Chest compressions should begin on a newborn when the heart rate remains below 60 beats per minute after 30 seconds of effective assisted breathing. This threshold has been consistent across every major update to neonatal resuscitation guidelines, including the most recent 2025 joint guidelines from the American Heart Association and the American Academy of Pediatrics. The key point many people miss: compressions are never the first step. Effective lung inflation comes first, and compressions only start when breathing support alone isn’t enough to raise the heart rate.
The 60 BPM Threshold
A healthy newborn’s heart rate typically rises quickly after birth, climbing well above 100 beats per minute within the first minutes of life. When a baby’s heart rate stays below 60 bpm, cardiac output is too low to sustain organ function. That number, 60 bpm, is the internationally recognized trigger for starting chest compressions, and it has remained unchanged through multiple cycles of guideline review by the International Liaison Committee on Resuscitation (ILCOR).
But the threshold alone doesn’t tell the whole story. The heart rate must still be below 60 after the resuscitation team has already provided 30 seconds of effective positive pressure ventilation (PPV), which means air or oxygen delivered through a mask or other device that visibly moves the baby’s chest. If ventilation hasn’t been optimized first, compressions won’t help, because the most common reason a newborn’s heart rate drops is that the lungs haven’t inflated properly. Fixing the breathing problem fixes the heart rate in the vast majority of cases.
Why Ventilation Always Comes First
Newborn resuscitation follows a deliberate sequence, and skipping steps makes outcomes worse. When a baby is born limp, not breathing, or with a very low heart rate, the first intervention is stimulation and warmth. If that doesn’t work, assisted breathing begins immediately. The team delivers PPV for 30 seconds, then reassesses the heart rate.
If the heart rate is still below 60 bpm at that point, the team optimizes ventilation: checking the mask seal, adjusting head position, suctioning the airway if needed, and increasing pressure. Only after confirming that air is actually reaching the lungs and the heart rate remains below 60 do compressions begin. This sequence matters because a newborn’s low heart rate is almost always a breathing problem, not a heart problem. Effective lung inflation alone resolves bradycardia in most cases without ever needing compressions.
How Newborn Compressions Are Performed
Chest compressions on a newborn look very different from adult CPR. The preferred technique is the two-thumb method: the rescuer places both thumbs side by side (or stacked, depending on the baby’s size) on the lower third of the sternum, wrapping the fingers around the baby’s torso to support the back. An alternative is the two-finger technique, where two fingertips press on the sternum while the other hand supports the baby from behind. Guidelines favor the two-thumb approach because it generates more consistent pressure and is less fatiguing.
The compression depth is about one third of the chest’s front-to-back diameter. On a full-term newborn, that translates to roughly 1.5 centimeters, though the guideline deliberately uses a proportion rather than a fixed number because babies vary in size. The goal is to compress deep enough to generate a palpable pulse.
The 3:1 Ratio
Newborn CPR uses a 3-to-1 ratio of compressions to breaths, which is unique to neonatal resuscitation. In practice, that means three compressions followed by one breath, repeated in a smooth cycle. The target pace is 90 compressions and 30 breaths per minute, totaling 120 events per minute. This ratio reflects the fact that breathing failure, not cardiac failure, is almost always the underlying problem in newborns.
Oxygen During Compressions
When resuscitation reaches the compression stage, guidelines recommend increasing supplemental oxygen to 100%. Earlier in the process, many teams start with lower oxygen concentrations (even room air for term infants), but once compressions are needed, the priority shifts to maximizing oxygen delivery to the heart and brain. As soon as the heart rate recovers, the oxygen concentration should be reduced to avoid the risks of giving too much oxygen, which can cause tissue damage in newborns.
When Compressions Should Stop
The team pauses briefly after about 60 seconds of coordinated compressions and ventilation to recheck the heart rate. If it has climbed above 60 bpm, compressions stop and the team continues with assisted breathing alone. If the heart rate remains below 60 despite good-quality compressions and confirmed lung inflation, the next step in the algorithm is medication, typically adrenaline delivered through an umbilical vein catheter or, in some cases, through a breathing tube.
How Heart Rate Is Monitored
Accurate heart rate measurement drives every decision in this process, and not all monitoring methods are equally fast. Pulse oximetry, the clip placed on a baby’s hand or foot, is common but can take 60 to 90 seconds to pick up a reliable signal after birth. Electrocardiography (ECG) with leads attached to the baby’s limbs provides a heart rate reading faster and more reliably. For this reason, many delivery teams now place ECG leads early in resuscitation so they have a continuous, accurate heart rate to guide their decisions about starting or stopping compressions.
Putting the Sequence Together
The full decision chain looks like this:
- Birth: Dry, stimulate, and warm the baby. Assess breathing and heart rate.
- Heart rate below 100 bpm or no effective breathing: Begin positive pressure ventilation.
- After 30 seconds of effective PPV, heart rate still below 60 bpm: Optimize ventilation (check seal, reposition, suction). Reassess.
- Heart rate still below 60 bpm after optimized ventilation: Start chest compressions coordinated with ventilation at a 3:1 ratio. Increase oxygen to 100%.
- After 60 seconds of compressions, heart rate still below 60 bpm: Consider medication.
Each step depends on the one before it succeeding or failing. Compressions without effective ventilation are unlikely to help, which is why the guidelines are structured as a sequence rather than a checklist. The 2025 AHA/AAP guidelines, now reflected in the 9th edition of the Neonatal Resuscitation Program, reinforce this same stepwise approach with updated educational materials but no change to the fundamental 60 bpm compression threshold.