Neonatal Resuscitation

BJA Education, xxx(xxx): xxx (xxxx)
doi: 10.1016/j.bjae.2021.07.008
Advance Access Publication Date: XXX
Matrix codes: 1B04,

2B07, 3D00
Neonatal resuscitation: current evidence and

guidelines
E. Kariuki1, C. Sutton2 and T.A. Leone3,*
1
New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center,
New York, NY, USA, 2Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA and
3
Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Morgan Stanley
Children’s Hospital, New York, NY, USA
*Corresponding author: [email protected]
Keywords: infant; newborn; parturition; resuscitation
Learning objectives Key points

By reading this article, you should be able to: The unique physiology of transition from fetal to
Distinguish normal physiological changes from neonatal life informs resuscitation
pathological findings in a compromised newborn recommendations.
at the time of birth. Preparation is essential for teams and individuals
Describe the steps recommended for neonatal caring for newborn infants at the time of birth.
resuscitation at the time of birth. Ventilation is the most important intervention in
Explain the reasons for recent changes in neonatal resuscitation.
neonatal resuscitation recommendations.
make this transition without any significant medical in-
terventions. However, for those neonates who do need
Resuscitation at the time of birth is different from all other
assistance at birth, resuscitation guidelines emphasise prior-
forms of resuscitation because of the physiological transition
ities that account for these unique physiological circum-
from fetal to neonatal life. The vast majority of neonates will
stances.1 Table 1 provides a summary of current key
recommendations for neonatal resuscitation. The guidelines
also stress the importance of effective communication, pre-
Elizabeth Kariuki MD is a fellow in neonataleperinatal medicine at paredness and teamwork.
New York-Presbyterian Morgan Stanley Children’s Hospital, For the anaesthetist actively caring for a mother, one of the
Columbia University Irving Medical Center. Dr Kariuki is interested most dreaded quandaries is being called upon to lead the
in neonatal resuscitation and is currently performing both observa- resuscitation of her struggling neonate at the same time.
tional and interventional studies in newborn infants at the time of Multiple national and international practice guidelines
birth. strongly recommend that an anaesthetist caring for a mother
should not be responsible for neonatal resuscitation.1,2
Caitlin Sutton MD is assistant professor of paediatrics and chief of Despite this recommendation, survey data demonstrate that
the Division of Maternal-Fetal Anesthesia at Texas Children’s Hos- anaesthetists are commonly called upon to assist or lead
pital, Baylor School of Medicine. She trained in both paediatric and resuscitation of the newborn.3 Anaesthetists’ involvement in
obstetric anaesthesia, and brings a unique level of expertise to her neonatal resuscitation is unsurprisingly quite variable based
role. on the practice setting, with an increased likelihood of
involvement in hospitals with fewer deliveries.3
Tina Leone MD is associate professor of paediatrics and director of
Should the anaesthetist be asked to care for both a mother
the neonataleperinatal medicine programme at Columbia Univer-
and her neonate simultaneously, the anaesthetist’s first re-
sity Vagelos School of Medicine. She is a member of the Neonatal
sponsibility is to the mother, and the first step should always
Resuscitation Program Steering Committee.
Accepted: 26 July 2021

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Neonatal resuscitation
Table 1 Summary of key recommendations for neonatal resuscitation. PPV, positive-pressure ventilation.
Category Recommendation
Cord management Defer umbilical cord clamping for 1e2 min, if feasible.
Initial steps Position and dry infant, stimulate if not breathing and suction the mouth and nose if necessary.
If the infant is born through meconium-stained amniotic fluid, assess and proceed with resuscitation as needed.
Tracheal suction with a meconium aspirator is indicated if airway obstruction prevents effective PPV.
Monitoring Determine HR to guide resuscitation by auscultation, ECG, SpO2 or umbilical cord palpation.
Use ECG if significant resuscitation is required or anticipated.
Use preductal (right hand) SpO2 to guide oxygen delivery.
PPV Start PPV if inadequate respiratory effort or HR <100 beats min 1.

