homebirth and oxygen? - Page 2

[womenswisdom]

Originally Posted by rnra 

Let's think this one through...

9:00  Infant is born, has difficulties that necessitate resuscitation
9:03 Resuscitation is not successful, Midwives call paramedics
9:04 Midwives finish paramedic call, paramedics are dispatched
9:09 Paramedics arrive--this is assuming that they are conveniently close to your house, not busy with another call, etc.
9:10  Infant is intubated--this is assuming that the paramedics have skill in intubating newborns--which many do not.  If they aren't experienced, add another few minutes.

Can you hold your breath for 10 minutes?  Can your baby?  

Actually, yes, let's think this one through...
9:00 Infant is born, has difficulties that necessitate resuscitation
9:03 Resuscitation is not successful, Midwives call paramedics WHILE STILL ADMINISTERING PPV - POSITIVE PRESSURE VENTILATION/ARTIFICIAL RESPIRATION
9:04 Midwives finish paramedic call, paramedics are dispatched. MIDWIVES ARE CONTINUING TO GIVE THE BABY PPV THROUGH THE BAG/MASK AND CHEST COMPRESSIONS IF APPROPRIATE
9:09 Paramedics arrive--this is assuming that they are conveniently close to your house, not busy with another call, etc. MIDWIVES HAVE BEEN GIVING PPV AND CHEST COMPRESSIONS AS NECESSARY THIS ENTIRE TIME
9:10 Infant is intubated--this is assuming that the paramedics have skill in intubating newborns--which many do not. If they aren't experienced, add another few minutes.

I don't know where you are getting the idea that the baby is "holding its breath" for 10 minutes while they are waiting for the squad to come. You continue to perform resuscitation until the squad arrives and then THEY continue resuscitation during the ride to the hospital. The baby is getting oxygen from the bag/mask and chest compressions (rarely needed). Resuscitation being "not successful" doesn't mean you stop giving breaths, it means that the baby has not taken over respiratory effort on its own.

[Katie8681]

If air is not getting into the baby's lungs because they're full of meconium, all the PPV in the world isn't going to keep the baby oxygenated while they wait. It's rare, but certainly there are situations where a resuscitation fails because of the absence of someone with the capability of intubation.

[womenswisdom]

I agree with you that there are situations where intubation can be lifesaving, but they are exceedingly rare when dealing with a term, low-risk pregnancy with no signs of distress during the labor.

The following is my understanding of meconium and intubation, which would be outside of my scope of practice, so feel free to correct any misunderstandings I may have. A baby who has already inhaled meconium is not going to be effectively treated with intubation, unless you are meaning intubation for suctioning of the trachea in order to prevent inhalation. If the lung surfaces are coated with mec, it doesn't matter whether air is delivered by PPV or intubation. As long as the trachea is clear and you have an open airway, oxygenation will not be improved simply by intubating.

This AHA article outlines the stages at which intubation may be beneficial, and it does not appear that that is one of them: http://circ.ahajournals.org/content/122/18_suppl_3/S909.full. In fact, it also states "Although depressed infants born to mothers with meconium-stained amniotic fluid (MSAF) are at increased risk to develop MAS, tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants. The only evidence that direct tracheal suctioning of meconium may be of value was based on comparison of suctioned babies with historic controls, and there was apparent selection bias in the group of intubated babies included in those studies."

[IdentityCrisisMama]

Moderator stepping in for a moment, here...

There are some comments and interjections on this thread that border on removal, however, my experience with our homebirth mamas is that they are compassionate towards folks to have concerns about the choice to homebirth. We see this here on this thread. As a homebirth mama myself, I appreciate being thoughtfully challenged and I welcome folks who wish to learn more about homebirth. That said, if you are generally antagonistic towards homebirth and/or are not here to learn and discuss according to our user agreement, I suggest you either read-only or post in the general birth section. Homebirth mamas wishing to discuss a topic in a support-only environment are very much welcome to begin your thread as "support-only" and I will help honor that request by moderating with that in mind. 

Womenswisdom and many others - thank you for your thoughtful explanations!  

