Why the first minutes matter
Newborn resuscitation follows a different logic from adult resuscitation. The focus is effective ventilation, not chest compressions. The ERC Guidelines 2025 state that most newborns who need support require only ventilation [1]. Internalising this priority helps avoid two common errors: starting chest compressions too early, and providing inadequate, unverified mask ventilation.
According to ERC 2025, the immediate measures can be condensed into five steps [1]:
- Start the clock
- Maintain temperature
- Open the airway (head in neutral position)
- If breathing is absent or inadequate, or heart rate (HR) < 100/min: 5 inflation breaths
- Then reassess the heart rate
In the prehospital setting, use whichever algorithm, NLS or PLS, the team is more familiar with, switch if needed, and call for help early [1].
Preparation in the prehospital setting
If birth is imminent, a brief structured preparation is worthwhile. The ERC 2025 checklist includes [1]:
- Warmth: room temperature 23–25 °C (below 28 weeks' gestation, preferably above 25 °C), heat source, pre-warmed towels, hat and plastic bag for preterm infants
- Ventilation: T-piece (preferred, particularly for preterm infants) or bag with manometer and PEEP, appropriately sized masks, suction, newborn-size laryngeal mask, intubation set with videolaryngoscope and a direct laryngoscope as back-up
- Monitoring: stethoscope, ECG, pulse oximeter with the sensor on the right hand (preductal), clock
- Access and drugs: umbilical venous catheter or intraosseous access, adrenaline (epinephrine) 0.1 mg/ml prepared, NaCl 0.9 %, glucose 10 %
- Team: allocate roles, ask about gestational age and risk factors
Asking about gestational age is not a formality. It determines thermal management, initial oxygen concentration and inflation pressure.
Thermal care
The target body temperature is 36.5–37.5 °C. Both hypothermia and hyperthermia should be avoided [1].
- Term infants and preterm infants from 32 weeks' gestation: dry the infant, remove wet towels and put on a hat.
- Preterm infants < 32 weeks' gestation: dry only the head and put on a hat. Place the body in plastic wrap or a plastic bag without drying, and use a radiant warmer.
Temperature on admission should be measured and documented. It is regarded as both a prognostic and a quality indicator [1].
Umbilical cord clamping
ERC 2025 differentiates according to the infant's condition [1]:
- No support required: clamp the cord no earlier than 60 s. Waiting longer may be beneficial.
- Stabilisation required: if it can be done safely, provide care with the cord intact and clamp later. This is particularly preferred below 34 weeks' gestation.
- Delayed cord clamping not possible: cord milking is considered only from 28 weeks' gestation, not below 28 weeks' gestation.
Initial assessment: breathing, heart rate, tone
Assessment takes place within the first seconds and continues throughout [1]:
| Good | Impaired | Poor | |
|---|---|---|---|
| Breathing | vigorous, crying | irregular, inadequate | absent / gasping |
| Heart rate | > 100/min | 60–100/min | < 60/min |
| Tone | good | reduced | floppy |
| Action | warmth, with the mother, observe | open airway, ventilate | airway, ventilate, call for help |
Points of practical relevance:
- Heart rate: a stethoscope is acceptable as a first step. ECG provides the most accurate, continuous measurement.
- Skin colour: give it only secondary weight, because it is subjective and unreliable depending on skin type.
Opening the airway
Position the head in a neutral position [1].
- Suction: do not suction routinely. Suction under direct vision only if airway obstruction is suspected.
- Meconium: do not routinely suction the pharynx or trachea, because this only delays ventilation. If the infant is not breathing, start ventilation immediately.
Ventilation: the core of newborn resuscitation
Parameters according to ERC 2025
| Parameter | ≥ 32 weeks' gestation | < 32 weeks' gestation |
|---|---|---|
| Inflation breaths | 5 ×, inspiration up to 2–3 s | 5 ×, up to 2–3 s |
| Inspiratory pressure (initial) | 30 cmH₂O | 25 cmH₂O |
| PEEP | 6 cmH₂O | 6 cmH₂O |
| Oxygen (initial) | 21 % (room air) | ≥ 30 % |
| Thereafter | 30 breaths/min, inspiration approx. 1 s, until adequate spontaneous breathing | as left |
Source: ERC 2025 [1]
- Reduce the pressure as soon as the chest rises and the infant improves.
- Sustained inflations longer than 5 s are not recommended.
- Spontaneously breathing preterm infants < 32 weeks' gestation with respiratory distress should receive CPAP 6 cmH₂O as initial respiratory support [1].
