43 responses to “Resuscitation Of The Newborn”

  1. tie-dyed doula

    This is awesome! The pictures are bringing chills and tears! Thank u! I want to share and learn and I have done both by reading your post. I believe in you and I believe in birth-keep the positivity coming! Shine On-Tie-dyed doula :O

  2. Midwifery is catching

    Great photos – possibly the only ones I’ve ever seen that show a normal birth and a nice blue babe pre-pinking up. You are doing amazing work with this blog.

  3. midwife of the plains

    Thank you so much for this post. I apprenticed w/ a midwife who did not/does not carry O2. Your blog is an inspiration to me. The photos really do tell a story all their own.
    I am new to the blogging world. I am happy I came upon yours.

  4. Sarah Stewart

    Great photos, as usual. Will show them to my midwifery student. cheers Sarah

  5. Sarah Stewart

    Apart from times when you get caught on the hop, would you ever go to a home birth without resuscitation equipment?

    1. Marlene Waechter

      although I have o2 & an ambu bag, I never use either. My 1st response, if resus is needed is to do mouth to mouth/nose. If that alone didn’t work, the I would have my asst get out the equip, but have never needed to in over 30 yrs of doing births!

  6. Lisa Barrett

    I would if the woman had a preference, mouth to mouth is as good as bagging. I was at a birth last night and I didn’t even get the stuff out of the bag. If you read the work of John Stevenson he didn’t carry anything.

  7. Sarah Stewart

    This is a fabulous conversation and I hope you don’t mind if I disagree with you.

    I actually think you are opening yourself up for major legal problems if you are not ‘properly’ equipped to deal with maternal and infant resuscitation at a home birth and things turn to custard. I am not saying you have to take the ‘Special care baby unit’ with you – oxygen, suction etc can be discretely placed out of the way but at hand if required.

    Often as not, its the ‘didn’t have time to get anything out’ births that are problem free.

    As for woman’s choice – yes, of course you have to regard that. And again, equipment can be kept out of the way but still available. But if I felt a woman’s choice was putting me at risk professionally (she wouldn’t let me have that equipment somewhere at hand), then I would have to seriously consider whether I continued working with her.

    Would be very pleased to hear what others say.

  8. Lisa Barrett

    Of course I don’t mind you disagreeing with me. In the UK it is already common place not to carry O2 and all the research says that suction is of no benefit. It’s all according to what you deem is preparation over what is custom and practice in your area. I do carry O2 and a deelee sucker as it’s what is custom and practice and I would be judged on that if there were a problem. I would always do what the woman wanted which means sitting in the car outside if she’d prefer, but I understand midwives who feel compromised by this.I feel that a woman’s choice is just that and as long as she is willing to own her decision then the responsibility is with her. I am also happy to be a point of contact for women who UC. I don’t consider this to undermine my professional status but enhance it. I too would love comment on this.

  9. Lisa Barrett

    You can see by the pictures that I do have the equipment.

  10. Sarah Stewart

    I have to admit, Lisa, that I am speaking from a rather out of date point of view. It’s been a couple of years since I have done a resuscitation update so I acknowledge that my knowledge isn’t so current as it should be. I haven’t had a case for a couple of years so this will be something I’ll have to attend to when I pick up cases again.

    My context is that I only have a few cases a year and even fewer home births, so I do not have the confidence that I would have if I was practicing full time. This is something I have reflected on in my ePortfolio and NZCOM standards review: http://tinyurl.com/6x46pn

    The way I handle this is to make sure I have excellent back-up.

  11. I am Brooke...

    And again, freakin’ fantastic Lisa!

    You are just an amazing well of knowledge on all things birth!

    I can’t shake the urge to have another baby just so you can catch it ;-) .

  12. sarmakala

    MY 3rd birth was my second UC birth. My son was born face/brow with his cord tight in his nuchal hand. It was a waterbirth, and I was experienced with my 1st UC waterbirth where the baby was relaxed and slower to react to being born, but there was something different with my son, and I knew he needed a little help. I gave him mouth-to-mouth until he responded. We were quite relieved when he started to fuss and pink up.
    I would not have wanted him to be deelee’d or have plastic over his face when this worked fine. (I had done research on it before-hand.)