[WildDoula]

Homebirth midwives should NOT be intubating, sorry. It is a very invasive procedure and require great skill to get it right, especially in a newborn. Even if you were trained in the theory of intubating, you would never see enough cases in a homebirth practice to become remotely skilled at it. 

[emily11megan]

I was also taught in NRP training last year that room air is now the preferred method for neonatal resuscitation in the UK, and as the US is typically behind in making these kinds of changes, it will be here in the near future as well. 

http://www.resus.org.uk/pages/nls.pdf

Good for you for being so proactive in your care!
 

[KimPekinCPM]

Originally Posted by quantumleap 

KimPekin - do you carry bag, mask and et tubes? 
I'm puzzled at this further information. That's great that your midwife carries oxygen, but how is she going to use it to resuscitate without a bag and mask? I mean, blowing it over his face is sometimes all that is needed (that's all my son would have needed), but if you're really in trouble, your midwife without a bag and mask will have to do plain old artificial respiration. While there's nothing wrong with this, it remains that there is equipment that could help her maintain an airway (the et tubes), and consistent, safe (no risk of transmission of disease, although, I would hope she at least carries a disposable pocket mask!), and that is also the same equipment that EMTs and hospital staff will use if it comes to that. Heck, *I* had an infant bag and mask at our kids' births! You can get them online, and they're effective and not expensive. 
To be noted, I'm not being critical of your birth choices. I don't know if those comments were directed at me. I just think you should be fully awake of the risks and benefits as you move forward with your birth choices, and I think it's awesome that you're asking these questions of your midwife. 

I do carry a bag/mask and use that for resuscitation. I also carry a DeLee suction device for meconium, if needed. I do not intubate, but I do carry a laryngeal mask airway (never needed to use it).

Kim

[InfoThirsty]

In Canada all midwives carry oxygen to a home birth. Quite frankly, I wouldn't agree to homebirth if they didn't! They bring oxygen for mom and oxygen for baby. You never know when a real emergency will crop up, and oxygen truly can make all the difference!

[phathui5]

Originally Posted by WildDoula 

Homebirth midwives should NOT be intubating, sorry. It is a very invasive procedure and require great skill to get it right, especially in a newborn. Even if you were trained in the theory of intubating, you would never see enough cases in a homebirth practice to become remotely skilled at it. 

I agree. And as a parent, I think that if you feel like you need a provider who does intubation, maybe you should be in a hospital setting. It's important to think about what sets of risks you're comfortable with when you choose to birth at home. Myself, I am more comfortable being at home than in the hospital, where routine hospital procedures cause complications. 

[Ratchet]

Snarkiness is getting me steamed.  I live 5 min from a lovely community hospital with outcomes similar to any other typical american hospital.  If I had a baby in the middle of the night there who unexpectedly required intubation at birth, it could be the nurses or OB doing it, who have practice on plastic dolls at NRP but probably rarely actually intubated.  The on-call pedi can be up to 20 min away.  This is not some third-rate hospital in the middle of nowhere, it's just a typical community hospital.  And you know what?  That's life.  Nothing is instant.  Not at home, not at a hospital.  People always think there is some magic that happens in hospitals that just can't be replicated elsewhere.  Maybe they're right, it's called 'nosocomial infections' and 'iatrogenic injuries.'  Birth where you want, I respect everyone's choices, but let's not create a fairy tale about what happens in hospitals.  

An interesting point on the oxygen intubation etc debate is that sometimes having too many interventions at your fingertips delays getting the help you really need.  like O2 for mom in labor- my understanding is that has lost favor, the thought being it doesn't help much and it is one more thing that delays more effective methods of improving the heart rate (like position changes or stopping pitocin).  I think it's good to know that your CPM knows when to call it and get more help, not to just keep trying different things.

[Harmony96]

I'm glad it was just a misunderstanding and she carries oxygen after all.

In my homebirth six days ago, my baby was born purple and not breathing, with a low-ish pulse (80s/90s), and he needed some PPV and a lot of suctioning before he breathed on his own.