Start PPV with 21% oxygen for term infants and 21e30% oxygen for preterm infants <35 weeks’ gestation.
Adjust oxygen concentration to achieve target preductal SpO2 values. Increase oxygen concentration to 100% if HR
<60 beats min 1 and chest compressions are indicated.
Use PEEP during PPV if possible.
Alternate airway Place an alternate airway if mask PPV is ineffective despite adjustments.
1
Place an alternate airway before starting chest compressions if HR <60 beats min .
Use a supraglottic airway as needed if intubation is not possible.
Chest compressions Begin chest compressions if HR <60 beats min 1 despite providing at least 30 s of PPV through an alternate airway
that moves the chest.
Use the two-thumb technique from the head of the bed (if possible) for provision of chest compressions.
Coordinate chest compressions with inflations in a 3:1 ratio regardless of the presence of an alternate airway.
Medications Give adrenaline if 45e60 s of chest compressions does not increase the HR to >60 beats min 1.
Give adrenaline i.v. or i.o. (10e30 mcg kg 1 per dose) every 3 min if HR remains <60 beats min 1.
Give adrenaline via the tracheal tube (50e100 mcg kg 1 per dose) if i.v. or i.o. access cannot be obtained.
Consider giving isotonic crystalloids or blood if infant is unresponsive to resuscitation and volume depletion is
possible.
Temperature Use a warm delivery room, a radiant warmer and adjuncts in preterm infants (plastic wrap and chemical mattress)
management to prevent hypothermia.
Use a skin temperature probe to monitor and servo-control the radiant warmer to avoid hypo- and hyperthermia.
be to call for help. If a second anaesthesia provider is un-

available but the mother is stable, it may be reasonable to
consider assisting with the resuscitation of the newborn while Table 2 Factors associated with need for resuscitation at
another healthcare provider (e.g. midwife or operating theatre birth. Based on data from Aziz and colleagues5 and Weiner.6
nurse) monitors for any change in the mother’s vital signs or
clinical status. Factor
As the anaesthetist’s involvement in neonatal resuscita-
Antepartum Preterm birth <36 weeks or post-term birth
tion is often unplanned and sporadic, any anaesthetist
>40 weeks
providing obstetric care should maintain familiarity with Multiple pregnancy at <35 weeks’ gestation
current practices in neonatal resuscitation. As the adage goes, Maternal hypertension, pre-eclampsia or
neonates are not ‘tiny adults’, and adult or paediatric life eclampsia
support does not account for the physiological considerations Maternal infection
pertinent to the transition from fetal to neonatal life.4 This Polyhydramnios or oligohydramnios
Fetal anaemia
article discusses the most up-to-date recommendations for
Fetal hydrops
neonatal resuscitation with a focus on the most recent evi- Intrauterine growth restriction or fetal
dence for suggested interventions. macrosomia
Major fetal anomalies or malformations
No prenatal care
Preparation Intrapartum Emergency Caesarean section
The birth of a neonate usually occurs with enough warning Meconium-stained amniotic fluid
Breech or other malpresentation
that a team of providers has time to prepare for a resuscitation
Maternal general anaesthesia
if necessary. Risk factors known before birth can help deter- Maternal magnesium therapy
mine the likelihood that resuscitation may be needed Placental abruption
(Table 2).5 Clear communication with the obstetric and Intrapartum bleeding
anaesthesia teams is essential to alert the neonatal resusci- Chorioamnionitis
tation team of the level of risk for resuscitation. Neonatal Narcotics administered to mother within 4 h
of delivery
resuscitation teams should be organised and have a plan for
Prolapsed umbilical cord
how to manage varying levels of resuscitation requirements. Abnormal fetal HR pattern
This plan includes determining which team members will be Shoulder dystocia
present and which tasks team members should be ready to
perform. At the time the team is called to attend the birth of a
2 BJA Education - Volume xxx, Number xxx, xxxx
newborn who may need resuscitation, the team members members to be comfortable performing all roles and to work
should be briefed with clear communication about all poten- together in an organised and efficient manner.8 Such simu-
tial risk factors, roles should be assigned and equipment lated practice is ideally performed in situ (where resuscitations
should be prepared. The neonatal resuscitation team may also normally occur) during the workday so that teams may get to
initiate communication with the parents to begin preparing know their environment and team members as well as
them for the events that will occur. The anaesthetist can often possible. A team that works well together is likely to perform
assist with communication with the mother as events resuscitation in a highly effective manner when these skills
progress. become necessary. Figure 1 demonstrates the typical position
Neonatal resuscitation equipment must be readily avail- for a newborn on the radiant warmer, and Figure 2 shows the
able whenever it may be needed (Table 3). Equipment will be positioning of team members around the bed.
needed to maintain warmth, clear the airway, monitor the
infant, provide ventilation, place an alternate airway and
provide circulatory support. It is critical to ensure that correct Cord management
sizes of each piece of equipment needed are available.
Over the last several years, much attention has been paid to
Equipment should also be checked to ensure its function and
the practice of umbilical cord clamping after birth. The ob-
that it is primed for use (i.e. radiant warmer turned on to full
stetric practice of immediate clamping of the umbilical cord
power, and suction and gas flow turned on and ready to use).
was initiated as a component of the active management of
For particularly high-risk situations, such as emergency
the third stage of labour in an effort to prevent postpartum
Caesarean section, the team members should consider having
haemorrhage.9 However, clamping the cord immediately af-
the emergency supplies set out and prepared to be used
ter birth as compared with allowing the cord to stay intact for
quickly, rather than simply available. In these situations,
having an umbilical catheter opened, prepared and flushed
could save precious minutes during a critical resuscitation.
Resuscitation training occurring in frequent small
amounts seems necessary to maintain strong resuscitation
skills.7 Regular practice through interdisciplinary simulation
helps teams work well together, enabling resuscitation team
Table 3 Equipment checklist for neonatal resuscitation. PIP,

