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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 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 to 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