# Birth Asphyxia Management

> Birth asphyxia and neonatal resuscitation for FMGE Obstetrics: NRP steps, PPV rates, chest compression ratio, adrenaline dose and cooling.

- Canonical URL: https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/birth-asphyxia-management
- Exam / course: FMGE · Subject: Obstetrics and Gynaecology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Birth Asphyxia Management", PrepElephant, https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/birth-asphyxia-management

## Direct answer

The first minute after a non-breathing birth follows the NRP/NNF sequence, not a drug chart: dry and stimulate, position the airway, clear it only if obstructed (routine suction is abandoned), then ask the three questions — term? good tone? breathing or crying? A baby answering no to any moves to positive-pressure ventilation with room air at 40-60 breaths per minute, the single most life-saving step, assessed by rising heart rate and chest movement. If the heart rate stays below 60 after 90 seconds of effective ventilation, add chest compressions at a 3:1 ratio with ventilation (120 events per minute); if below 60 despite 60 seconds of coordinated compressions and ventilation, give adrenaline (epinephrine) 0.01-0.02 mg/kg of the 1:10,000 dilution umbilically, and consider volume. Apgar scores at 1 and 5 minutes describe condition, never guide resuscitation; moderate-to-severe hypoxic-ischaemic encephalopathy in babies of 36 weeks or more receives therapeutic hypothermia (33.5°C for 72 hours) started within six hours.

## What you must remember

- **The three rapid questions:** term gestation? good tone? breathing or crying? — all yes means routine care (warm, dry, skin-to-skin); any no means initial steps now and reassessment at 30 and 60 seconds.
- **Ventilation rules:** positive-pressure ventilation at 40-60 breaths/minute in room air (21 per cent oxygen for term babies; higher concentrations only per oxygen-target guidance) — start within the first minute for an apnoeic baby; most "resuscitations" end here.
- **Chest compressions:** heart rate below 60 despite 90 seconds of effective ventilation — two-thumb technique on the lower third of the sternum, 3:1 compressions-to-ventilations, 90 compressions and 30 breaths per minute.
- **Adrenaline:** 0.01-0.02 mg/kg IV (0.1-0.2 mL/kg of 1:10,000) via umbilical venous catheter, repeated every 3-5 minutes; the endotracheal route is a fading second choice; volume (10 mL/kg normal saline or O-negative blood) for suspected hypovolaemia or shock.
- **Apgar honesty:** score 0-2 at 5 minutes flags asphyxia (with umbilical artery acidosis, pH under 7.0 and base deficit over 12 commonly quoted as biochemical anchors) — but resuscitation starts before the one-minute score, always.
- **Meconium rule change:** routine intrapartum suction and direct tracheal suction of non-vigorous meconium-stained babies is abandoned — resuscitate with the standard sequence.
- **Therapeutic hypothermia:** 33.5°C whole-body cooling for 72 hours, initiated within 6 hours of birth, for 36-week-and-over infants with moderate or severe HIE — reduces death and disability; Sarnat staging grades the encephalopathy.
- **Equipment arithmetic:** a self-inflating bag with a term mask, a bulb syringe or suction at 100 mmHg or less, a radiant warmer checked before every delivery, and a clock — the FMGE vignette usually hides a missing warmer.

## The first minute of a depressed neonate

Stand at the warmer. A term boy is born through thick meconium, floppy and silent. He is laid on the warmer, dried with a warm towel and the wet towel removed — stimulation in the drying itself. The three questions return: term yes, tone poor, breathing absent — so 30 seconds of positioning (slight neck extension) and clearing the mouth then nose only because the airway looks obstructed. He gasps once and relapses. Positive-pressure ventilation begins by 60 seconds: mask seal, five initial inflation breaths, then 40-60 breaths per minute in air, with the heart rate counted or watched on a monitor. His chest rises; the rate climbs toward 80 but stalls below 60 at the 90-second check — thumbs lock onto the lower sternum and 3:1 compressions begin, calling out the cycle.

Sixty seconds of coordinated compressions later he is still under 60: the umbilical line is cut and adrenaline 0.15 mL of 1:10,000 (for a 3 kg baby — the arithmetic the exam tests) goes in while compressions continue. His rate crosses 60, compressions stop, ventilation tapers as he grunts and pinks; he is transferred with the mother's team to the neonatal unit, where staff grade his encephalopathy (Sarnat II — moderate) and start whole-body cooling at 33.5°C within the six-hour window, parents counselled that cooling changes outcomes. Every step ran on a clock the exam can quote: 30 seconds of initial steps, 90 of ventilation before compressions, 60 of compressions before adrenaline.

## The classic one-liners

NBE asks the ratio (3:1), the rate of PPV (40-60), the adrenaline dose (0.01-0.02 mg/kg of 1:10,000), and — the perennial trap — what the Apgar at one minute is for (communication and record, not a treatment trigger). The meconium question flips old teaching: non-vigorous meconium-stained babies get the standard sequence, not laryngoscopy and suction. Cooling's two numbers, 33.5°C and 72 hours within six, close the set.

## Frequently asked questions

### When are chest compressions started in neonatal resuscitation?

When the heart rate remains below 60 per minute after at least 90 seconds of effective positive-pressure ventilation.

### What is the compression-to-ventilation ratio in newborn resuscitation?

Three compressions to one ventilation — 90 compressions and 30 breaths per minute — using the two-thumb technique on the lower third of the sternum.

### What is the dose and route of adrenaline in neonatal resuscitation?

Adrenaline 0.01-0.02 mg/kg intravenously (0.1-0.2 mL/kg of the 1:10,000 dilution), preferably through an umbilical venous catheter, repeated every 3-5 minutes.

### Is tracheal suctioning routine for meconium-stained newborns?

No — non-vigorous meconium-stained babies receive the standard resuscitation sequence; routine intrapartum and tracheal suction has been abandoned.

### Which babies receive therapeutic hypothermia?

Infants of 36 weeks or more with moderate or severe hypoxic-ischaemic encephalopathy, cooled to 33.5°C for 72 hours, started within six hours of birth.