    Thank you for your excellent website and your dedication to normal, natural birth. =)

  13. pinky

    Lisa: That is not true. We wait 60 seconds before we give the 1 minute apgar. And 5 minutes for the 5 minute apgar.

    We use 100 percent 02 on term babies. Preterm babies we delay the cord clamp and give room air for ppv. However, if they do not resolve we then give o2.

    I have to beg to differ when you say mouth to mouth is just as good. You do not know how much pressure you are putting in the babies lungs with your mouth. With a bag mask, you can measure to make sure you do not over inflate. Over inflate = pneumothorax….Remember 1st do no harm.

    1. Amy in Oz

      With mouth-to-mouth or air blown from a human, you get the benefit of humidified, warmed air. This is something that cannot be done with resus equipment.

      Also, blowing with your mouth, you would get the feedback of feeling the pressure changes in the sensitive areas of your mouth and lips, and not just seeing chest rise and fall like with resus equipment. While having a pressure gauge when you are bagging will give you a visual cue to avoid a pneumothorax, experience also teaches you how firmly/softly to bag. I am not a midwife, but as a PICU RN, I bag patients on the majority of shifts (not just for desaturations/resus, but also when suctioning intubated patients or those with trachies), on neonates to 18year olds, without a pressure gauge. It absolutely is not necessary, and having the experience of bagging means you are looking at the person you are bagging, not the gauge by the cylinder/wall outlet…

  14. Lisa Barrett

    Having been in charge of a unit in the UK and in Australia I know exactly how resus works in a hospital situation. Plus I was talking generally and not about you specifically.

    100% O2 on term babies – there is plenty of research on that and I know how you love evidence Pinky.

    I would love the stats from your hospital that show there has never been a pneumothorax with resus.

    Maybe before saying do no harm you can look at the hospital practice. I have extensive experience in both settings, what about you? How is your homebirth experience going?

  15. Marta

    Thank you so much for this article! I am a doula an aspiring midwife and just discovered your site. You have beautifully answered a question I’ve had for awhile. I doula’d a hospital birth awhile back in which the mother received Stadol twice by injection. No other interventions. The baby was born with one loop of cord and bright blue. About 10 seconds after birth, since he had not started to breathe, they hacked off the cord (blood everywhere) and began to handbag him for 10 minutes before he started to breathe again. He was fine, but I never understood why they had severed the cord. One nurse said it was so that the resuscitation team could reach him, but didn’t the cord still provide him with 02? Would you hazard that he would have “pinked up” sooner had he been bagged with the cord intact?
    Thanks again,
    Marta

  16. Rebekah Costello

    Wow! Thank you so so so much for this post!

    I mentioned a while back that I had an unattended birth that turned out to be footling (surprise!). Looking at these pictures set to rest something I’ve been quietly harboring for the past 17mo. Abigail was born limp like that and not breathing. Heartrate was steady (I could actually feel the cord pulsing between my legs) and she did move her foot once. I didn’t have a bag (obviously) so instead I blew on her face, turned her over and rubbed her back (while trying to keep her head inclined more towards the floor) and turned her back over and just gently sucked out her nose and her mouth with my own. The whole process took less than a minute thirty and she was really letting us know how much she didn’t appreciate the “kiss of life” by the end of it.

    Somewhere in my head I’ve always struggled with telling this part of the story. The few people I’ve shared it with say “Oh well you were lucky she didn’t die”. Maybe so, maybe all of us with living children are. But it’s nice to have solid “proof” in front of me that we did the right things (well, lol, aside form the fact that she’s 17mo old and getting into everything and growing like a weed!).

    Anyway, thank you, this was very informative and I learned some things I didn’t know, too. I do wonder, though, I don’t know if I’d call what we did resus. What do you think? She was pinking up already before I started rubbing her back, just not breathing. she was on the perenium for a good 6 minutes before she was born, too, but she was kicking her feet and moving around quite a bit up until that last minute. I’ve always wondered about that but been afraid to ask.