peak inspiratory pressure.
Procedure Equipment
Warm Preheated warmer

Warm towels/blankets
Temperature sensor and cover
Hat
Plastic bag/wrap (for preterm <32 weeks)
Thermal mattress (for preterm <32 weeks)
Clear airway Bulb syringe
10 Fr or 12 Fr suction catheter
Meconium aspirator
Monitor Stethoscope
ECG leads and monitor
Pulse oximeter and sensor
Ventilation Flowmeter set to 10 L min 1
Oxygen blender set to 21% for term; 21e30%
for preterm
T-piece set to PIP 20e30; PEEP 5 cmH2O
Self-inflating bag or flow-inflating bag
Appropriately sized masks
8 Fr feeding tube and large syringe
Alternative Laryngoscope handle
airway Laryngoscope blades (Miller 00, 0 and 1)
Stylet
Tracheal tubes (sizes 2.5, 3 and 3.5)
End-tidal CO2 detector
Tape
Scissors
Fig 1 Neonatal resuscitation team positions and tasks. The typical posi-
Supraglottic airway sizes 1 and 5 ml syringe
tioning of the newborn on the radiant warmer is shown. The oval repre-
Circulation Adrenaline 100 mcg ml 1
sents the clinician at the head of the bed. This team member is often
Normal saline
responsible for airway management. The square represents the clinician
5 Fr umbilical catheter
on the left side of the baby. This clinician may be responsible for auscul-
Stopcock
tating the HR and temperature management. The polygon represents the
Syringes 1, 3, 5 and 20 ml
clinician on the right side of the baby. This clinician may be responsible for
Saline flushes
placing the SpO2 probe and ECG leads.
BJA Education - Volume xxx, Number xxx, xxxx 3
The Royal College of Obstetricians & Gynaecologists