[amlikam]

Ok this has baffled me through this tread and I need to ask: doesn't the placental provide oxygenation for a several minutes after the baby is born? My understanding is most rescesitation needs are able to be determined before the placenta stops pulsating so the mentioned time schedule is skewed?
OP I am glad that your midwife has O2 for the slight chance you might need it in labor. I believe most midwives don't carry intubation supplies for liability reasons. When it comes to neonatal rescesitation I would be more incline to trust a certified midwife's knowledge of up to date information as most certifying organizations require recertification

[amlikam]

Ok this has baffled me through this tread and I need to ask: doesn't the placental provide oxygenation for a several minutes after the baby is born? My understanding is most rescesitation needs are able to be determined before the placenta stops pulsating so the mentioned time schedule is skewed?
OP I am glad that your midwife has O2 for the slight chance you might need it in labor. I believe most midwives don't carry intubation supplies for liability reasons. When it comes to neonatal rescesitation I would be more incline to trust a certified midwife's knowledge of up to date information as most certifying organizations require regular recertification- most of the midwives I know certify every 2 yrs!!!! And my understanding certifying doesn't mean just sitting for an exam, it also means taking a continuing Ed course with it.
There is a misconception that midwives are not highly trained professionals and that families who chose home births are misinformed "crazy" people willing to risk their child's life. However all the midwives I know have had extensive trainin coupled with active continued education and most parents who choose home birth spend significant amounts of time researching the facts and asking great questions.
I am thankful we have this forum and I am especially thankful the OP asked about this because it has helped me greatly with my own question.

[rnra]

There is no way to know how much oxygen is actually being delivered through the umbilical cord.  I know that the following blog is not liked among posters here, but it has a good explanation of placentas and oxygen transfer...http://www.skepticalob.com/2011/05/ncb-stupid-pulsing-umbilical-cord.html

[Margo Nelson]

Oxygen is actually a very dangerous drug that is overused and causes damage when used by those who don't understand it.  Midwives on the cutting edge of science now understand that it should not be carried to homebirths - if you want more information, contact Jill McDanal on facebook.  She teaches an entire class on this topic if you want to know the science and reasoning behind this position.  It should be noted that hyperoxia (too much oxygen) at birth, due to the use of o2, is being theorized as causing brain damage - http://www.ncbi.nlm.nih.gov/pubmed/21659719 .  The irony is that the o2 is used because they are afraid that the hypoxia (not enough oxygen) will cause brain damage.  Like someone else mentioned already too, the new NRP guidelines call for hte use of room air in a resuscitation situation. 
 

[rnra]

NRP--the gold standard for resuscitating newborns who are in compromising situations--does not say to completely avoid supplemental oxygen.  NRP says to have supplemental oxygen immediately available, closely evaluate the infant, and prudently administer oxygen when it is indicated.

There are legitimate and emergent needs for oxygen at a delivery.  Risks come from both too little and too much oxygen after birth.  Completely avoiding the use of supplemental oxygen in all situations (which is what happens when you don't have any supplemental oxygen available at a delivery) is not "on the cutting edge of science."

[phathui5]

Originally Posted by rnra 

There is no way to know how much oxygen is actually being delivered through the umbilical cord.  I know that the following blog is not liked among posters here, but it has a good explanation of placentas and oxygen transfer...http://www.skepticalob.com/2011/05/ncb-stupid-pulsing-umbilical-cord.html

Here's another post that describes the process and is a bit less offensive:

http://midwifethinking.com/2012/05/05/an-actively-managed-placental-birth-might-be-the-best-option-for-most-women/

[Alenushka]

She is going to wait 3 minutes to call 911? Really?

The first thing she should do is to direct someone to call 911 while she starts resuscitation

[homebirthing]

Actually, it is more like two and half minutes before calling 911. Not immediately as PPV alone is often enough to start a baby breathing on their own. 

[CookAMH]

This isn't related to homebirth, but I thought it might be interesting to add that my SIL who is a paramedic in KS told me last year that they're finding room air and not oxygen to be better when assisting someone in need - too much oxygen isn't helpful. This is "new research" being used for emergency calls.