Resuscitation of a baby after birth is turned into a huge deal at the hospital, where a compromised baby is detached from it's only supply oxygen (the cord) and placed away from the mother on a hard surface so that the care providers have a clear view to oxygenate the baby in their space.
There is a significant amount of information that tells us that the cord should not be cut early. With this in mind why do hospitals continue the practice?
There is also an on going discussion on whether oxygen should be used as the best means of resuscitating a baby. Midwives in Australia who birth with women at home carry oxygen, this seems to reassure families that if a baby is having a problem at the time of birth the miracle of modern science will help them out.
This is a literature search on the benefits of oxygen:
Background: It is discussed whether depressed newborn infants should be resuscitated with room air or 100% O2.
Objective: To perform a systematic review and meta-analysis including studies that report resuscitation of depressed newly born infants with 21 or 100% O2.
Methods: Inclusion criterion was randomized or pseudo-randomized, blinded or not, studies of depressed newborn infants resuscitated with either 21 or 100% O2. The literature was searched in Medline/Pubmed/EMBASE and The Cochrane library databases. All identified studies were included.
Results: Five studies fulfilled the inclusion criterion in which 81 infants were resuscitated with 21% O2 and 856 with 100% O2. Neonatal mortality was 8.0 vs. 13.0% in the 21 and 100% O2 groups respectively, OR 0.57, 95% CI 0.42-0.78. In term infants neonatal mortality was 5.9% in the 21% O2 group and 9.8% in the 100% O2 group, OR 0.59, 95% CI 0.40-0.87. The figures for the premature infants were very similar. In infants with 1-min Apgar score <4,>
As you can see infants bagged with room air using a resuscitator fared just as well, if not better, than those using pure oxygen.
Here is another:
Both experimental and clinical studies have demonstrated that room air is as efficient as 100% oxygen for newborn resuscitation and improves short-term recovery. The recent meta-analysis by Davis and colleagues in the Lancet includes five studies from the past 10 years where asphyxiated infants were randomised or pseudo-randomised to be resuscitated in room air or in 100% oxygen. A significant reduction in mortality was seen when infants were resuscitated in room air compared to 100% oxygen.
It is astonishing that a brief exposure of only a few minutes to 100% oxygen may be so toxic to the newborn infant; this finding, however, is supported by increasing evidence from experimental work emphasising that resuscitation in 100% oxygen may be associated with an aggravation of cellular injury when compared with resuscitation in air. It is imperative that these findings are reflected in the new newborn resuscitation guidelines and that further research continues in this area of neonatal medicine. Key areas include defining the best resuscitation practice for the preterm infant, designing adequate multicentre, randomised and blinded studies of term newborn resuscitation with adequate outcome data, and pursuing intense experimental research into the mechanisms and prevention of injury from oxygen free radicals.
Read the complete article.
With this in mind, if a baby needs help is the hospital going to use best practice? It doesn't really appear so.
At the birth of a baby an apgar score is taken. This is just a mental picture taken by the care provider of the condition of your baby at 1 minute, 5 minutes and 10 minutes. It is very interesting to see how many midwives and doctors actually wait any time at all before taking the initial apgar.
The apgar is a method of assessing the likely condition of a newborn by measuring its heart rate, respiration rate, muscle tone, response to stimuli and colour. Each test gets a score of between 0 and 2 depending on what the CP thinks. A total score of 7 to 10 means the baby does not need any attention whatsoever, a score of 4 to 6 means the baby probably needs a little help and a score of less than 4 means the baby is likely to need stimulating.
Rubbing a baby and gently blowing and talking is usually enough to ensure the baby opens her eyes to look and take a breath. There is usually no rush as with a cord pulsing the baby is normally getting plenty of oxygenation and will come into herself pretty soon.
Some babies do need a little extra help and bagging with or without oxygen can inflate the baby's lung and with a great heart rate is enough to move the baby into regular breathing.
Midwives have all the skills needed to help out a baby that is slow to come into themselves. At home this doesn't happen often. With a water birth baby's often take a slow transition but with a good pulsing cord the midwife will just wait whilst the mother brings the baby to her chest to celebrate the birth.
Is there another way if the baby needs res us to help out without panic or stressing the baby by cutting the cord and moving away from the mother? OF COURSE THERE IS.
Here is a set of pictures of a baby receiving help whilst in her mothers arms in the water. This was a breech birth and the baby had the cord twice around her neck, which we obviously didn't know until after the birth. Her heart rate was excellent and breech babies often lose muscle tone and response. The cord is pulsing around 120 b/min and you can see that it's full and chunky.
Here resus begins with a bag, mask and a little positive pressure. Stimulation is also being used on the baby's feet.
The baby's heart rate and resps are being assessed by while still being bagged.
This picture is 1 minute and 20 secs after initial bagging began. The baby is now responding and mum can take her eyes from her baby for a minute.
All is well. Mother and baby haven't been separated and they didn't even step out of the water.
If you don't have an ambu bag I think slow shallow breaths into the baby directly will produce the same result.
17 comments:
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
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.
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.
Great photos, as usual. Will show them to my midwifery student. cheers Sarah
Apart from times when you get caught on the hop, would you ever go to a home birth without resuscitation equipment?
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.
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.
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.
You can see by the pictures that I do have the equipment.
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.
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 ;-).
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. =)
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.
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?
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
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.
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
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