Clinical overview
Roughly 85% of term babies establish regular respiration within 10–30 seconds of birth, and the great majority of the rest respond to drying, stimulation and a clear airway. Only a small minority — classically around 1 in 10 babies need some help and far fewer than 1 in 100 need full resuscitation (standard NRP teaching) — require active inflation breaths, and chest compressions or drugs are needed in only a fraction of those. The corollary is that neonatal resuscitation is overwhelmingly about establishing effective ventilation: a dry, warm, well-ventilated newborn almost always recovers. Cardiac arrest in the newborn is, with rare exception, the end-stage of respiratory failure, not a primary cardiac event — which is why the priority order differs fundamentally from adult ACLS.
For the FCOG(SA) candidate this objective is squarely HOTS: you must be able to demonstrate the resuscitation drill under pressure, assess using the Apgar score correctly (and know its limits), interpret a cord blood gas to time and characterise an intrapartum insult, and recognise the spectrum of birth injuries. In South Africa, where birth asphyxia and intrapartum-related events remain a leading cause of early neonatal death and a recurring theme in perinatal mortality audit, competent resuscitation at every level of care — from a district labour ward to a tertiary unit — is a core registrar skill. Every birth attendant should anticipate the need, prepare the equipment, and be able to deliver effective positive-pressure ventilation. See also initiation-of-respiration and neonatal-transition for the underlying physiology.
Core knowledge
The physiology of transition and asphyxia
At birth the fetus must clear lung fluid, establish a functional residual capacity, drop pulmonary vascular resistance and switch from placental to pulmonary gas exchange. The first effective breaths are generated against high surface tension; this is why aerating the lung — not chest compression — is the engine of newborn resuscitation. When gas exchange fails (cord compression, abruption, prolonged labour, shoulder dystocia), the fetus passes through a stereotyped sequence first described in experimental work: primary apnoea (a period of no breathing with maintained heart rate, responsive to stimulation), then gasping, then terminal (secondary) apnoea (heart rate and gasping fail; only positive-pressure ventilation will recover the baby). Clinically you cannot reliably tell primary from secondary apnoea at the bedside, so treat every apnoeic, non-vigorous newborn as if in terminal apnoea and ventilate.
Apgar score
The Apgar score (Virginia Apgar, 1953 — standard teaching) is a structured description of the newborn's condition at fixed time points, assigned at 1 and 5 minutes, and continued every 5 minutes (10, 15, 20) while resuscitation continues if the 5-minute score is < 7. It scores five signs 0–2:
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (colour) | Blue/pale all over | Body pink, extremities blue (acrocyanosis) | Pink all over |
| Pulse (heart rate) | Absent | < 100/min | ≥ 100/min |
| Grimace (reflex irritability) | No response | Grimace | Cry / cough / sneeze |
| Activity (tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow / irregular / weak | Strong cry |
Key teaching points the examiner wants: the Apgar is a descriptor of condition and response, not a trigger for resuscitation — you do not wait for the 1-minute score to begin (heart rate and breathing drive intervention from the first seconds). It has poor sensitivity and specificity for long-term neurological outcome; a low score reflects many things (prematurity, sedation, sepsis, malformation, hypotonia) besides hypoxia. A persistently low Apgar (e.g. ≤ 3 at 5 and 10 minutes) carries more prognostic weight than a single 1-minute value but must always be interpreted alongside the cord gas, the clinical course and evidence of evolving encephalopathy. Record the score honestly, including the components and the interventions in progress at the time.
Cord blood gas
Paired arterial and venous umbilical cord sampling, taken from a doubly-clamped segment of cord immediately after delivery, gives an objective, retrospective measure of the fetal acid–base state at birth — far more reliable than the Apgar for documenting intrapartum hypoxia. The artery reflects the fetal/placental condition; the vein reflects maternal–placental supply. Correctly drawn, the arterial pH and base deficit should be the more acidotic of the pair (this also confirms you truly sampled an artery and a vein).
Commonly taught thresholds (standard physiology / textbook canon — confirm exact local cut-offs):
- Normal term arterial pH ≈ 7.18–7.38 (mean ~7.26).
- Significant acidaemia: arterial pH < 7.10.
- Severe metabolic acidaemia (a component of the consensus definition of an acute intrapartum hypoxic event): arterial pH < 7.00 and base deficit ≥ 12 mmol/L.
