- Indications and Technique
- Coordination, Reassessment, and Escalation
Indications and Technique
When chest compressions are required, the indication threshold, technique, and coordination with ventilation differ from adult and pediatric CPR in ways that directly affect performance. The differences are clinically significant, particularly for providers whose primary experience is adult resuscitation.
Indication for chest compressions
Chest compressions are indicated when the heart rate remains below 60 bpm despite 30 seconds of effective PPV delivered via an advanced airway (either endotracheal tube or laryngeal mask). The requirement for an advanced airway before compressions begin is deliberate: coordinating compressions with mask PPV is significantly less effective than with a secured airway, and the 30-second window of effective PPV ensures that failure to respond is genuine rather than a product of inadequate ventilation.
The moment chest compressions begin, two additional actions are taken simultaneously:
- Oxygen concentration is increased to 100%: blended oxygen is appropriate for PPV, but 100% O₂ is indicated once compressions start
- A provider is designated for umbilical venous catheter insertion: epinephrine administration via UVC should be anticipated
Compression technique
Two techniques are used for neonatal chest compressions. The two-thumb encircling technique is strongly preferred in all circumstances where access to the umbilical area is not required (Table 11):
Technique | Description | When used |
|---|---|---|
| Two-thumb encircling (preferred) | Both thumbs placed on the lower third of the sternum, side by side or overlapping; fingers encircle the torso and support the back | Standard technique for all neonatal compressions |
| Two-finger technique | Index and middle fingers of one hand placed on the lower third of the sternum | Only when UVC insertion is being performed simultaneously and provider positioning requires access to the umbilical area |
The two-thumb encircling technique is preferred because it generates higher peak systolic pressure and better coronary perfusion pressure than the two-finger technique. The thumbs should be placed on the lower third of the sternum (not on the xiphoid process, which risks liver laceration) with enough force to depress the chest by approximately one-third of its anteroposterior diameter.
Full chest recoil between compressions is as important as the compression itself. Incomplete recoil reduces venous return to the heart and diminishes cardiac output. The chest must fully return to its resting position before the next compression.
Compression depth and rate
- Target depth: one-third of the anteroposterior diameter of the chest
- Compression rate: 90 compressions per minute, coordinated with 30 ventilations per minute in a 3:1 ratio
- Combined rate: 120 events per minute - 90 compressions and 30 ventilations
The 3:1 compression-to-ventilation ratio is specific to neonates and differs from the 15:1 or 30:2 ratios used in pediatric and adult resuscitation. Neonatal cardiac arrest is almost always asphyxial, where hypoxia and hypercapnia are the primary drivers, which is why ventilation carries as much weight as cardiac output in the 3:1 ratio.
The 3:1 ratio is unique to neonates. Providers experienced in adult or pediatric resuscitation should be aware that neonatal compression-to-ventilation coordination is different and requires deliberate adjustment.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
