Chest Compressions
Indication
Compressions are indicated when the heart rate remains below 60/min after at least 60 seconds of effective ventilation - usually with 100% oxygen by that point. The commonest error is starting compressions for a low heart rate while ventilation is still inadequate; ventilation is always the rate-limiting step in neonatal bradycardia.
Technique and coordination
Use the two-thumb encircling hands technique on the lower third of the sternum, compressing to about one-third of the anteroposterior chest diameter. Coordinate with the ventilator at a 3:1 ratio - 90 compressions and 30 breaths per minute - counting aloud to keep the rhythm. Use a 3-lead ECG for heart rate. Reassess after each 60-second cycle without interrupting compressions for the check. Intubate if not already done, and arrange umbilical venous access if the heart rate does not respond. Stop compressions once the heart rate is 60/min or more, and wean oxygen as the saturation rises.
Traps
Using a 15:2 ratio; two-finger technique in a newborn; interrupting compressions to place a pulse oximeter or to listen; leaving the FiO2 unchanged; forgetting that compressions without effective ventilation cannot restore a heart rate.
Rule of thumb
One minute of compressions = one minute of quality. Worked example: after intubation and 45 seconds of PPV at 100% oxygen, HR is 50 - begin 3:1 compressions, get a UVC, and reassess at 60 seconds; if still under 60, give epinephrine without pausing compressions.