currently recommends deferring cord clamping whenever
feasible for at least 2 min after birth.9 The European Resusci-
tation Council (ERC) recommends that cord clamping be de-
ferred until at least 1 min of life for infants who do not need
immediate resuscitation.1 Adequate communication between
the obstetrician, paediatrician and anaesthetist as to the plan
for cord management is essential to providing appropriate
care. The timing of giving uterotonic drugs in relation to cord
clamping has not been adequately studied, but does not
appear to affect maternal or newborn outcomes.10
Initial assessment
In the first moments after birth, a quick assessment of the
newborn will help determine the next steps. If the baby is
term, crying and breathing, and has good tone, the newborn
may stay with the mother and engage in skin-to-skin care.
However, if all of those criteria are not present, the baby
should be assessed more carefully. After the umbilical cord
has been clamped, the baby should be brought to a radiant
warmer and placed in a neutral position. Newborns over 32
weeks’ gestation should be dried immediately. Those new-
Fig 2 Neonatal resuscitation team. The photograph shows how the team
borns under 32 weeks’ gestation should be wrapped in plastic
members described in Figure 1 function at the bedside. without drying (except for the face) to maintain adequate
temperature.14 The ERC recommends maintaining the de-
livery room (DR) temperature between 23 C and 25 C and
greater than 25 C for infants less than 28 weeks’ gestation.1
a longer period of time (‘delayed or deferred’ cord clamping) The use of thermal mattresses can also help preterm infants
results in lower neonatal blood volumes after birth. A sig- maintain normothermia.14 If the newborn is not breathing
nificant portion of the feto-placental blood volume will well during the initial assessment, gentle stimulation, such as
remain in the placenta instead of infusing into the newborn that associated with drying the baby, should be attempted to
when the cord is clamped immediately. The duration of time encourage the baby to breathe adequately and consistently.
that the cord is left intact after birth affects the amount of Although previously recommended for all newborns, suc-
blood that is transferred to the newborn. The respiratory tioning the oro- and nasopharynx is now recommended only
status of the infant will also affect the transfer of blood from when there are clearly excessive secretions present, espe-
placenta to the newborn so that a newborn who begins cially if the airway seems obstructed.15 Suctioning should also
breathing spontaneously will receive a greater volume of be performed when positive-pressure ventilation (PPV) is
blood transfer from the placenta before cord clamping indicated and should be attempted if the PPV provided with a
compared with a newborn who does not initiate spontaneous face mask does not result in effective ventilation as noted by
breathing.10 chest rise. Of note, suctioning the trachea through a tracheal
In term infants, the effect of the increased blood volume tube (TT) is no longer recommended in newborns born
that is transferred from placenta to the newborn in response through meconium-stained amniotic fluid unless resuscita-
to later cord clamping can lead to improved iron stores in tion is ineffective because of airway obstruction. This change
infancy, which has the potential to improve neurological in practice is based on the lack of evidence for benefit from
development.11 In preterm infants, the effect can be seen universal tracheal suctioning and the potential risk from
more immediately in the newborn period with improved delaying resuscitation and performing unnecessary
haemodynamic stability during the transition from fetal to laryngoscopy.16
neonatal life. Meta-analysis of available clinical trials also
demonstrated lower mortality rates in infants treated with
delayed cord clamping, fewer blood transfusions and lower
Monitoring
incidence of intraventricular haemorrhage.12 Assessment of HR and oxygen saturation (SpO2) is an integral
Based on physiological observations in animal models that part of neonatal resuscitation and guides clinical manage-
demonstrate a more stable haemodynamic transition from ment. Heart rate is the most important vital sign in deter-
fetal to newborn life when ventilation begins before the cord is mining the effectiveness of resuscitative interventions.
clamped, several ongoing studies are evaluating the practice Acceptable methods of assessing HR during neonatal resus-
of providing respiratory support before the cord is clamped in citation include ECG, pulse oximetry monitoring, cardiac
infants who do not breathe spontaneously after birth.10 Other auscultation and umbilical cord palpation.1 However, palpa-
studies have evaluated ‘milking’ or ‘stripping’ the cord, in tion of pulses, including the umbilical cord, is less reliable in
which the obstetrician attempts to transfer blood more the immediate newborn period.17 The ideal tools used to help
quickly from the placenta to a newborn who is not breathing the neonatal resuscitation team measure vital signs in the DR
spontaneously. Unfortunately, this practice may be harmful can also provide continuous monitoring of the newborn.18
to more preterm infants who are at risk of intraventricular Pulse oximetry has the advantage of simultaneously
haemorrhage.13 providing both HR and SpO2. The pulse oximeter sensor should
be applied to the right wrist or hand of a newborn to obtain team should look for signs of effective and adequate ventila-
pre-ductal SpO2, which represents the oxygenation of cerebral tion evidenced by observable chest rise and an increase in HR.
blood flow. There is a normal pre-to post-ductal difference of Alternatively, a CO2 detector can be used to demonstrate
10e15% during the first 10 min of life. Motion artefact, acro- ventilation with colour change.1
cyanosis, skin oedema or a low-volume state can lead to de- Providing ventilation with excessive tidal volume over
lays or inaccurate readings.18 This can be mitigated by even a few inflations can cause lung injury especially in
warming and drying the newborn and using sensors designed extremely preterm infants.20 The T-piece offers the benefit of
