Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Neonatal Complications at Delivery

1 Contact Hour
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Saturday, April 25, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

FPTA Approval: CE24-1199514. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

≥ 92% of participants will know the potential causes of complications of a neonate at delivery and how to care for them.


After completing this continuing education course, the participant will be able to:

  1. Identify normal fetal circulation.
  2. Explain what physiologic changes occur at birth.
  3. List the risk factors impacting fetal transition.
  4. Examine the complications that can occur at delivery.
  5. Create a plan for evidence-based intervention if complications occur at delivery.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Neonatal Complications at Delivery
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)


The transition from intrauterine to extrauterine life depends on physiologic changes that occur at the time of birth. Most of the time, this happens without difficulty. About 85% of term infants will begin breathing within 30 seconds of life, and 10% will breathe after drying and stimulation, leaving about 5% to need extra intervention (American Academy of Pediatrics [AAP], 2021).

Fetal Circulation

Fetal circulation is unique. Before birth, the placenta provides gas and nutrient exchange for the fetus from the maternal circulation. The blood from the mother and fetus do not mix, so exchange occurs by diffusion (Saha, 2023). Blood is transported between the fetus and the placenta through the umbilical cord, which consists of 2 arteries and 1 vein (Marty et al., 2023).

Image 1:
Cross Section of the Umbilical Cord

graphic showing cross section of umbilical cord

The placenta has the lowest vascular resistance and receives 40% of the fetal cardiac output. This leads to low systemic pressure within the circulation. The fetal lungs are filled with fluid and have the highest vascular resistance, receiving less than 10% of the fetal cardiac output.Two right-to-left shunts occur in the fetus because there is high pulmonary vascular resistance and low systemic pressure (Fernandez, 2024; Anthony & McKinlay, 2022). During fetal development, a small opening called the foramen ovale is normally present in the wall between the right and left atria of the heart (Mayo Clinic, 2022). The fetus also has a ductus arteriosus, an artery connecting the aorta and the pulmonary artery. The ductus allows blood to detour away from the lungs before birth (Fernandez, 2024).

Image 2:
Fetal Circulation Anatomy

graphic showing fetal circulation anatomy

Blood is oxygenated in the placenta. From the placenta, oxygenated blood flows through the umbilical vein into the fetus's abdomen. The majority of this blood flows through the ductus venosus into the inferior vena cava and then into the right atrium. The oxygenated blood is then shunted from the right atrium to the left atrium. A small amount of blood does flow into the pulmonary artery and lungs. Blood travels to the left ventricle and then enters into the coronary arteries and aorta, bypassing the lungs. The oxygenated blood then enters the fetal systemic circulation (Elshazzly et al., 2023; Anthony & McKinlay, 2022).

Image 3:
Flow of Fetal Circulation

graphic showing flow of fetal circulation

Some of the deoxygenated blood is then transported through the aorta to the umbilical arteries and back to the placenta, releasing carbon dioxide and waste products and collecting oxygen and nutrients (Fernandez, 2024).

Delivery Transition

As soon as the newborn has their first cry, breath, or the cord is clamped at delivery, rapid physiologic changes occur for the neonate to have a successful transition. Alveolar fluid clearance must occur for lung aeration. Labor contributes to this change. The initial effective breaths of the neonate create high transpulmonary pressures, which drive out alveolar fluid from the air spaces into pulmonary vasculature. The physical pressure on the infant's chest wall during delivery may also help this process. This fluid is cleared partially within a few minutes and should clear completely within 24 hours.

With the first breath, intrathoracic pressure falls and allows for lung expansion (Fernandez, 2024). When the umbilical cord is clamped, the placenta is removed from neonatal circulation, which causes a rise in neonatal systemic blood pressure. This clamping decreases right-to-left shunting at the ductus arteriosus, which results in increased left-to-right shunting. This shunting creates increased blood flow through the pulmonary arteries and lungs. There is an increased ventricular stroke volume which increases cerebral oxygen saturation. These changes stimulate the closure of the ductus arteriosus (Saha, 2023). While most of the changes occur shortly after birth, the full transition can take up to 6 weeks after birth (Saha, 2023).

Difficulties Transitioning

Risk Factors

There are numerous risk factors that can affect the transition at delivery.