Pattern interpretation is the high-yield skill:
- Respiratory acidosis (low pH, high pCO₂, near-normal base deficit) suggests a recent, acute event — e.g. cord compression in the final minutes — with little time for lactate to accumulate. Generally a better prognosis.
- Metabolic acidosis (low pH, high base deficit/lactate, pCO₂ not the main driver) implies a more prolonged hypoxic-ischaemic insult with anaerobic metabolism.
- Mixed acidosis combines both.
A normal arterial cord pH and base excess substantially argue against a significant hypoxic event around delivery and are medico-legally valuable; this is why universal or selective cord-gas sampling is good practice and is increasingly recommended in operative and instrumental births. See contractions-fetal-oxygenation and placental-insufficiency-response for how the insult arises.
Figure J4.1 — Apgar and paired cord-gas interpretation: Apgar describes condition and response, while arterial pH/base deficit patterns distinguish respiratory, metabolic and mixed acidosis and frame HIE/cooling concern.
Birth injuries
Birth injuries range from trivial and self-limiting to life-threatening. Group them for recall:
- Soft-tissue / scalp: caput succedaneum (diffuse, oedematous, crosses suture lines, resolves in days); cephalhaematoma (subperiosteal, does not cross suture lines, can worsen jaundice); subgaleal haemorrhage (bleeding into the loose subaponeurotic space — crosses sutures, can hold a large fraction of blood volume → hypovolaemic shock; classically associated with vacuum extraction — a true emergency to recognise).
- Nerve injuries: brachial plexus — Erb's palsy (C5–C6, "waiter's-tip", associated with shoulder dystocia) and the rarer Klumpff (C8–T1, claw hand); facial nerve palsy (often forceps-related, usually transient). See instrumental-delivery and oasis for delivery-related trauma context.
- Fractures: clavicle (commonest, often after shoulder dystocia — asymmetric Moro, crepitus; heals well); humerus / femur; skull (rare).
- Other: facial / conjunctival petechiae, sternomastoid haematoma (later torticollis), and intracranial haemorrhage in the compromised or instrumental delivery.
Figure J4.2 — Birth-trauma assessment board contrasting scalp swelling compartments, nerve injuries and fractures, with the subgaleal red flags that demand urgent action.
Assessment
Antenatal and intrapartum anticipation
Resuscitation begins before delivery. At every birth ask: who will resuscitate, is the equipment checked, is the radiant warmer on? Escalate to a second trained person, and to neonatal/paediatric support, for any anticipated high-risk birth: prematurity, meconium-stained liquor, abnormal CTG (ctg-interpretation), antepartum haemorrhage (antepartum-haemorrhage), instrumental or emergency caesarean, multiple pregnancy, growth restriction (intrauterine-growth-restriction), maternal sepsis or general anaesthesia. In the SA setting, communicate clearly with the neonatal team and arrange transfer to the appropriate level of care early — a baby needing ongoing support cannot be managed where it cannot be ventilated and monitored.
The three questions at birth
The moment the baby is born, make a rapid simultaneous assessment of three things, then reassess continuously:
- Tone — a floppy baby is sick.
- Breathing — absent, gasping, or regular?
- Heart rate — the single most important indicator of effective resuscitation. Assess by auscultation at the cardiac apex (palpating the cord base is unreliable and tends to under-read); apply pulse oximetry (right hand/wrist = preductal) and ECG early when help and equipment allow, as ECG gives the fastest, most accurate heart rate.
Heart rate, not colour, drives decisions. Colour is an unreliable sign; do not withhold or escalate care on cyanosis alone — use saturations against the accepted minute-by-minute targets (see below). Reassess heart rate and breathing approximately every 30 seconds.
Targeted preductal saturations
Newborns are physiologically cyanosed at birth and oxygenate over several minutes. Commonly taught NRP/ILCOR target preductal SpO₂ after birth: roughly 60–65% at 1 min, 65–70% at 2 min, 70–75% at 3 min, 75–80% at 4 min, 80–85% at 5 min, and 85–95% at 10 min (standard NRP nomogram — confirm against the local chart). Titrating oxygen to these targets avoids both hypoxia and hyperoxic injury.
Assessing the cord gas and Apgar together
When a baby is depressed, document the paired arterial and venous cord gases and the Apgar at 1, 5 and (if still < 7) 10/15/20 minutes. Read them together: a low Apgar with a severe metabolic acidosis and an evolving abnormal neurology supports an acute intrapartum hypoxic-ischaemic insult; a low Apgar with a normal cord gas points elsewhere (sedation, sepsis, prematurity, anomaly). This combined, honest assessment is both good clinical practice and central to the perinatal mortality audit that underpins Saving Mothers / perinatal care review in SA.
