Resuscitating a just born baby

[Ambivalent Dreams]

My DC #2 was born limp and blue.  We were in a hospital and the nurses whisked him over to a table across from me where I could not see exactly what they did to him to resuscitate him.  I do no think it involved any "mechanized" equipment, if that makes sense.  I imagine they suctioned him using a some sort of device?  He was revived and his second apgar score was fine.

What is the standard procedure for when a baby is born blue and limp?  Is it the same procedure in a hospital, birth center, and home birth?  The OB never touched my son after he was born.  The nurses did all the work on him and she never stopped tending to me.  What birth professionals have the training to revive a baby in this situation?  (OBs?, CNMs? CPMs? RNs in a labor and delivery unit?)

[rnra]

The gold standard for resuscitating newborns is called NRP.  NRP is an evidence-based approach to resuscitating newborns.  It is geared towards use in the hospital but its tenants are applicable outside of the hospital as well.  You can read more here...

http://www2.aap.org/nrp/about.html

Resuscitating newborns is not just about having a specific certification or course completed.  In addition to a strong knowledge base, it requires a set of skills that need frequent practice in order to remain current.  Many hospitals in my area require their staff to recertify with NRP every 12 months with frequent drills and real-life practice inbetween.  Every second counts.  When a baby is born "limp and blue" (as you described), he/she needs someone who can act immediately, instinctively, and accurately--not someone who sort of fumbles through.

As to who does the actual resuscitating in a hospital--that will vary based on the hospital staffing and usual patient population.  In the systems I am familiar with, there is a nurse specifically assigned to the baby at delivery.  If she runs into problems, there is a button she pushes and an anesthesiologist, two respiratory therapists, a neonatologist, and five other nurses arrive to assist with resuscitation.  Everyone runs--they are usually there in less than 45 seconds.  If potential problems are noted prior to delivery (persistant low heart rate, meconium, etc.) then those other people are even closer--they usually wait outside the delivery room door for an "all clear" or a "come and help."

[Alenushka]

This level of NRP is not possible at home with one MW or at a  stand alone birth center that is ran by CPMs. They simply do not have the kind of qualifications and practice requires.

[Ambivalent Dreams]

rnra: Thank you. This is a matter of concern for me. I don't think that level of support was available at the hospital where I delivered. No one ever entered the room except this OB, my doula and husband, and several nurses. I wonder if most small hospitals have the capacity you described?

Alanushka: what about free standing birth centers run by CNMs? Are they capable of adequately performing NRP?

[Ambivalent Dreams]

More thoughts: so what did they likely do to revive my son? Run a suction of some sort down his throat? What is the process?

[womenswisdom]

Originally Posted by Alenushka 

This level of NRP is not possible at home with one MW or at a  stand alone birth center that is ran by CPMs. They simply do not have the kind of qualifications and practice requires.

I see you talking a lot about what CPMs are qualified to do with no evidence that what you are saying has any basis in actual experience or fact. CPMs are required by NARM to maintain the exact same certification for NRP as providers in the hospital, the instructors trained and approved by the same organization. In fact, the NRP classes I have taken were specifically for OOH birth and lasted several hours longer than a hospital-based NRP class because it covered additional material. "This level" of NRP, as you stated...what does that mean? We have no idea what level of NRP was done for this baby - 90% of NRP efforts are stimulation only (per AAP), which could certainly be done by one mw. PPV or chest compressions should be done by two people, with one to administer the PPV and one to check heart rate, but that is only 1% of all births and unlikely to have happened in this scenario since she saw no equipment being used.

Anyways, OP, it's impossible to tell what type of thing was done for your baby at birth from what you have described. Likely it was just stimulation and possibly suctioning (although that is not part of NRP unless more advanced measures are going to be used, but is still very commonly done). The next level would have been positive pressure ventilation, which would have involved a bag and mask over the baby's face and inflating the lungs. If you saw no equipment being used, it's likely that the resuscitation was only stimulation and possibly suctioning. Many babies who appear to need help recover very quickly but I'm sure it was difficult for you to see what was being done with the baby on the other side of the room. It's a very scary situation to be in as a mother, which is why, when we do resuscitate at home, we leave the baby connected to the cord to continue to receive whatever oxygenated blood might still be going to the baby from the placenta and for the mother to be able to see what is going on with her baby while we do whatever needs to be done on or right next to the mother. If you want to know for sure what happened, you can request a copy of the medical records, which will have everything documented.

[Ambivalent Dreams]

Womenswisdom: I assume home birth midwives would have this face mask and suctioning devices with her when she comes for a delivery?

[womenswisdom]

Yes, that would be part of the normal equipment that a home birth midwife would carry.