  17. Marina

    I’m writing from Roma, Italy. During the last home birth I attended the baby was born limp and I had to perform resuscitation and chest massage,well I believe that what really made that baby to “decide” to live was his mother talking all the time to him and calling his name
    Marina

  18. Anonymous

    I just wanted to say you warmed my heart with your post on providing contact for UC women.

    DH and I really love the idea of an UC and also recognize the skill and passion of midwives. It's hard feeling rejected not only by the medical community, but by midwives as well.

    Thankfully we found an amazing midwife who didn't bat an eye at our choices. If she wasn't underground, I would tell every woman I know about her.

  19. nat

    Hi everyone!
    I've really enjoyed reading this blog and will definitely keep an eye out for more info. I'm due in Feb with my 4th bub and my second homebirth. I think alot about this topic and i do believe i need to know more about newborn re sus. You can never have too much information. I'm a huge believer of mothers intuition but i am also aware of things that can evolve that we dont always expect. I'm also just writing to say thanks so much for sharing this information and i'll be looking into this topic more from now! xo

  20. Anonymous

    I just happened to stumble across your blog and found the pictures beautiful!

    I am a PICU nurse expecting my first baby in just a few short weeks (will be a home birth).

    Although I understand the benefits of not clamping the cord to resus, I would personally find it extremely difficult to resus a baby who is being held in his mom’s arms… So although not clamping may appear ideal, I would prefer a quick clamp and cut in order for the midwife to resus more efficiently (on a flat surface, good light etc…)

    But that’s just my out of my own resus experience, if some midwives can effectively resus as you’ve shown then why not…

    Ashley

    1. Kate

      Hi Ashley, given your experience and preference to clamp and cut, I would love it if given your profession and access to medical information if you would explore research on placental transfusion.
      My son had his cord cut BEFORE he was born because he presented with a nuchal cord and that was the ‘preference and experience’ of the medwife. Cord compression, then clamp (I thought I was being cut, i was on hands and knees and couldn’t see a thing), then cut, then ask me to quickly push out my 9lb10oz baby that was yet to rotate.
      The resus, respiratory distress, infant formula to treat his hypoglycaemia (HYPOVOLEMIA!) and subsequent developmental delay was entirely avoidable!
      Home birth would have protected my son from this harm and placental transfusion via an intact cord would have reperfused my son and supported his transition.
      I can’t help but feel aggravated by medical training and hospital practice when I read comments like yours, sorry.
      K

    2. Jaime

      Ashley, Are you familiar with a resuscitation board used by some homebirth midwives?

      Some more info…

      http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2010/8/26/resuscitation-board.html

  21. Rebecca Costello

    Ashley I read your comment (congrats on the new little one coming soon!!) and was wondering: do you think your training on how to resus may be affecting your perspective? I just mean that if you have been trained to do it a certain way and have always done it that way, I could see how imagining doing it differently would seem difficult.

  22. Tracy

    The first surprise footling breech that I attended the baby needed resus I didn’t hesitate to resus on the mother’s chest with her in the birthing pool. The stories that I have come across of babies that were barely making it then there mothers hold them or call to them and they come around is enough for me to know that babies need their moms. They also need that placenta to stay attached when they are having trouble. The mom needs the baby too. It helps her to expel the placenta and not bleed. Because the baby never left the mother this was not a trauma at all just a little help.

    I think this is very important. How we handle what could turn into an emergency affects the bonding of that mother and baby. This carries lifetime consequences. This better not be overlooked when we are choosing how best to help mothers and babies.

    I was truly blessed to have just read some of Lisa’s material and watch a video of a footling breech birth these made me quite clear on what to expect and what to do and what not to do. Thanks Lisa for all that you do.

  23. Jade

    I have 2 children, neither breathed immediately after birth (1 minute apgars were 7 (son, hospital birth) and 6 (daughter, home birth))
    My son was immediately severed from his cord, given O2 and suctioned (not with a sucker though they used a tube and shoved it right down his throat) It was treated like an emergency, he never recovered from the experience and refused to feed in any way shape or form, he didn’t want to know about anything near his mouth for weeks. I have never recovered from allowing that to be done to my son. After reading more about it after the even t I have realised just how wrong it was, not only did he not need to be deep suctioned but he didn’t need resuscitating at all.
    My daughter’s cord was never cut, we blew into her face while my mum went to grab the O2 which we put kinda near her nose, I was encouraged to talk to her and rub her feet. No one ever felt like it was an emergency, no one was ever worried and she pinked up beautifully very quickly and took to breastfeeding like a pro.