Maternal conditions that can increase the risk of issues with transitioning include (Saha, 2023):

  • Advanced maternal age (>35)
  • Diabetes
  • Hypertension
  • Cardiac disease
  • Respiratory disease
  • Severe anemia
  • Infection
  • Substance use

Fetal conditions that can impact a successful transition include (Saha, 2023):

  • Prematurity
  • Postmaturity
  • Congenital anomalies
  • Birth trauma
  • Respiratory distress syndrome
  • Placenta anomalies (previa, abruptio)
  • Fetal-maternal hemorrhage

Delivery complications that have the potential to impact fetal transitioning include (Saha, 2023):

  • Chorioamnionitis
  • Meconium-stained fluid
  • Antenatal asphyxia
  • Prolonged labor
  • Narcotic administration
  • Magnesium sulfate (MgSO4) administration
  • Premature rupture of membranes (PROM)
  • Delivery with instrumentation

Placental anomalies ranging from a placenta previa with a small amount of bleeding to a placental abruption in which the woman is hemorrhaging can cause mild to severe complications of the neonate at delivery as well. With placental abruption, the fetus can also lose a large amount of blood. This fetus is likely to be delivered and subsequently require a full resuscitation as well as blood volume replacement.


If the neonate does not have regular, vigorous respiration at birth, there is a disruption to alveolar fluid clearance, lung inflation, and reduction of pulmonary vascular resistance. Causes of impaired respiratory effort can be mild and reversible, such as exposure to maternal opioids, to severe and non-reversible, such as prolonged hypoxia (Fernandez, 2024).

A lack of respiratory effort could occur in an infant that is neurologically depressed. Blockage of the airway can prevent initial breaths. A blockage can be caused by a congenital malformation such as choanal atresia or the presence of meconium or mucus in the airway (Fernandez, 2024). Impaired lung function can cause respiratory distress in a newborn. Some causes of impaired lung function are external causes such as pneumothorax or pleural effusions. Pulmonary hypoplasia can be caused by a diaphragmatic hernia that can impair lung function. Intrinsic lung disease may impact lung function, and some causes are deficient surfactant in a preterm infant or transient tachypnea of the newborn in a full-term infant (Fernandez, 2024).

Persistent pulmonary hypertension (PPHN) is another cause of a complicated transition at birth. In this disorder, the pulmonary vascular resistance remains elevated after birth due to abnormal blood shunting right to left through fetal circulatory pathways. This abnormal shunting can be a life-threatening condition. Severe congenital cardiac disease can cause difficulty for the newborn to transition to extrauterine life as well. Preterm infants are also more likely to have difficulties transitioning to extrauterine life (Fernandez, 2024).

Other Complications at Delivery

Difficulty transitioning to extrauterine life is usually correlated with fetal circulation or respiratory issues. There are some other causes of complications that a nurse in the delivery room should be aware of.

Preterm birth puts the neonate at risk for respiratory problems, hypothermia, hypoglycemia, infection, intracranial hemorrhage, and necrotizing enterocolitis. Most of these complications do not cause immediate problems at delivery (other than respiratory problems), but they are important to be aware of (Mandy, 2023a).

Multiple gestation pregnancies are at increased risk of problems such as preterm birth, fetal growth restriction, discordant growth, and congenital anomalies. Both fetal growth-restricted and discordant growth fetuses are at risk of complications at delivery, similar to a preterm infant.

Twin to twin transfusion is a disorder with an uneven distribution in fetal blood flow.

Image 4:
Twin-to-Twin Transfusion

graphic showing twin to twin transfusion

This phenomenon can cause serious problems at delivery. These neonates can have an abnormal cardiac function, anemia, hypovolemia, or hydrops, leading to the need for neonatal resuscitation at birth. There can be long-term problems with neurological development (Mandy, 2023b). Infants can also have issues with thermoregulation at birth. Preterm and small babies are at an increased risk, but all babies should be kept warm after delivery.

Neonatal Resuscitation in the Delivery Room

At every delivery, there should be at least one provider whose only responsibility is the newborn, and this provider should have the skills to initiate resuscitation. There should also be an immediately available provider to carry out full neonatal resuscitation, including intubation and medications. Equipment needed for resuscitation should also be available at every delivery (AAP, 2021).