[nilatti]

My husband actually got certified in NRP before our second homebirth because my first was so fast, I was really afraid that the (CPM) mw wouldn't get there in time! He had an ambi bag and stethoscope and everything. The CPM also had this certification, as I believe is required in VA. Luckily, it wasn't needed, but it made me feel better to know that he had that training, just in case.

[phathui5]

Originally Posted by Alenushka 

This level of NRP is not possible at home with one MW or at a  stand alone birth center that is ran by CPMs. They simply do not have the kind of qualifications and practice requires.

Yes, resuscitation at home can be different than it is in the hospital, but you are incorrect when you say that CPMs do not have the qualifications. NRP is required to maintain the CPM credential.

[katelove]

Originally Posted by Ambivalent Dreams 

More thoughts: so what did they likely do to revive my son? Run a suction of some sort down his throat? What is the process?

I am from Australia and we often do things differently over here but generally the first thing we do with a newborn would be stimulation (drying them generally) while assessing their heart rate and respiratory effort. Often just stimulation is enough. If not the next tho g would probably be oxygen, either blow by with a tube held under their nose or using a neopuff (a mask with a little finger-controlled valve to deliver breaths). The majority of babies won't need more than this. 

Suction should only be used if there is obviously a lot of fluid in the mouth and nose. It will only be used to clear those spaces though, it won't be put down their throat. That is only done if there is a lot of meconium present and even then it's controversial. That said suction does tend to be overused (IMO) and is often done where just some gentle wiping and good positioning would suffice.

[Ambivalent Dreams]

We think he was blue from aspirating meconium, but can't really be sure, I guess. My water was heavily stained with meconium and it was a long, exauhsting labor for me, so maybe it was for him too.

[Ratchet]

It used to be standard practice to deeply suction any baby with meconium stained fluid.  It has not been found to be as helpful as was once hoped (and can be harmful) but is still common in the care of babies with meconium stained fluid, and might be helpful in some cases (or at least makes providers feel like they are doing something).  That is probably what happened with your baby.

Alenushka- the type of NRP described by the second poster would not be available in a lot of settings.  Most community hospitals do not have a pediatrician, NICU staff, or anesthesiologist present in-house at all times and it is the birth attendant and nurses who do most of the initial rescuscitation.  People get all uppity about what is NOT at a home birth and forget that MANY hospitals don't have extensive staff.  IMO, nurses and home birth providers are MUCH better prepared for NRP in these limited settings than in big hospitals, because they are the ones running the show, not a NICU resident etc.  All equipment for initial NRP(what would happen in the first few minutes-- such as oxygen, bag/ mask, ET tubes, suction, etc) is absolutely present in birth centers and at home births, and most home birth providers are not there alone, but have an assistant who is also NRP trained with them.  Pretty similar to my neighborhood hospital.  I would also like to point out that this baby would have likely risked out of a home or birth center birth because of heavily stained amniotic fluid (and maybe due to the length of labor too) -- and for women or providers who would choose to remain at home in those situations, I would hope that all parties are making informed decisions, regarding what was available for resuscitation.  

[ShaneR]

Originally Posted by rnra 

The gold standard for resuscitating newborns is called NRP.  NRP is an evidence-based approach to resuscitating newborns.  It is geared towards use in the hospital but its tenants are applicable outside of the hospital as well.  You can read more here...

http://www2.aap.org/nrp/about.html

Resuscitating newborns is not just about having a specific certification or course completed.  In addition to a strong knowledge base, it requires a set of skills that need frequent practice in order to remain current.  Many hospitals in my area require their staff to recertify with NRP every 12 months with frequent drills and real-life practice inbetween.  Every second counts.  When a baby is born "limp and blue" (as you described), he/she needs someone who can act immediately, instinctively, and accurately--not someone who sort of fumbles through.

As to who does the actual resuscitating in a hospital--that will vary based on the hospital staffing and usual patient population.  In the systems I am familiar with, there is a nurse specifically assigned to the baby at delivery.  If she runs into problems, there is a button she pushes and an anesthesiologist, two respiratory therapists, a neonatologist, and five other nurses arrive to assist with resuscitation.  Everyone runs--they are usually there in less than 45 seconds.  If potential problems are noted prior to delivery (persistant low heart rate, meconium, etc.) then those other people are even closer--they usually wait outside the delivery room door for an "all clear" or a "come and help."

Thanks for this informative post. It can be very useful for a lot of people out there. By the way, I had read several articles regarding resuscitation. There was a quote that caught my attention. It says that witnessing the resuscitation would “help family members understand that everything possible to bring the patient back to life has been implemented.”

[Ambivalent Dreams]

Shane, your link directed to a malpractice attorney's page. Is that where you meant for it to go? I didn't see anything articles about resuscitation.

