Briefing, which includes reviewing the case, checking equipment and supplies, role allocation, use of checklists and anticipation of possible scenarios is a tool that improves teamwork. It can apply to different circumstances, from clinical simulation to health care delivery, and be integrated as part of care quality programs.7

The evidence on the effect of briefing on neonatal outcomes is limited, and there are no data from controlled trials regarding its impact on neonatal mortality, neonatal care needs or adverse neurologic outcomes. In 2020, the ILCOR published a systematic review that did not find sufficient evidence to support its recommendation,8 while the 2025 guideline cites four studies with observational data from before and after the implementation of an intervention, concluding that they were generally supportive of the use of briefing but that the evidence was insufficient to justify a new systematic review.9,10

When anticipating the need for resuscitation, the guidelines recommend a prebirth briefing of the neonatal and obstetric care teams and midwives to plan neonatal care.1–3 They recommend the use of checklists before each delivery to ensure the presence and function of equipment and supplies and allocate roles, including communication with the family during resuscitation.

Performance of a structured briefing is recommended before high-risk deliveries, including the analysis of the case and risk factors, role allocation, communication with the family, checking material resources, reviewing algorithms and developing a care plan. This strategy, combined with debriefing and documentation of data following resuscitation, should be integrated in everyday practice.

Delayed cord clamping (DCC) supports the transition to extrauterine life by maintaining the umbilical venous return during lung aeration, which contributes to an adequate cardiac preload. In addition, the transient connection to the placenta prevents abrupt changes in blood pressure and the associated bradycardia. The increase in placental transfusion is associated with a decreased frequency of iron-deficiency anemia, decreased need of red blood cell transfusions and lower mortality in preterm infants.11,12 However, in neonates with low muscle tone or who are not breathing, DCC can delay the initial stabilization measures, so alternatives such as cord milking (CM) or intact cord resuscitation (ICR) are proposed for these cases.13

The evidence on umbilical cord management in preterm infants was evaluated in 2024 through a systematic review and the corresponding CoSTR.14 Based on study-level and network meta-analyses (48 studies involving 6367 preterm infants), DCC is associated with a reduction in mortality compared to immediate cord clamping (ICC).15 In infants born before 32 weeks, DCC (compared to ICC) is associated with a decreased need of transfusion but also an increased probability of hypothermia at admission, while CM (compared to DCC) is associated with an increased risk of intraventricular hemorrhage in infants born before 28 weeks.15 A study in 1730 nonvigorous term neonates compared early cord clamping (ECC) with CM and found no significant differences in admission rates, although there were differences in some secondary outcomes.16 Some studies have demonstrated the feasibility of stabilization maneuvers with an intact umbilical cord in preterm infants, but none have demonstrated the superiority of this approach over DCC in reducing mortality or the incidence of intraventricular hemorrhage.17

The ILCOR 2025 consensus proposes definitions to standardize the terminology and better reflect real-world clinical and research scenarios (Table 1).1 For vigorous neonates, it recommends deferring clamping for at least 60 seconds after birth to decrease mortality in preterm infants and improve hematological outcomes in term infants. When this is not feasible due to factors related to the mother or child, CM is recommended rather than ICC. The recommendation to avoid CM in infants born before 28 weeks’ gestation is maintained.

The NRG-SENeo recommends planning umbilical cord management in collaboration with the obstetrics team and the family before the birth. For neonates who are breathing and have good tone, DCC (≥60 seconds) is recommended, regardless of gestational age. In infants with poor tone and inadequate respiratory effort, initiating tactile stimulation for 30 seconds prior to umbilical cord clamping is recommended. Cord milking is not recommended for infants born before 28 weeks.

Laryngeal masks (LMs), also known as supraglottic airway devices (SGADs), have featured in neonatal resuscitation guidelines since 2000, proposed for use in infants born at or after 34 weeks or with weights of at least 2000 g as an alternative to tracheal intubation (TI) or face masks for IPPV when either of these two techniques is not possible or is ineffective.18

The ILCOR 2025 guideline considered three randomized controlled trials and one observational study comparing the use of SGADs with TI, and one quasi-randomized trial comparing SGAD to FM ventilation.19,20 To date, no studies have been conducted in neonates comparing the performance of chest compressions or the administration of medication in relation to the use of SGADs in the delivery room. A systematic review published in 202221 showed that ventilation was more effective when delivered with SGADs versus FMs (higher probability of improvement and lower proportion of intubation).

The ILCOR proposes replacing the term LM by SGAD and maintains the recommendations issued in 2015 (updated in 2022), adding some considerations as good practice statements.1 It contemplates the use of SGADs if FM ventilation is ineffective or as an alternative to TI, including during chest compressions.

Laryngeal masks are easy to insert and to use and should be available in all delivery rooms. Their use must be considered, even in infants who require chest compressions, as an alternative to FM ventilation if the latter is not effective and to IT if it is not feasible or is ineffective, either due to lack of experience or to the anatomical characteristics of the patient. To fit the patient, the size of the LM must be selected according to the manufacturer’s directions.

The rate of successful neonatal intubation on the first attempt in the delivery room is low, especially in preterm infants and when performed by staff in training. Video laryngoscopy (VL) provides indirect visualization of the glottis on a screen, facilitating intubation and supervision by instructors and potentially improving success rates.22–25

The ILCOR 2025 systematic review included six randomized controlled trials (817 neonates, 862 intubations) and demonstrated that VL increased overall and first-attempt intubation success, in addition to reducing the number of attempts.26 Most studies were conducted in neonatal units, so the evidence for delivery room intubation is indirect. There was no evidence of an increase in adverse events. The benefits seemed greater when the procedure was performed by inexperienced intubators and in the context of training.