for neonatal resuscitation, which have maximal sensitivity consistent PIP delivery, which may help avoid excessive tidal
and minimal averaging time. volume delivery. Another approach aimed at minimising PIP
Because of its reliability and efficiency, ECG is currently the delivery has been to provide a recruitment manoeuvre, such
gold standard for assessment of the newborn’s HR during as a sustained inflation (holding the PIP at a constant level for
advanced neonatal resuscitations requiring advanced airway more than 5 s). This approach has not been shown to be safe
for ventilation or more interventions.18 Importantly, use of and is not currently recommended.21
ECG also allows the newborn’s HR to be displayed continu- Physiologically, newborns have an SpO2 of about 60% at 1
ously on a monitor that is available to the whole team during min of life, which increases to 85% at 5 min of life.22 Oxygen
the resuscitation. Although ECG is an accurate and efficient use during neonatal resuscitation has been studied exten-
tool, it should not be the only method used during resuscita- sively. Use of a lower FIO2 (0.21e0.30) compared with higher
tion to assess a newborn’s HR, as pulseless electrical activity, FIO2 (0.6e1.0) during neonatal resuscitation decreases short-
although rarely reported in newborns, can occur. Other diffi- term mortality in term newborns.23 In preterm newborns,
culties with ECG can arise if the leads do not adhere well to the the best initial FIO2 remains unclear, but most will require
newborn’s chest because of amniotic fluid, vernix or meco- some supplemental oxygen during initial stabilisation.23
nium. The primary barrier to use of ECG for neonatal resus- Therefore, initial FIO2 is set at 0.21 in term and 0.21e0.30
citation is its availability outside of the neonatal ICU in many for preterm newborns. If the newborn’s HR does not in-
institutions. crease with PPV and 0.21 FIO2, the FIO2 should be increased.1
Temperature management has also been shown to be an If an infant requires chest compressions at any time during
essential part of neonatal resuscitation, particularly with resuscitation, the FIO2 should be increased immediately to
preterm neonates. Hypothermia at the time of admission in- 1.0.
creases the risk of morbidity and mortality in neonates.14 The Placement of an advanced airway (TT or supraglottic
ideal temperature targets are between 36.5 C and 37.5 C.1 airway [SGA]) is indicated if the HR does not improve despite
Setting a temperature target on the radiant warmer and use use of corrective steps to optimise mask ventilation. The team
of a skin temperature probe will help ensure that a newborn should choose the appropriately sized TT and laryngoscope or
meets the minimum target temperatures to maintain SGA based on the newborn’s size.6 Although an SGA should
normothermia without developing hyperthermia. always be readily available in case of a difficult intubation,
size limitations may preclude the use of an SGA in preterm or
growth-restricted neonates.
Positive pressure ventilation For newborns who are spontaneously breathing but have
Once the initial steps of resuscitation are completed, reas- signs of respiratory distress, such as use of accessory muscles
sessment of the newborn will help determine the next steps. If or grunting, CPAP can be considered to help stabilise the
a newborn is apnoeic, gasping or has HR <100 beats min 1 newborn. In preterm newborns, the use of CPAP can help
after a brief period of drying and stimulation has been per- avoid the need for mechanical ventilation and improve
formed, PPV should be initiated. An appropriate-sized mask longer-term outcomes, such as death or bronchopulmonary
that covers the newborn’s mouth and nose should be chosen dysplasia.20
that allows the provider to minimise mask leak without
compressing the eyes. Ventilation can be provided using a
self-inflating bag, flow-inflating bag or a neonatal T-piece
Chest compressions
resuscitator. Neonatal T-piece resuscitators are devices that The vast majority of newborns respond to resuscitation when
use a constant flow of blended air and oxygen to provide ventilation is provided effectively. Therefore, neonatal
controlled assisted inflations. resuscitation guidelines support the establishment of effec-
The goal of assisted ventilation during resuscitation is to tive ventilation, including placing an advanced airway before
help the newborn infant transition from the fetal state of starting chest compressions.1 If a newborn has severe
fluid-filled lungs to the neonatal state of air-filled lungs. This bradycardia with HR <60 beats min 1 despite effective venti-
transition allows the fetus to develop a functional residual lation for 30 s, chest compressions are indicated.
capacity (FRC) that will allow the lungs to stay inflated. The Chest compressions should be coordinated with breaths in
optimal levels of peak inspiratory pressure (PIP) or PEEP for a 3:1 pattern. The ideal method of providing chest compres-
starting resuscitation are unknown, but current ERC recom- sions is to use the two-thumb technique and compress the
mendations suggest starting with a PIP of 30 cmH2O for term newborn’s chest to one-third of the anterioreposterior
newborns and 20e25 cmH2O for preterm newborns.1 The use diameter at the lower third of the sternum. The two-thumb
of PEEP during ventilation has been shown to facilitate the technique has been shown to provide consistent compres-
development of FRC after birth in animal studies.19 The flow- sions of the appropriate depth when compared with the two-
inflating bag and T-piece can both provide PEEP effectively, finger technique in manikin studies.24 Figure 3 shows place-
but the self-inflating bag requires an additional PEEP valve to ment of the hands using the two-thumb technique. With
provide PEEP, and it may not be as effective. either technique, the provider giving chest compressions
The ERC recommends that the first five inflations be held should keep their thumbs or fingers in contact with the
for 2e3 s each to help open the lung.1 Once PPV has begun, the newborn’s chest at all times.
tie should be secured around the cord to prevent bleeding and