[MissAnthrope]

What was probably done, as others have said, was suction, drying/stimulation of the scalp, and possibly bagging.

Midwives are generally taught to talk to the baby or invite the mother to talk to the baby, keep the baby in skin-to-skin contact with the mother, and to leave the cord attached, in addition to the usual procedures.

[Cynthia Mosher]

I removed Shane's link as it was probably placed in error. Linking to pages for promotion of a business or service is not appropriate, especially for something as sensitive in nature as this topic. 

Shane, if you intended to promote a malpractice attorney by linking to that page please contact [e-mail] to inquire about advertising opportunities. 

[Buzzbuzz]

"Midwives are generally taught to talk to the baby or invite the mother to talk to the baby, keep the baby in skin-to-skin contact with the mother, and to leave the cord attached, in addition to the usual procedures."

I must admit I see a lot of confusion around the cord issue.  I have actually run across people on the internet who seem to think that a baby cannot suffocate so long as the cord is attached.  This is patently false.

I do wonder how effective NPR is, for example, performed on the mom when the mom is in the tub for waterbirth.  Aren't you supposed to be getting that baby warm and dry?  I also have concerns that things with more "value" from an NPR standpoint are being compromised for something that is not of as much value (cord blood/being on top of mom).

"I see you talking a lot about what CPMs are qualified to do with no evidence that what you are saying has any basis in actual experience or fact. CPMs are required by NARM to maintain the exact same certification for NRP as providers in the hospital, the instructors trained and approved by the same organization."

Let's all acknowledge that it is very different to be *certified* in a practice and to actually have done it a bunch of times.   If a homebirth midwife is seeing 48 babies a year (which from my understanding is a very busy practice) -- how many of those are needing NPR?  How often is the midwife actually performing NPR? 

There is something to be said for the "higher volume" in a hospital -- it leads to greater experience and familiarity with with lifesaving procedures like NPR.

[mothercat]

I'm an NNR instructor and need to clear up a few things.

If a baby is not vigorous and there was meconium in the fluid, suctioning to be sure there is no mec below the cords is the first thing done. The point is to avoid stimulating the baby first so they don't suck mec further down into the lungs. The baby not being vigorous is far more serious than a baby that is vigorous. A meconium aspirator should be used to assist suctioning.

Although oxygen should be carried by the midwife, it is not the first thing used in resuscitating a baby. It is only when the baby's heart rate does not rise to normal levels after at least 30 seconds of adequate ventilation. This means that positioning must be correct, the airway must be clear, and the person performing the resuscitation must be using the correct technique. AAP/NNR are quite explicit about oxygen that it may be needed but resuscitation should and can be started with room air because we may be causing neurobehavioral harm to the baby by using this medical gas when it is not needed. Oxygen is no substitute for poor technique.

Buzzbuzz, I have needed to do resuscitation on a baby born in  water. Of the few times I have, it has never been more than a few puffs with bag and mask, or some suction. Suction by itself can be enough stimulation to make the baby gasp and start respirations if previously unresponsive. But as a lactation consultant, if you need to suction, please do it as gently as possible to avoid causing trauma.

And lastly, AAP/NNR are also explicit that successfully completing a class in NNR does not certify anyone. You have completed the class, it is not a certification program and does not guarantee competency or proficiency. Those things come with  practice and experience.
 

[mothercat]

Originally Posted by Ambivalent Dreams 

My DC #2 was born limp and blue.  We were in a hospital and the nurses whisked him over to a table across from me where I could not see exactly what they did to him to resuscitate him.  I do no think it involved any "mechanized" equipment, if that makes sense.  I imagine they suctioned him using a some sort of device?  He was revived and his second apgar score was fine.

What is the standard procedure for when a baby is born blue and limp?  Is it the same procedure in a hospital, birth center, and home birth?  The OB never touched my son after he was born.  The nurses did all the work on him and she never stopped tending to me.  What birth professionals have the training to revive a baby in this situation?  (OBs?, CNMs? CPMs? RNs in a labor and delivery unit?)

From what you are describing and what you wrote in later posts (mec and the long labor) it sounds like the staff did what was appropriate. Usually a respiratory therapist is also involved as they would be most familiar with the suctioning and oxygen equipment, but the team needs to work together. Extra hands are not a bad thing in this situation. CPMs may have completed the NNR class, but their apprentices may not have the experience or expertise to be another fully functioning member of the resuscitation team. That could be critical in the situation you describe.

Do you know what the first Apgar score was? It is worrisome that he wasn't fine until the 5 minute score. By NNR guidelines he would require some close watching for several hours as a follow up. This might require a pediatrician at minimum, or a very experienced nurse who knows what to look for.