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of ineffective BVM ventilation or failed ET intubation. Although LMAs may be
used as a secondary device to ventilate newborns by health care practitioners
skilled in their use, data supporting use of LMAs in preterm infants are
insufficient to routinely recommend their use. Additionally, use of LMAs is not
recommended during chest compressions or for administration of emergency
medications.

Supporting Circulation
Chest Compressions
Chest compressions are needed in less than 0.1% of all births. Bradycardia and
asystole are virtually always a result of respiratory failure, hypoxemia, and tissue
acidosis and are successfully treated with airway management and effective
ventilation. Chest compressions are indicated if the HR remains less than 60 bpm
despite adequate PPV.
The two-thumb–encircling (Thaler) technique generates higher blood pressure
and coronary perfusion pressure with less rescuer fatigue, and is therefore the
preferred method for delivering compressions ( Fig. 9.10 ). Compressions should
be delivered to the lower third of the infant’s sternum, to a depth of one-third the
anterior–posterior diameter of the chest. Allow the chest to reexpand fully after
relaxation, and coordinate compressions and ventilations at a 3:1 ratio, or 90 chest
compressions and 30 ventilations per 1 minute (rate of 120 events/min) ( Table
9.5 ). A ratio of 15:2 may be used if the neonatal arrest is believed to be of
cardiac origin, an extremely rare occurrence.
Increase supplemental oxygen concentration to 100% whenever chest
compressions are provided. Once the HR recovers, wean oxygen to reduce the
risks of complications associated with hyperoxia.
Vascular Access
The umbilical vein is the preferred site for vascular access during neonatal
resuscitation; it is easily located and cannulated, and medication delivery requires
insertion only to the point at which blood can be aspirated (usually 2 to 4 cm) (see
Chapter 130 Procedures ). Vascular access may also be obtained by placing

peripheral catheters in the extremities or scalp. IO lines may also be used. A 20or 22-gauge spinal needle may replace the 16- or 18-gauge larger IO needles;
however, the procedure for line placement in the proximal tibia is the same as for
older children. The ET tube may be used for administration of epinephrine when
vascular access has not yet been established; given lack of evidence for ET