  24. Nicole

    I am curious as to what is going on in the neonates body while blue/limp and why you use the term “come into herself’? Does the pulsing cord (if 120ish bpm) provide adequate oxygen to the baby??? If so why are they still blue/limp? Is there cerebral compromise at this point? It sounds from most posts that no, their blue babies pinked up and have went on to be very healthy kids. I am just nervous as I am a pediatric nurse, and have had to have a scheduled C/S for my breech boy at 40 weeks. (I live in the US)…I would love to have a home birth for my next one but my husband is very sold on the idea that we need to be near the “emergency equipment” in case something happens to either of us, mom or baby.

    Also do we know why some babies come out crying immediately and why some dont?? Is it simply how quickly the fetal/placental/lung circulation switches over??? Or is it other things like the baby had a nucchal cord, was breech etc?

  25. Saucy Johnstone

    Lisa-

    I am so glad that you opened up this conversation! I want to share with you and your blog readers the story of Milosh Kalapasev one of only 150 males in the world who lives with a rare genetic disorder called Barths Syndrome.
    http://www.barthsyndrome.org/english/view.asp?x=1

    Please excuse my spelling as I need to rush off to prenatals shortly : )
    Brie Chandler Kalapasev and Ned Kalapasev, his parents have Ok’d me discussing his birth.

    I stopped Carrying 02 about four years ago due to the overwhelming support of scientific literature that it damamges babies. I have only needed it at one birth for a baby that had an extrodinary PVC pattern. The family chose to birth at home after NSTs and other test showed that there was not a congenital problem. Premature Ventricular Contractions are an “electric” problem, not a heart muscle problem. I did not bag with O2, but did low rate blow by for nearly two hours till the baby transitioned
    We transported in labor beause of nonvariable FHTs, and a very strong gut feeling on my part. In the hospital, his cord was not cut, and when he didn’t start to come around the way that we wanted to My friendly and open minded OB was open to bagging him with 02. However, at the hospital they do not have self inflating bags! They only have bags that work when hooked to straight 02, and there is no 02 mixer on L&D. It’s either all or nothing. I sent my student to the car for my bag, and when I attempted to inflate his lungs, I didnt get chest rise on the right side, and then said “OK, 02 it is!” Milosh did NOT recieve 02 untill nearly 20 minuites after his birth.

    This may have SAVED HIS LIFE!!!!!

    One of the issues with Barth’s Syndrome is that free radicals, a byproduct of 02 breakdown and usage by the body, are not able to carried out of cardiac cells, due to the lack or weak production of a certain protien. The enlarges due to the stress, and then heart failure can occur.

    Milosh was born with an enlarged heart, his cardiac muscles could barely handle three chambers working in utero- remember that the ductus arteriosus is open allowing blood to bypass the right chamber whch pumps blood into the lungs for oxygenation because baby is not breathing.

    Because there are only about 150 males alive with Barth’s, and because no one has done any reasearch on the effects of babies born with cardiomyopathy being recussitated, ( I doubt any hospitals in the US would be willing to do any clinical trials on the effects of recussitation with 21% 02 which is room air, due to the fact that is STILL standard of care to use 100% 02 on neonates, but NOT Adults in cardiac failure, despite the evidence of it’s dangers) I can not state that it a fact that 100% oxygen could have pushed Milosh over the edge. He did go into heart failure the next day at Children’s Hospital.

    It was not known that Milosh had Barth’s for nearly six weeks. The Hospital that he was born at was VERY displeased that he had initally been bagged by me, and with room air. The fall out from this was extrodinary.

    All we knew in those first weeks was that he had left ventricle cardiomyopathy, which can be caused by anything from an in-utero infection to congenital defects. I scoured the literature, because I knew with every fiber of my being that if his cord had been severed immediately after birth, whch is standard practice in the US and causes 1/3 of the baby’s total blood volume to be trapped in the placenta, as well as shocking the ductus ateriosus shut, he would have flatlined then and there.