Heart rate not rising: check ventilation
According to ERC 2025, if the HR does not rise after the inflation breaths, ventilation is almost always ineffective [1]. Proceed step by step:
- Is the chest rising? Position the head in neutral. If enough personnel are available, the two-person technique with jaw thrust is preferred.
- Still no chest rise: suction under direct vision, increase the pressure, insert a laryngeal mask or intubate (videolaryngoscope), then repeat the inflation breaths.
- Chest rising: continue ventilation for 30 s, then reassess the HR.
A laryngeal mask is indicated when mask ventilation is ineffective and when intubation is not possible or too hazardous. If the size is appropriate, it can also be used primarily instead of a face mask. The evidence mainly concerns infants from 34 weeks' gestation [1]. This is relevant in the prehospital setting, because neonatal intubation is rarely practised outside specialist teams.
Titrating oxygen
Preductal SpO₂ targets (right hand) according to ERC 2025 [1]:
| Minute after birth | 3 | 5 | 10 |
|---|---|---|---|
| SpO₂ target | 70–75 % | 80–85 % | 85–95 % |
Check SpO₂ and FiO₂ every 30 s and titrate oxygen. If SpO₂ is > 95 %, reduce the oxygen supply. Hypoxia and hyperoxia should be avoided, particularly in preterm infants [1].
Indication for chest compressions
According to ERC 2025, chest compressions are indicated for an HR < 60/min despite at least 30 s of effective ventilation, as shown by visible chest rise [1]. The second part of this condition is decisive. Without demonstrably effective ventilation the indication is not met, and optimising the airway takes priority.
| Parameter | Approach |
|---|---|
| Technique | two-thumb technique, hands encircling the chest |
| Compression point | lower third of the sternum |
| Depth | ⅓ of the anteroposterior chest diameter, allow full recoil |
| Ratio | 3 : 1 – 90 compressions + 30 breaths per minute |
| Oxygen | increase to 100 % |
| Monitoring | HR every 30 s; stop when HR > 60/min |
| Airway | consider laryngeal mask or intubation, call for experienced help, prepare vascular access |
Source: ERC 2025 [1]
When compressions are not enough
Drugs are considered only if the HR remains below 60/min and does not rise despite a secured airway, effective ventilation and at least 30 s of chest compressions. The umbilical venous catheter is the preferred route, with intraosseous access as an alternative [1].
- Adrenaline (epinephrine) IV/IO: 10–30 µg/kg (RCUK standard: 20 µg/kg, corresponding to 0.2 ml/kg of the 0.1 mg/ml solution), repeated every 4 min as long as the HR is < 60/min [1, 2].
- Sodium bicarbonate is no longer recommended during resuscitation [1].
Refer to the current guideline for further drugs and volume administration [1, 2].
What is new in NLS ERC 2025?
- Initial oxygen now in only two categories: ≥ 32 weeks' gestation 21 %, < 32 weeks' gestation ≥ 30 %
- PEEP and CPAP uniformly 6 cmH₂O
- SpO₂ targets from minute 3, with oxygen reduced when SpO₂ is > 95 %
- Adrenaline repeated uniformly every 4 min
- Sodium bicarbonate removed from resuscitation
- No cord milking below 28 weeks' gestation; care with the cord intact preferred if safe
- Airway: two-person technique, early laryngeal mask, videolaryngoscope
- Monitoring: ECG as the most accurate HR measurement, skin colour secondary
Practical summary
Initial newborn care follows a clear sequence:
- Maintain temperature
- Open the airway
- Ventilate effectively
- Monitor the heart rate closely
If the HR remains low, the first question is not "Compressions?" but "Is the chest rising?". Chest compressions are indicated only for HR < 60/min after at least 30 s of demonstrably effective ventilation. After successful stabilisation, the infant should be monitored in a neonatal intensive care unit, and early liaison with the receiving centre is advisable [1].
References
- Hogeveen M, Monnelly V, Binkhorst M et al. European Resuscitation Council Guidelines 2025 Newborn Resuscitation and Support of Transition of Infants at Birth. Resuscitation 2025;215 Suppl 1:110766.
- Resuscitation Council UK. Newborn resuscitation and support of transition of infants at birth – 2025 Resuscitation Guidelines (nationale Adaptation der ERC-Leitlinien 2025).
- International Liaison Committee on Resuscitation (ILCOR). Neonatal Life Support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Circulation 2025.
This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.