The ILCOR has updated its recommendation in 2025 and proposes the use of VL were training and resources allow, especially in settings where less-experienced clinicians are intubating.1 The AHA/AAP 2025 guidelines state that VL “can be useful” for newborn infants who require intubation.2 Lastly, the ERC 2025 recommends using VL if available, keeping conventional direct laryngoscopes available as an alternative.3

Where resources allow, it is reasonable and warranted to consider VL as the preferred method for intubation in the delivery room, prioritizing its use when intubation is performed by staff in training or in the case of an anticipated difficult airway. The use of direct laryngoscopes is a valid alternative, and these devices should always be available. Specific training should be offered at regular intervals for both intubation with both direct and video laryngoscopy.

There is evidence since the 1990s that resuscitation with room air can be effective and reduce mortality and the adverse effects of hyperoxia.27 In 2010, initiating resuscitation with room air was recommended for term infants. In preterm infants, studies did not find clear differences in outcomes between a higher and a lower FiO2, and in 2015, the ILCOR recommended a low initial FiO2 (0.21−0.3). Since then, pulse oximetry has been introduced to gradually titrate the oxygen concentration. In 2019, the ILCOR reviewed the evidence on the initial FiO2. In infants born at or after 35 weeks, initiating resuscitation with a FiO2 of 0.21 reduces mortality without increasing neurologic morbidity.28 In infants born before 35 weeks, the evidence did not identify clear differences with the use of a lower FiO2.29 The 2020 guidelines maintained these recommendations and discouraged the use of high FiO2.

A recent meta-analysis (2024) suggests that, in infants born before 32 weeks, a high initial FiO2 (≥ 0.90) could reduce mortality compared to a low or intermediate initial FiO2, although the heterogeneity between studies could limit the robustness of this conclusion.30 On the other hand, failure to achieve an oxygen saturation (SatO2) greater than 80% at 5 min is associated with an increase in the risk of intraventricular hemorrhage and mortality,31 and, at present, nearly half of patients do not reach target concentrations with the existing oxygen supplementation strategies, which suggests that they may need a higher initial FiO2, more aggressive escalation or different SatO2 targets.32 In the recent TORPIDO 30/60 trial, the incidence of hypoxemia and of bradycardia was lower in the group managed with an initial FiO2 of 0.6 compared to the group with an initial FiO2 of 0.3, but there were no differences in survival without brain injury.33 The evidence in infants born between 32 and 34 weeks6 is insufficient to make a recommendation regarding the initial FiO2.

For neonates born at or after 35 weeks, the ILCOR, AAP/AHA and ERC recommend an initial FiO2 of 0.21.1–3 For infants born before 32 weeks, the ILCOR and ERC recommend an initial FiO2 of 0.3 or greater and the AAP/AHA a FiO2 of 0.3 to 1. For infants born between 32 to 34 weeks,6 the ILCOR does not make a recommendation, the AHA recommends a FiO2 of 0.21 to 0.3, and the ERC maintains the recommendation of 0.21. On the other hand, the ILCOR eliminates the previous recommendation to exert caution regarding the use of a FiO2 of 1 for term infants.

For infants born at or after 35 weeks, we recommend initiating resuscitation with a FiO2 of 0.21, and for infants born between 32 to 34 weeks,6 an initial FiO2 of 0.21 to 0.3. For infants born before 32 weeks, we recommend an intermediate initial FiO2 of 0.3 to 0.5, independently of the respiratory support. We recommend preductal oximetry to adjust the FiO2 according to the target oxygen saturation range.

The IO route can be used to administer medication and fluids during neonatal resuscitation.34

In the context of hypoxic-ischemic encephalopathy, outcomes are poorer in neonates with hypoglycemia compared to those with glucose levels in the normal range.35

Since 2005, infusion of sodium bicarbonate has been recommended in prolonged resuscitations over not administering it.

Three observational studies have reported outcomes in infants managed with IO access without direct comparison to intravenous access. The most widely used IO access site is the proximal tibia, as it is feasible and relatively safe.36,37

There is evidence that neonates with dysglycemia are at increased risk following a hypoxic-ischemic insult.38

We found no new evidence supporting the use of sodium bicarbonate in neonatal resuscitation, while a potential mechanism of injury has been described in anesthetized newborn piglets.39

The ERC and the AHA, in agreement with the ILCOR, continue to recommend umbilical venous catheterization as the preferred vascular access in neonates and, when not feasible, consider IO access a reasonable alternative. They also recommend measuring the blood glucose concentration early in the postresuscitation period and maintaining blood glucose in the normal range.1–3 The recommendation to infuse sodium bicarbonate has been eliminated in the 2025 guidelines.

Umbilical venous catheterization is still considered the primary method of vascular access in neonatal resuscitation, while the IO route is a reasonable alternative in certain settings or if umbilical venous catheterization is unsuccessful. In out-of-hospital settings, training by instructors experienced in umbilical venous catheterization should be promoted. Blood glucose should be monitored from the beginning of the postresuscitation period and maintained in the normal range (45−150 mg/dL). Administration of sodium bicarbonate during neonatal resuscitation is not recommended.