the cord should be cut to allow access to the vessels. The
clinician identifies the vein as one vessel with a thinner wall
and larger lumen compared with the two thicker-walled ar-
teries. The clinician then advances the umbilical catheter to a
position just beyond the cord at a point where blood return is
confirmed. Medications and volume can then be given rapidly.
Although rare, some newborns are hypovolaemic at birth
and respond to infusion of fluids. For newborns with a history
consistent with possible hypovolaemia (e.g. from blood loss),
infusions of saline or O-negative blood may be given in 10 ml
kg 1 boluses. Emergency transfusion with blood is preferred
in newborns with suspected severe blood loss to both
replenish the lost volume and correct the resultant anaemia,
but this may take longer to prepare.
For any newborn who is not responding to resuscitation
efforts, other causes of newborn compromise should be
considered. Pneumothorax or unrecognised anomalies, such
as congenital diaphragmatic hernia, may prevent successful
resuscitation. Such causes should be considered in an infant
who remains persistently bradycardic before determining
that resuscitation has been unsuccessful. For newborns who
are born with no detectable HR and have not responded to
effective resuscitation efforts for more than 20 min, a decision
may be made to discontinue resuscitation.23 It is critical to
Fig 3 Chest compressions. The photograph demonstrates the proper hand
position for providing chest compressions using the two-thumb technique. communicate with the family, and allow them time to see and
Note that the clinician providing chest compressions stands at the head of hold their child when appropriate.
the bed when the infant’s trachea is intubated, and the person to the right
of the baby performs lung inflations coordinated in a 3:1 manner with
compressions. Conclusions
Most newborns can be stabilised at birth with minimal
intervention. When needed, resuscitation is usually success-
ful if adequate ventilation is provided. The events around the
During chest compressions, ECG and pulse oximetry can
time of birth can have important long-term implications for
provide continuous monitoring of the HR to the entire resus-
the health and neurological outcome of the child. All pro-
citation team. Once an advanced airway is established, the
viders who may help resuscitate newborns at the time of birth
person providing ventilation should stand to the side to pro-
should be aware of current recommendations and the unique
vide inflations, allowing the provider performing chest com-
needs of the newborn transitioning from fetal life. Ongoing
pressions to stand at the head of the bed to provide the most
training and improvement practices are important to main-
effective chest compressions (see Fig. 3). The provider per-
tain resuscitation skills.
forming chest compressions should count out loud to help
with coordination of chest compressions and ventilation.
Heart rate should be assessed after 60 s of chest compressions. MCQs
During HR assessment, chest compressions should stop.
Heart rate is a sensitive indicator of a newborn’s clinical status The associated MCQs (to support CME/CPD activity) will be
and will improve with effective resuscitation. accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
Medications
Declaration of interests
Infants who are born severely compromised and remain
The authors declare that they have no conflicts of interest.
bradycardic with a HR >60 beats min 1 despite effective
ventilation and chest compressions may respond to adrena-
line (epinephrine). During neonatal resuscitation, it is rec-
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