    If he had been given 100% 02 if that had occured, or immediately after birth even with the cord still attached, I truly belive he would not have come out of cardiac failure the next day.
    As well, in my recent conversations with Brie and Ned, it has been interesting to hear about the use of N02, nitrious oxide, by Childrens to help Milosh’s lungs work better while he was waiting for his heart, and afterwards. N02 is used by experienced divers who recieve a NITROX certification, to increase the efficency of their oxygen usage (which is 21% in the tanks) so they can stay down on a dive longer.

    So my questions are-

    Why aren’t we studying recussitations with N02 and < 100% 02 on babies who are diagnosed prenatally with an enlarged heart, or other heart defect? (Milosh did not show an enlarged heart during prenatal scans)
    Why do only SOME leve III NICU's have 02 mixers? Why isn't this standard as it is in cardiac NICUs?

    WHY ARE WE DAMAGING BABIES TO PROTECT HOPITAL AND PHYSICIAN LIABILITY???????????

    The science is there in animal models and in international studies. It is now standard protocol in the US to bag adults in cardiac arrest of with an anuryism with room air, and to cool their body by icing them to lower free radical damage. Why, Why Why, are we cutting cords, giving babies 100% and making sure they are 98.6 degrees by sticking them in a warmer and hatting them, when intercranial cooling from the condendation of births fluids off the baby's very large head PROTECTS THE BRAIN from any free radical damamge that may have occured from the natural occurance of mild hypoxia that most newborns experience during second stage???

    This is why I am a midwife, so I can practice evidence based care, and not kill or damage babies in the name of liability. Those of us who can practice evidenced based care need to hound our medical communities to put babies lives first!

    To see a local news story on Milosh and his journey to a new heart please see-
    http://www.wcpo.com/dpp/news/health/healthy_living/ft.-wright-baby-fights-for-life-and-new-heart

    May is International Barth's Syndrome Month, and April was International Organ Donor Month. Please, if you have not already signed up to be an organ donor consider doing so.

  26. Eve

    Excellent article and comments. We don’t usually carry O2 here in the UK for homebirths. I did mouth to mouth /nose resus at a homebirth, baby was gasping, and it worked fantastically. I wouldn’t think twice about doing it again. I felt happy to do this as had attended the NLS course, where they mentioned it. Gentle breaths, from a human being. Baby picked up brilliantly. Ensured my faith that babies are made to breathe, however scary it looks to us on the outside.

    Thankyou for all your inspiring blogposts. I agree at your point of contact for UC women. They are making a choice for themselves and their babies, and we should respect that.

  27. Gillian Kozinka

    I Have read all the comments on the site and feel its only a matter of time before you run out of luck and really the long term sequelae of your actions due not impact you, only the infant and the family that engages your sevices.

    I have been at the rescue end of many home births as an NICU clinician, and firmly believe it is irresponsable to attend a neworn’s delivery without equipment. We do not use O2 initally the guidelines have changed according to the evidence and we practice delayed cord clamping as it is evidence based. Perhaps a trip to Neonatal follow up clinic may help clarify some of your misconceptions.

  28. Rachael

    Clearly Gillian, you didn’t read the post very well. Lisa very clearly stated that she does carry resus equipment and uses it as required. It just isn’t rush in and separate the mother and baby needlessly, as that is not safe practice. You can see by the pictures that Lisa is using a bag and mask to resus. All homebirth midwives carry appropriate equipment should it ever be necessary. All homebirth midwives have appropriate training in ALS, neonatal resus, ALSO, MaCRM and the array of other courses out there. All homebirth midwives are well researched and carry out appropriate clinical practice, whether this is sitting on their hands staying out of the way of the birthing mamma or actively resuscitating a baby. Homebirth midwives do more training than hospital midwives because they highly regard their practice, their women and babies. Don’t you dare judge a homebirth midwife when it is very obvious you have never attended a homebirth, don’t think for a minute you understand what happens at a homebirth!

