Most babies breathe on their own at birth. But according to the World Health Organization and the American Academy of Pediatrics’ Helping Babies Breathe programme, around one in ten newborns needs some help to start breathing, and a smaller number need full resuscitation. Birth asphyxia remains a leading cause of newborn death, especially in sub-Saharan Africa and South Asia. The nurse or midwife at the delivery is usually the first, and sometimes the only, person who can help.
Prepare before every birth
- A warm room and a clean, dry, flat surface.
- Two warm, dry cloths or towels and a hat.
- A bag and mask in newborn sizes (size 0 and 1), checked to make sure it works.
- Suction device, cord clamps or ties, sterile scissors, a clock or timer, gloves.
- Know who you will call for help, and how.
The golden minute
Helping Babies Breathe teaches that a baby who is not breathing well should be breathing or receiving ventilation within one minute of birth. Every minute of delay increases the risk of death or brain injury.
- Dry thoroughly straight after birth. Drying keeps the baby warm and stimulates breathing. Remove the wet cloth and cover with a dry one.
- Assess: is the baby crying or breathing well? If yes, keep skin-to-skin with the mother, delay cord clamping (at least 1 minute), and do routine care.
- If not breathing well: keep warm, position the head in a neutral (“sniffing”) position, clear the airway only if needed (secretions blocking it), and stimulate by rubbing the back.
- Still not breathing? Clamp and cut the cord and start bag-mask ventilation at 40–60 breaths per minute. Watch for chest rise.
- Call for help and keep ventilating.
Making ventilation work
If the chest is not rising, the most common causes are a poor mask seal or a blocked airway. Many programmes use the memory aid MR SOPA:
- Mask: reapply for a good seal over the mouth and nose.
- Reposition the head to neutral.
- Suction the mouth, then the nose.
- Open the mouth slightly.
- Pressure: increase it a little.
- Airway alternative: an advanced airway, by a trained provider.
Check the heart rate (with a stethoscope or by feeling the cord base) after about 30 seconds of effective ventilation. Above 100 beats per minute with breathing is reassuring. If the heart rate stays below 60 despite 30 seconds of effective ventilation, trained teams start chest compressions at a ratio of 3 compressions to 1 breath, and give oxygen. Follow your national neonatal resuscitation algorithm (for example, the Resuscitation Council UK NLS or the AAP Neonatal Resuscitation Program).
The APGAR score
Developed by Dr Virginia Apgar in 1952, the APGAR score is recorded at 1 and 5 minutes after birth (and every 5 minutes after that if the score is below 7). It describes the baby’s condition. Do not wait for the 1-minute APGAR before starting resuscitation.
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (colour) | Blue or pale all over | Body pink, hands and feet blue | Pink all over |
| Pulse (heart rate) | Absent | Below 100 | 100 or more |
| Grimace (reflex irritability) | No response | Grimace | Cry, cough or sneeze |
| Activity (muscle tone) | Limp | Some flexion | Active movement |
| Respiration | Absent | Slow, irregular, weak cry | Good, strong cry |
- 7–10: normal.
- 4–6: moderately low. The baby may need support.
- 0–3: very low. Needs immediate resuscitation.
Colour can be harder to judge in babies with darker skin. Look at the lips, tongue, palms and soles. Many healthy newborns have blue hands and feet for a while, so a score of 2 for appearance is uncommon at 1 minute.
Meconium-stained liquor
Current guidelines no longer recommend routine suctioning of babies born through meconium-stained fluid. If the baby is vigorous, give routine care. If not breathing, start the same steps, and clear the airway if it is obstructed. Do not delay ventilation.
After resuscitation
- Keep the baby warm: skin-to-skin if stable; hypothermia is dangerous.
- Monitor breathing, heart rate, colour, temperature and blood glucose closely.
- Start breastfeeding as soon as the baby is able.
- Refer to a neonatal unit if the baby needed prolonged ventilation or shows signs of encephalopathy (abnormal tone, seizures, poor feeding).
- Talk with the mother and family, and document times, actions and APGAR scores.
Keep your skills fresh
Resuscitation skills fade within months. Short, regular practice on a newborn manikin, even five minutes a week, keeps them sharp. If your facility offers Helping Babies Breathe, Newborn Life Support or NRP courses, take them.
Related: Postpartum haemorrhage · Pre-eclampsia and eclampsia · Normal vital signs in newborns
Based on Helping Babies Breathe (American Academy of Pediatrics), WHO newborn care guidance and Resuscitation Council UK Newborn Life Support. Educational content: follow your national algorithm and get hands-on training.