Examining for birth injury
Examine every newborn systematically, and examine the at-risk baby with particular care: palpate the clavicles and long bones, test Moro and limb movements (asymmetry → fracture or plexus injury), inspect and gently palpate the scalp for a boggy, expanding swelling that crosses sutures (subgaleal haemorrhage — serially measure head circumference, watch for tachycardia, pallor and falling haematocrit), and assess facial symmetry on crying.
Management
The resuscitation drill — make it unmistakable
Run the resuscitation as a structured, time-keyed sequence (ILCOR/ERC Newborn Life Support / AAP NRP). Call for help early and keep the clock running.
0–30 s — Prepare, position, clear, dry, stimulate, assess
- Delayed cord clamping for the uncompromised baby (commonly ≥ 60 s) supports placental transfusion; the baby who needs resuscitation is moved to the resuscitaire.
- Warm and dry vigorously (the drying is also the stimulation); remove the wet towel; keep warm (radiant warmer; for the preterm < 32 weeks, place in a plastic bag/wrap without drying and use a hat — hypothermia worsens outcome and is a quality marker).
- Position the airway: head in the neutral ("sniffing") position; consider a shoulder roll. Suction only if the airway is obstructed by secretions/blood and under direct vision — routine suctioning is harmful (vagal bradycardia). For non-vigorous babies through meconium, current ILCOR teaching does not mandate routine intubation/tracheal suction; prioritise effective ventilation.
- Assess tone, breathing, heart rate.
~30–60 s — If apnoeic/gasping or heart rate < 100: VENTILATE (the key step)
- Give 5 inflation breaths with a well-fitting mask and a T-piece or self-inflating bag, each held for ~2–3 seconds, in air (21% O₂) for the term baby (a blended, lower starting FiO₂ for the preterm), titrating O₂ to the SpO₂ targets.
- Look for chest rise. If the chest does not move, the lungs are not being aerated — everything downstream is futile until ventilation is corrected.
Ventilation correction — "MR SOPA / DOPE" (the reflex when there is no chest rise / no response):
- Mask reapply (seal), Reposition the airway (neutral), Suction mouth then nose under vision, Open the mouth, Pressure increase (cautiously), Airway — consider an oropharyngeal/Guedel airway, two-person technique, and intubation/LMA if skilled.
Reassess heart rate after effective ventilation. A rising heart rate is the best sign of success.
Chest compressions — ONLY when heart rate remains < 60/min despite 30 s of effective ventilation (confirmed chest rise)
- First secure the airway (intubate/LMA if able) and increase to 100% oxygen once compressions start.
- Two-thumb encircling technique, lower third of sternum, depth ~one-third of the AP chest diameter.
- Ratio 3 compressions : 1 ventilation, aiming ~90 compressions + 30 breaths = 120 events per minute.
- Reassess heart rate every ~30 s; this is a respiratory arrest — keep ventilating.
Drugs and volume — rarely needed, and only with secured airway + ongoing compressions
- Adrenaline (epinephrine) if heart rate stays < 60/min despite effective ventilation and compressions: the intravenous/intraosseous (umbilical venous) route is strongly preferred. Commonly taught dosing: IV/IO 10–30 micrograms/kg (0.1–0.3 mL/kg of 1:10 000), repeat every 3–5 min; the endotracheal route is less reliable and uses a higher dose (~50–100 micrograms/kg) only while access is being obtained (standard NRP — confirm exact local dosing).
- Volume for suspected hypovolaemia/blood loss (e.g. abruption, vasa praevia, subgaleal bleed): 10 mL/kg of 0.9% saline or O-negative blood, IV/IO, repeated as needed.
- Consider and correct reversible causes: pneumothorax, hypoglycaemia, congenital airway obstruction, severe anaemia.
After resuscitation — the "golden hour" and therapeutic hypothermia
- Maintain temperature, glucose and saturations; do not over-oxygenate.
- A term/near-term baby with evidence of an acute intrapartum event and moderate-to-severe hypoxic-ischaemic encephalopathy should be considered for therapeutic hypothermia (cooling, target ~33–34°C for 72 h) started within 6 hours — this requires neonatal/tertiary referral, so recognise it early and arrange transfer. (Standard neonatal teaching; confirm local cooling protocol and eligibility.)
