During the first few minutes of life, oxygen saturation (saturation by pulse oximetry, SpO₂) increases from intrapartum levels of 30–40%.¹ In algorithms for neonatal resuscitation published by the International Liaison Committee for Resuscitation,² European Resuscitation Council³ and Australian Resuscitation Council,⁴ clinical assessment of an infant’s colour (a measure of oxygenation) and heart rate are used as major action points. However, studies have shown that clinical assessment of colour during neonatal transition is unreliable.^5,6 O’Donnell et al⁶ showed that the SpO₂ at which observers perceived infants to be pink varied widely, ranging from 10% to 100%. Assessing colour is difficult and therefore is a poor proxy for tissue oxygenation during the first few minutes of life.

Kattwinkel⁷ suggested pulse oximetry may help achieve normoxia in the delivery room. The American Heart Association⁸ suggests that “administration of a variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly”. Although “normoxia” and an acceptable time to achieve this during neonatal transition have not been defined, Leone and Finer⁹ advocate a target “SpO₂ of 85 to 90% by three minutes after birth for all infants except in special circumstances”—for example, diaphragmatic hernia or cyanotic congenital heart disease. International surveys show that oximetry is increasingly used during neonatal resuscitation.^10,11

To date, there are no evidence-based guidelines for using oximetry to measure an infant’s SpO₂ and to guide interventions during neonatal transition after birth. We reviewed the literature to evaluate the evidence on the use of SpO₂ measurements immediately after birth.

HOW DOES PULSE OXIMETRY WORK?

Pulse oximetry measures SpO₂ continuously and non-invasively, without the need for calibration, and correlates closely with arterial oxygen saturation.¹² Pulse oximetry is based on the red and infrared light-absorption …