Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.^1,2,5,6

Endotracheal suctioning of vigorous* infants is not recommended.^1,2,5,6

Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.^1,2,5

A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.^1,6

Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.⁶

Initial PIP of 20 cm H₂O may be effective, but a PIP of 30 to 40 cm H₂O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.⁵

Ventilation rates of 40 to 60 breaths per minute are recommended.^5,6

Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.^5,6

Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.^5,6

No evidence exists to support or refute the use of mask CPAP in term infants.^2,5

PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.⁵

Delivery rooms should have a pulse oximeter readily available.^5–7

A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.^5–7

Supplemental oxygen should be administered using an air/oxygen blender.^5–7

It is recommended to begin resuscitation with 21 percent oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low^5–7 (see Figure 1).

It is recommended to increase oxygen concentration to 100 percent if the heart rate continues to be less than 60 bpm (despite effective positive pressure ventilation) and the infant needs chest compressions.^5–7

Initial PIP of 20 to 25 cm H₂O should be used; if the heart rate does not increase or chest wall movement is not seen, higher pressures can be used. Excessive chest wall movement should be avoided.^2,6

In spontaneously breathing preterm infants with respiratory distress, either CPAP or endotracheal intubation with mechanical ventilation may be used.^1,5,6

In preterm infants less than 32 weeks' gestation, an initial oxygen concentration of more than 21 percent (30 to 40 percent), but less than 100 percent should be used. The goal should be to achieve oxygen saturation targets shown in Figure 1.^5,6

When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.^5–7

Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.^5,6

If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.^1,2,5–7

Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.^5,6

Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.^1,2,5,6

Very rarely, sodium bicarbonate may be useful after resuscitation.⁶

Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.^5–7

Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.^5,6

It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. Hyperthermia should be avoided.^1,2,6

Delivery room temperature should be set at at least 78.8°F (26°C) for infants less than 28 weeks' gestation.⁶