Neonatal Resuscitation: Chest Compression Rate and Technique (American Heart Association Guidelines)

Compression Rate and Compression‑Ventilation Coordination

The recommended chest compression rate during neonatal resuscitation is 90 compressions per minute combined with 30 ventilations per minute in a 3:1 compression‑to‑ventilation ratio, resulting in approximately 120 total events per minute. This timing allocates about half a second per event, with exhalation occurring during the first compression after each ventilation. 1

In newborns, impaired gas exchange is the predominant cause of cardiovascular collapse; therefore the 3:1 ratio is designed to prioritize ventilation while still providing circulatory support, a strategy that differs from adult resuscitation where primary cardiac causes are more common. 1

When a primary cardiac etiology is strongly suspected (as opposed to the typical asphyxial arrest), clinicians may consider using a higher compression‑to‑ventilation ratio such as 15:2, aligning with pediatric and adult protocols. This approach is uncommon in neonates and should be applied only when cardiac pathology is evident. 1

Compression location and depth: Perform compressions on the lower third of the sternum to a depth of roughly one‑third of the anterior‑posterior chest diameter. 1
Hand placement: The two‑thumb encircling‑hands technique is the preferred method because it generates higher arterial blood pressure and coronary perfusion pressure. 1
Chest recoil: Allow the chest to re‑expand fully during the relaxation phase, and keep the thumbs in contact with the chest throughout the cycle. 1

Ventilation first: Do not initiate chest compressions until at least 30 seconds of effective ventilation with visible chest rise has been provided.
Indication for compressions: Chest compressions are indicated only when the heart rate remains below 60 beats per minute despite optimal ventilation, preferably delivered via an endotracheal tube. 1

Preliminary animal studies and small pilot trials suggest that continuous chest compressions at 120 compressions per minute with asynchronous ventilation may improve carotid blood flow and shorten time to return of spontaneous circulation. However, current guideline recommendations remain the 3:1 ratio with 90 compressions per minute until robust clinical data in human neonates become available. 1

The American Heart Association recommends a compression to ventilation ratio of 3:1 for neonatal cardiopulmonary resuscitation, with 90 compressions and 30 breaths to achieve approximately 120 events per minute 2, 3, 4
Asphyxia is the predominant cause of cardiovascular collapse in newborns, making effective ventilation crucial for resuscitation 2, 3
Newborns have unique cardiopulmonary physiology with fluid-filled lungs at birth, justifying a different compression to ventilation ratio than other populations 2, 3

The two-thumb technique with hands encircling the chest is the preferred method for performing chest compressions in newborns 5, 6, 4
Compressions should be administered in the lower third of the sternum to a depth of approximately one-third of the anteroposterior diameter of the chest 5, 6, 4
The two-thumb technique generates higher peak systolic pressure and coronary perfusion pressure than the two-finger technique 5, 6

The American Academy of Pediatrics recommends ventilation at a frequency of 40 to 60 breaths per minute to maintain or rapidly achieve a heart rate above 100 beats per minute 7
Initial inflation pressure may be 20 cm H₂O, but ≥30 to 40 cm H₂O may be necessary in some newborns without spontaneous ventilation 7

The American Heart Association recommends increasing oxygen concentration to 100% when providing chest compressions 4
To reduce the risks of complications associated with hyperoxia, supplemental oxygen concentration should be reduced as soon as heart rate recovers 4

Improvement in heart rate is the primary indicator of effective ventilation and successful progress in neonatal resuscitation 7
Heart rate should be continuously monitored during resuscitation 7

Not initiating chest compressions without ensuring optimal ventilation: inadequate ventilation is the most common cause of persistent neonatal bradycardia 5, 6
Not allowing complete re-expansion of the chest: this compromises venous return and the effectiveness of compressions 5, 6
Not coordinating compressions and ventilations: simultaneous administration reduces the effectiveness of both interventions 5, 6, 7