INTRODUCTION The Neonatal Resuscitation Program (NRP) guidelines recommend positive pressure ventilation (PPV) in the first 60s of life to support perinatal transition in non-breathing newborns. Our aim was to describe the incidence and characteristics of newborn PPV using real-time observation in the delivery unit. METHODS Prospective, observational, quality improvement study conducted at a tertiary academic hospital. Deliveries during randomized weekday/evening 8-h shifts were attended by a trained observer. Intervention data were recorded for all newborns with gestational age (GA) ≥34wks that received PPV. Descriptive summaries and Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables were used to compare characteristics. RESULTS Of 1135 live deliveries directly observed over 18mos, 64 (6%) newborns with a mean GA 39±2wks received PPV: Median time from birth to warmer was 20s (IQR 15-22s); PPV was initiated within 60s of life in 29 (45%) and between 60 and 90s of life in 17 (27%). PPV duration was <120s in 38 (60%). Seven/21 (33%) newborns that received PPV after vaginal delivery were not pre-identified and resuscitation team was alerted after delivery. We found no association between PPV start time and duration of PPV (p=0.86). CONCLUSION We observed that most (94%) term newborns spontaneously initiate respirations. In over half observed deliveries receiving PPV, time to initiation of PPV was greater than 60s (longer than recommended). Compliance with current NRP guidelines is difficult, and it's not clear whether it is the recommendations or the training to achieve PPV recommendations that should be modified.