The abundance of angiogenic blood vessels and the fragile germinal matrix vasculature in the brain are prone to rupture and bleed, which can lead to intraventricular hemorrhage (IVH). 

IVH can be due to:

• Obstruction in venous drainage
• Rapid changes in CO₂
• Erratic blood pressure changes
• Changes in blood volume

Tissue ischemia in the brain can also occur after prolonged periods of inadequate blood flow to the brain, which can cause lifelong disabilities. Excessive oxygen administration also causes damage to the developing retina, causing visual loss.

Care must be taken with all handling of the preterm baby to prevent neurologic injury. It is easy to forget this aspect of care in intense situations such as resuscitation. The baby’s lower extremities must not be positioned higher than the head to avoid increased pressure in the brain. 

Care is required during PPV and CPAP to avoid delivering too much inspiratory pressure. High pressures cause volutrauma and pneumothorax. Increases in thoracic pressure also prevent venous return from the head and increase the risk of a brain hemorrhage. 

Oxygen concentration must be titrated appropriately using an oxygen blender and a pulse oximeter. Oxygen saturation should be monitored continuously until the baby demonstrates the ability to maintain normal oxygenation while breathing room air. Arterial blood gasses can aid during respiratory therapy to prevent rapid changes in CO₂. Large volumes of volume expanders are to be avoided. Volume replacement must be infused slowly over 5–10 minutes. Hypertonic solutions are not recommended.