The most widely used training program is the neonatal resuscitation program (NRP) which was developed by the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) as a training program teaching principles and skills (AAP, 2021; American Heart Association [AHA], 2023). NRP is appropriate for nurses, doctors, nurse practitioners, and respiratory therapists. Institutions should have a policy that states which staff must have this training (AAP, 2021).

NRP guides the healthcare personnel on how to provide resuscitation as soon as the need is determined. During the first minute of life, all newborns are assessed to determine the need for care. The initial steps are to dry and stimulate the infant, warm the infant (and maintain body temperature), and position the airway and clear secretions. If the baby is term gestation with good tone and breathing or crying, the infant may stay with the mother and continue evaluation. Resuscitation should begin if the infant has apnea, gasping, or a HR below 100 bpm.

NRP teaches an algorithm to be used during resuscitation (AAP, 2021). The algorithm is complex and tells the person using it to warm, dry, and stimulate the infant. Then if the infant is not breathing, is gasping, or has a heart rate < 100, positive pressure ventilation (PPV) should be started. If the PPV does not work, there are steps to do, including repositioning the mask, giving chest compressions, and administering epinephrine. The NRP class teaches the step-by-step algorithm and the skills to perform in order to the most up-to-date evidence based research.

Information regarding the NRP course, the AAP algorithm, as well as access to the NRP materials are available here.

Case Study

Marie is a 40-year-old female, pregnant with twins, at 29 weeks and 2 days gestation. She presents to the emergency room via ambulance because she is complaining of contraction pain at 10/10. Her vitals are:

  • HR 138
  • BP 90/62
  • Temperature 98.5
  • Respirations 22

Marie is bleeding. She states that her abdominal pain is 10/10 and will not stop. Marie is rushed to labor and delivery, where she is found to be 8 cm dilated. She is then taken to the operating room.

Let’s consider:

  1. What is happening?
  2. What are the risks to the neonate?
  3. For what do you and the team need to be prepared?

Marie is delivering preterm twins. The neonates have many risks. The neonates are preterm, so there are respiratory risks. There are also risks for hypothermia, hypoglycemia, infection, intracranial hemorrhage, and necrotizing enterocolitis but the biggest problem in the delivery room is the respiratory status. An RN, neonatologist, and respiratory therapist should be present at delivery for the neonate, as this neonate is likely to need full resuscitation.


Newborns will be born without complications up to 85% of the time. It is important for nurses who attend births to understand what can cause complications at delivery and how to care for neonates requiring assistance. If a fetus is known to have problems that will complicate delivery, it is best to discuss this case in an interdisciplinary group before delivery. This group can develop a plan and be ready for complications at birth.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
No TestDescribe how this course will impact your practice.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • American Academy of Pediatrics. (AAP). (2021). Textbook of Neonatal Resuscitation, (8th Ed). Visit Source.
  • American Heart Association. (AHA). (2023). Fetal circulation. American Heart Association (AHA). Visit Source.
  • Anthony, R. & McKinlay, C. (2022). Adaptation for life after birth: A review of neonatal physiology. Anaesthesia and Intensive Care Medicine, 24(1), 1-9. Visit Source.
  • Elshazzly, M., Anekar, A. A., Shumway, K. R., & Caban, O. (2023). Physiology, newborn. In StatPearls. StatPearls Publishing. Visit Source.
  • Fernandez, C. (2024). Physiologic transition from intrauterine to extrauterine life. UpToDate. Retrieved January 31, 2024. Visit Source.
  • Mandy, G. (2023a). Overview of short-term complications in preterm infants. UpToDate.  Retrieved January 31, 2024. Visit Source.
  • Mandy, G. (2023b). Neonatal complications of multiple births. UpToDate. Retrieved January 31, 2024. Visit Source.
  • Marty, M., Kerndt, C., & Lui, F. (2023). Embryology, fetal circulation. In StatPearls. StatPearls Publishing. Visit Source.
  • Mayo Clinic. (2022). Patent foramen ovale. Mayo Clinic. Visit Source.
  • Saha, U. (2023). Changes in the newborn at birth: Fetal-to-newborn transition. Clinical Anesthesia for the Newborn and the Neonate. Springer, Singapore. Visit Source.