    I find it very disappointing that you are also laying claim that in some way homebirth is unsafe, and for some obscure reason you feel like you are a hero for ‘rescuing’ all these mothers and babies. What rot! Research has very clearly demonstrated that homebirth is very safe. It is also practiced in various areas around the world, SAFELY! Don’t spill your vile here about what happens in hospitals, I too have worked in the hospital and know all to well what happens and it certainly is not evidenced based.

    Occasionally mothers or their babies need to transfer to hospitals, it would be more appropriate that you keep your antihomebirth slant to yourself….

  29. Gillian

    I too trained in the UK now practice in Canada. No where in my last comment did I mention a 100% safety record as anyone with access to google can find many references to errors in hospital care. The birth plan can go horribly wrong both at home and in the hospital, my point was to convey that having the safety equipment and the personnel at hand can reduce the long term problems for the infant, the comments above that I see the services NICU offer are in some way heroic couldnt be further from the truth, as the term “rescue” is the sad reality. Neonatal research is granted in its infancy but as stated the evidence we have is adopted, ie minimal o2 use and delayed cord clamping, it is most alarming that the comments above resort to personal attacks. If it is your aim with this blog to share information, you have to include information for your readers about the risks. I repeat hospital births go wrong too but at least the help is on hand instead of an ambulance ride away, which might be the difference between a healthy infant and a damaged one. With reference to the previous comment I have attended a home delivery, and women have the right to choose. Unfortunately ask any NICU nurse with the experiences we have had, we would choose the help on hand if its needed.

  30. Celesta with woman

    Wow……… have contemplated how i would resus while in tub and get good neck/head posture…… What do you think of mothers puffing into babies mouths instead of midwives…..

  31. Susan

    My baby was born in the hospital with the cord tight around her neck. The doc did a full episiotomy and after her head came out he clamped off the cord and cut it and then I pushed her body out. They had to bag her, and they took her away. I saw her about an hour later. She did great! So happy with my doc….

  32. Judy Chapman

    Interesting Susan. The episiotomy would have been done prior to knowing of the tight nuchal cord I guess, unless diagnosed by ultrasound, then there probably would have been a caesarian.
    Tight nuchal cord is not an indication for cutting the cord before the birth of the baby, there are ways to achieve birth with an intact cord. As soon as you cut the cord the baby has NO way to oxygenate its lungs and unless you can push the baby out straight away then they start to suffer hypoxia. There is no guarentee that you can push the baby out straight away, sometimes the shoulders are stuck, by this time the baby is in a dire situation. If the cord is intact, even though tight, the baby will be getting some oxygenated blood through any manouvers to get the shoulders birthed.
    Then, as Lisa has showed, if the baby is shocked at birth, the one thing this baby NEEDS is it’s full complement of blood, not to have a quarter of it’s needed post birth blood volume sitting uselessly cut off in a clamped cord and placenta. Resus with the mum and good results in most cases. Equipment for those small number that need more.
    There is good documentation of babies who have died because of cutting tight nuchal cords prior to the birth.

  33. Anaria

    I am a midwifery student currently training within the UK and have been researching the many different aspects of care that midwives provide. I have just discovered this website and love the way that the woman and her family’s choices are actively sought and followed. That said, there are a few comments on this page that I feel have become quite personal and somewhat unnecessary. I appreciate and understand that everyone practices differently and that not all midwives would agree with each other, but it feels like comments made are commenting against each other rather than providing a different perspective and insight! Surely as midwives we should be working together in a professional manner, one where we can learn and reflect upon each others practices, perhaps I’ve interpreted these comments incorrectly but it is this thread is beginning to lose it’s initial perspective and has a more personally critical and defensive feeling.

    I guess the reason I write this is my initial reaction was great what a fantastic source of information, however I am now a little cautious about whether it’s appropriate for me!

  34. Juli Townsend

    I used to tell the mother to talk to her baby, as well. I believe they respond better to known voices. Once in a hospital baby resus situation where the doctor had taken the baby to the resus cot, I asked the father to come and talk to the baby. It may have been a co-incidence, but the baby came good as soon as the father began talking to it.