Figure J4.3 — Newborn support drill: prepare, ventilate, correct absent chest rise, compress only after effective ventilation, give drugs/volume rarely, and protect the golden hour.
Withholding and discontinuing
Decisions to withhold resuscitation (e.g. confirmed extreme prematurity below local viability, lethal anomaly) and to discontinue (commonly considered if there is no detectable heart rate after ~10–20 minutes of effective, complete resuscitation — standard ILCOR teaching, individualised) are made with senior and neonatal input and compassionate communication with the parents. Document fully.
SA context and levels of care
In South Africa, follow the National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) and the structured basic and advanced neonatal resuscitation training built on Helping Babies Breathe (HBB) principles in lower-resourced settings, where a self-inflating bag-valve-mask and a trained attendant at every birth are the minimum standard. Every birth attendant must be resuscitation-competent; equipment (functioning warmer, suction, correctly sized masks, oxygen blender where available) must be checked before each delivery. Refer babies needing ongoing ventilation or cooling promptly to the appropriate district → regional → tertiary level, and feed every case of intrapartum-related death or HIE into perinatal mortality audit (Saving Mothers / perinatal review). Note the SA HIV context: maternal HIV does not change the resuscitation drill, but neonatal post-exposure prophylaxis and feeding decisions follow the relevant PMTCT/ART guidance for the exposed infant.
Red flags / pitfalls
- Chasing colour or the Apgar instead of heart rate and chest rise. The Apgar is a descriptor; the decisions are driven by heart rate and effective ventilation. Never delay ventilation to "wait for the 1-minute Apgar".
- No chest rise = no resuscitation. Compressions, adrenaline and volume are all useless if the lungs are not being aerated. If a baby is not responding, your first thought is ventilation correction (MR SOPA), not drugs.
- Routine deep suctioning (including routine tracheal suction of the non-vigorous meconium-stained baby) — harmful, vagal bradycardia, delays ventilation.
- Letting the baby get cold — hypothermia worsens outcome and is a measurable quality failure; wrap the preterm without drying.
- Misreading the cord gas: a respiratory acidosis (high CO₂, normal base deficit) is acute and usually recoverable and should not be over-interpreted as severe asphyxia; conversely a severe metabolic acidosis (pH < 7.00, BD ≥ 12) is significant. Mislabelling the arterial and venous samples reverses the interpretation — the artery should be the more acidotic.
- Missing subgaleal haemorrhage after vacuum delivery — a swelling that crosses sutures, with tachycardia and pallor, is concealed exsanguination; act on it.
- Mistaking a clavicle fracture / brachial plexus injury for normal — always check Moro symmetry and palpate the clavicles, especially after shoulder dystocia.
- Missing the cooling window — failing to recognise evolving HIE and refer within 6 hours forfeits the one neuroprotective intervention proven to help.
- Forgetting to call for help and keep time — solo resuscitation without a clock and without escalation is a recurring audit failure.
Evidence anchors
- ILCOR 2025 Consensus on Science with Treatment Recommendations (CoSTR), ERC 2025 Newborn Life Support, and AAP Neonatal Resuscitation Program (NRP, 8th edition) — the international evidence base for the resuscitation drill: delayed cord clamping, dry/warm, inflation breaths, ventilation as the priority, 3:1 compression:ventilation ratio, air → titrated oxygen, and the "golden hour".
- National Integrated Maternal and Perinatal Care Guideline, South Africa (NDoH, 2024) — the SA obstetric source of truth, including newborn care and resuscitation expectations at each level of care.
- Helping Babies Breathe (HBB) — bag-mask-based neonatal resuscitation for low-resource settings, the backbone of basic neonatal resuscitation training in SA district facilities.
- South African Saving Mothers / perinatal mortality audit (NCCEMD) — intrapartum-related ("birth asphyxia") events remain a leading avoidable cause of early neonatal death; feeds resuscitation-quality and avoidable-factor review.
- NICE NG235 — Intrapartum care (2023) and NICE NG229 — Fetal monitoring in labour (2022) — antenatal/intrapartum anticipation of the at-risk newborn (CTG categorisation, meconium, pyrexia) and paired cord-gas sampling in operative/instrumental birth.
- Apgar score and umbilical-cord acid–base thresholds are stated here as standard physiology / textbook canon (hedged in notes), not from a single line-itemed guideline; confirm exact local cut-offs and the NRP saturation nomogram before quoting numbers in an exam answer.