first minute when needed. Ventilate at 30–60 inflations/min with an inflation time of 0.5–1 s (AHA 2025 Part 5, COR 2a). Start with a peak inflation pressure of 25 cm H₂O, PEEP 5 cm H₂O. AHA 2025 calls an initial PIP of 20–30 cm H₂O reasonable (COR 2a) and says PEEP may be reasonable (COR 2b). The NRP acceptable PIP range is 20–25 cm H₂O under 32 weeks and 25–30 cm H₂O at 32 weeks or more. Titrate to chest rise and heart rate. Avoid excessive pressure (COR 3: Harm).
4. Check the response: look for chest rise. If there is none, correct the mask seal, reposition the head, suction, open the mouth and increase pressure (MR SOPA sequence).
5. Airway device: a supraglottic airway may be considered as the primary ventilation interface in place of a face mask, with training. 2025 AHA Guidelines for CPR and ECC, Part 5 gives a laryngeal mask as a reasonable alternative when face-mask ventilation is unsuccessful in newborns of 34 weeks or more (COR 2a, LOE C-LD), and as a reasonable primary interface at that gestation (COR 2b, LOE C-LD). AHA sets no weight limit, though many manufacturers state 2 kg. Video laryngoscopy is suggested for intubation where you have it and staff are trained. The tube depth mark sits at the anterior edge of the upper gum at the midline (tip-to-gum). That replaces the older tip-to-lip reference. Depth depends on gestational age and weight (NRP chart).

Chest Compressions

• When: only after at least 30 seconds of effective ventilation, and only if the heart rate is still under 60/min (COR 1, LOE C-EO).
• Technique: two-thumb-encircling-hands technique, which is preferred (COR 2b, LOE C-LD), compressing the lower one third of the sternum, just above the xiphoid process to protect the liver (COR 2b, LOE C-LD).
• Depth: one third of the anterior-posterior chest diameter (COR 2b, LOE C-LD), with full recoil between compressions.
• Ratio: 3 compressions to 1 breath (COR 2b, LOE C-LD), about 90 compressions and 30 breaths per minute. Pause compressions only briefly for each breath.
• Oxygen and monitoring: FiO₂ 100% may be reasonable during compressions (COR 2b, LOE C-EO). Once compressions stop, titrate to the saturation target. Use an endotracheal tube during compressions where possible (COR 1), and watch heart rate on ECG (COR 1, LOE C-EO).

Initial FiO₂ by Gestational Age

Pre-Ductal SpO₂ Targets

These numbers come from the targeted oxygen saturation table in the 2025 AHA Guidelines for CPR and ECC, Part 5 neonatal algorithm. The table starts at 2 minutes. There is no 1-minute target.

1. Initial steps (first 30 seconds): warm, dry, stimulate, position, and clear the airway only if needed. Assess breathing, heart rate and tone.
2. Ventilate when needed: start PPV within the first minute for apnea, gasping or a heart rate under 100/min, and monitor SpO₂ during ventilation. For labored breathing or persistent cyanosis, use SpO₂ monitoring and give oxygen or CPAP as the algorithm directs.
3. Reassess after 30 seconds of effective PPV (chest rise and heart rate). If the heart rate is still under 60/min, start chest compressions with ventilation at a ratio of 3:1, about 90 compressions and 30 breaths per minute (two-thumb-encircling-hands technique). FiO₂ may be raised to 100% (AHA 2025 Part 5, COR 2b).
4. Airway: if PPV does not work, check the MR SOPA steps, then place a supraglottic airway or endotracheal tube (depth at the gum; see High-Quality CPR). Use video laryngoscopy where available. Confirm placement and recheck depth after every move. During compressions, ventilate through an endotracheal tube (COR 1); if that is not possible or is unsuccessful, a laryngeal mask may be a reasonable alternative at 34 weeks or more (COR 2b, LOE C-EO).
5. At 60 seconds of compressions with effective ventilation: if the heart rate is still under 60/min, give epinephrine (Medications & Dosing) intravascularly, through the umbilical venous catheter or IO route (COR 1, LOE B-NR).
6. Repeat: repeat epinephrine every 3–5 minutes while the heart rate stays under 60/min. Look for reversible causes at each reassessment.
7. Stop compressions: when the heart rate is 60/min or more; continue PPV until the newborn breathes spontaneously or the heart rate is stable.

Keep ventilating and compressing, and treat the cause at the same time. The clues below point you to it. Doses live in Medications & Dosing.

Neonatal Resuscitation Drugs

Naloxone has no role in neonatal resuscitation (see Special Populations).

The first hour after a resuscitation is when the cause can come back. Keep the monitoring tight, and the handoff too.

• Call the neonatal team early for any newborn who needed PPV, compressions or epinephrine.
• Stopping: if every step has been completed effectively and no heart rate is detected by 20 minutes, the team and family may discuss redirection of care (2025 AHA Guidelines for CPR and ECC, Part 5).
• Document the times of PPV start, compressions, each epinephrine dose and the FiO₂ used.

Preterm Infants

• Use the lower initial FiO₂ range for 32–34 weeks and the 30% to 100% range under 32 weeks (High-Quality CPR table).
• Start with a PIP of 25 cm H₂O. Under 32 weeks the NRP acceptable range is 20–25 cm H₂O, so titrate to chest rise and heart rate. Don't work up to the 32-week-or-more range.
• Keep warm: place in a plastic bag or wrap under 32 weeks, and use heated, humidified gases where available.
• Cord management is individualized. Follow the neonatal team's guidance.
• Use the NRP chart for tube size and depth, and follow your protocol for cuffed or uncuffed tubes.

Newborns with Maternal Opioid Exposure

• Ventilation is the treatment: PPV is what supports breathing in apnea or poor respiratory effort.
• Naloxone is not part of neonatal resuscitation. The 2025 AHA Guidelines for CPR and ECC, Part 5 does not list naloxone among neonatal resuscitation drugs. In a newborn of an opioid-dependent mother, it can precipitate seizures or abrupt withdrawal. Later use is a NICU or medical-direction decision.

Congenital Heart Disease

• A pre- to post-ductal SpO₂ difference of more than 3% is a CCHD screening finding that needs evaluation. Screening happens after the newborn has stabilized, usually at 24 hours of age or later. It is not a delivery-room trigger.
• Low SpO₂ after stabilization also needs evaluation. Ductal-dependent lesions can get worse as the ductus closes, so bring in the neonatal team early.

• Equipment: neonatal bag and mask, a supraglottic airway in the neonatal size range, pre-drawn or colour-coded epinephrine at 0.1 mg/mL, and dextrose 10%.
• Warmth: keep the newborn warm for the whole transport. Heat loss is rapid.
• Destination: a neonatal or pediatric-capable receiving facility, per regional system protocol.
• Handoff: give a structured handoff, such as IMIST-AMBO or MIST, with gestational age, birth weight, Apgar scores and every drug dose and time.