Labor and transition to extrauterine function are physiological challenges that most humans overcome successfully. However, birth is the riskiest stage of life because failure of postnatal adaptation can result in immediate physiological instability, end-organ dysfunction, and death or disability. Approximately 10% of neonates require some resuscitative assistance during transition in the delivery room. In subgroups such as very low–birth-weight newborns (<1500 g), 90% receive immediate respiratory support; although most of these neonates need only oxygen, approximately 6% reportedly require advanced resuscitation, including chest compressions.

Prenatal history and intrapartum evaluation allow clinicians to anticipate most newborns who will need resuscitation after delivery; still, unexpected complications are common. Immediate assistance aimed at ensuring stabilization and appropriate transition of the neonate must be available and effectively established, usually in the first few minutes of life. Thus the American Academy of Pediatrics and American College of Obstetrics and Gynecology, in their Guidelines for Perinatal Care, recommend that “At every delivery, there should be at least one person whose primary responsibility is the neonate and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation.… It is not sufficient to have someone ‘on call’ (either at home or in another area of the hospital).”[1]

A skilled resuscitator does not suffice to ensure an effective resuscitation. An integrated approach involving all perinatal staff is needed for immediate recognition of distressed neonates, communication among care providers, and rapid implementation of accepted resuscitation procedures. The Neonatal Resuscitation Program (NRP) (www.aap.org/nrp/), jointly sponsored by the American Heart Association and the American Academy of Pediatrics,[2] provides evidence-based guidelines and expert opinion on neonatal resuscitation. The guidelines include a curriculum for training and evaluating neonatal primary care providers, individually and in teams, and practical tools to guide resuscitation. Because the NRP curriculum is now used to train most care providers of neonatal resuscitation in the United States (and in some other countries), hospitals base their neonatal resuscitation procedures on principles espoused by the NRP, adapted to local resources. As a result, this chapter suggests practices closely aligned with those published by the NRP.

This chapter, intended for primary care physicians and other providers of neonatal primary care who may practice at hospitals without a tertiary care perinatal center and focuses on practical evaluation and management of neonates who need assistance during transition in the delivery room setting. After briefly reviewing the physiological basis of neonatal resuscitation, the necessary physical infrastructure, provider roles, and procedures for routine and contingency resuscitations are outlined. Routine care of neonates and evaluation of sick newborns after the delivery room transition are addressed in Chapter 75, Identifying the Infant Who Requires Specialized Care; and Chapter 96, Follow-Up Care of the Graduate of the Neonatal Intensive Care Unit.