Oxygen Meant to Resuscitate May Damage Brain - Article

[CMcC]

Here is the article, I found it very interesting.

[pigpokey]

Three years ago, when I was pregnant, I told a midwife on the phone that I had reviewed the evidence, and if she attended my birth, I did not want the oxygen tank near my baby -- I wanted any resus to be with room air. She said 'if I attend I will use my oxygen tank because that is what my neonatal resus cert requires'. What a horrible example of the kind of gaps we see even in midwifery care that should be full of patient choice and evidence based care.

[CMcC]

Originally Posted by pigpokey

Three years ago, when I was pregnant, I told a midwife on the phone that I had reviewed the evidence, and if she attended my birth, I did not want the oxygen tank near my baby -- I wanted any resus to be with room air. She said 'if I attend I will use my oxygen tank because that is what my neonatal resus cert requires'. What a horrible example of the kind of gaps we see even in midwifery care that should be full of patient choice and evidence based care.

Really!?! I can't imagine a MW not willing to go with evidence-based care!

This is the first I've heard on this subject. Do you have other sources that support this? With my very first doula birth the doctor slapped the oxygen on the mother... I didn't think twice about it until now.

[Defenestrator]

On the other hand, the one time that I transported a baby after a resuscitation, the hospital was very angry that I had used an ambu-bag without a resevoir (providing a lower concentration of oxygen). I had started the resus on room air and then added o2 only when it seemed that the baby was not responding on room air. I had a resevoir. I just chose not to use it.

I have come to believe that not using oxygen and then using less oxygen actually saved this baby's life. Most hospitals are resuscitating with as much oxygen as they can manage, though.

[Defenestrator]

Originally Posted by CMcC

With my very first doula birth the doctor slapped the oxygen on the mother... I didn't think twice about it until now.

This is also different. Usually at this point, the baby has not suffered any cell death from lack of oxygen and increasing the oxygen saturation in the mom's blood would be helpful instead of harmful.

I had a conversation once, though with a research doctor at one of the teaching hospitals near me and it was his opinion that maternal o2 doesn't do a whole lot because women in labor have very high 02 saturation levels already, so taking their o2 saturation from say 98% to 99% doesn't do a lot for the baby. Doing a position change, backing off on "purple pushing", or running an iv might work better.

[BeckiCNM]

I have heard this before - and I have heard that room air resuscitation has been incorporated into the new NRP guidelines. I am taking the recert class tomorrow, and I'll pass on if that is true or not.

[Reha]

Originally Posted by CMcC

Really!?! I can't imagine a MW not willing to go with evidence-based care!

I know MANY midwives (home and hospital settings) who do not always go with evidence-based care. Sucks, doesn't it? :

Originally Posted by CMcC

This is the first I've heard on this subject. Do you have other sources that support this?

This has been talked about/researched for a long time. It is just that very few providers have been listening. : I feel like I am always suggesting her book, but I highly suggest getting a copy of "Research Updates for Midwives" by Gail Hart. She has a whole chapter in her book on the use of oxygen and what the research shows.

Here is some handouts written by Gail, one of which is on oxygen.

[Reha]

Originally Posted by Defenestrator

I had a conversation once, though with a research doctor at one of the teaching hospitals near me and it was his opinion that maternal o2 doesn't do a whole lot because women in labor have very high 02 saturation levels already, so taking their o2 saturation from say 98% to 99% doesn't do a lot for the baby. Doing a position change, backing off on "purple pushing", or running an iv might work better.

I have heard this before, and I agree. My preceptor thinks that the times where you DO see a recovery in FHTs, it isn't due to the o2 given to mom, but the adrenaline that often accompanies the worry and commotion around worried midwives and putting o2 on her.

I would have no problem attending births without an oxygen tank. I know that is a bold statement to some, but I feel very comfortable without it, given what we know about it's use and resuscitation.

[pamamidwife]

I think we need to even re-evaluate doing blow-by oxygen for babies. We're too quick to need to rush the transition (I know, I'm still working on this) to breathe and "pink up" for newborns. By leaving the cord intact, we can leave the baby skin to skin in mom's arms and not interrupt it's breathing efforts with cold air blown on its face.

I also have come to believe that perhaps we are pinking up babies that are still have respiratory issues - and we don't see it because we're focused on the color, rather than watching other signs.

The only time I use my O2 is when a mom has suffered hypovolemia and is shocky.

(I did use it once recently on a baby, against my better judgment, because Gramma was an RN and didn't like baby's color or "gurgles")

[pamamidwife]

Thanks for putting that link to Gail's stuff, Lennon! I was searching for it and couldn't find it!

[CEG]

The new NRP guidelines state that there is no clear benefit to using oxygen with resuscitation and room air can be used. The hospital I work at tends to deep suction every baby and give blow by but that's what NRP says.

[mwherbs]

just took the new nnr which was out last summer- and they say ok to not resus with oxygen for the first 30 seconds but after that- they whole nine yards comes out- after the first round which lasts all of 30 seconds the procedure is laryngoscope with epinephrin -- put an umbilical line in ... and use oxygen that is what the evidence is supporting-- as a home birth midwife I cannot provide this type of care-- even if this is what the evidence says is best.... does that mean we stop doing births ?
I am wondering if the epinephrin is standard resuscitation care now because the majority of the population is on delivery drugs and so babies need this kind of resuscitation and that is what the EVIDENCE is showing - because the study base is contaminated-- I have watched when epidurals are put in and the heart tones drop to nothing-- and with out any flipping out or anything already prepared as a matter of course they give mom a shot of epinephrin and the heart tones respond...( if you watch medical staff anything that they are not anticipating they tend to filp out- by their calm smooth unremarkable response to this I take it the expect to see the epidural lower heart tones- sharply)
as for oxygen it is still being recommended because if you are doing resuscitation for longer than 30 seconds it does improve outcomes....

[junamoss]

I had the new NRP and it was discussed but we have made no policy changes.

[junamoss]

Also during a mandatory ed. inservice at work we discussed O2 on mom, basically this is a CYA procedure, for the courtroom. It takes at least 9-15 minutes to pass to fetal circulation.

[BeckiCNM]

Originally Posted by mwherbs

just took the new nnr which was out last summer- and they say ok to not resus with oxygen for the first 30 seconds but after that- they whole nine yards comes out- after the first round which lasts all of 30 seconds the procedure is laryngoscope with epinephrin -- put an umbilical line in ... and use oxygen that is what the evidence is supporting-- as a home birth midwife I cannot provide this type of care-- even if this is what the evidence says is best.... does that mean we stop doing births ?

OK, I had my NRP class yesterday, and this is not what I came away with. After 30 seconds, if the baby is not breathing at all, then the baby needs bagging. This can be done with room air. If another 30 seconds passes, and the baby is still not breathing, and the heart rate is less than 60, do chest compressions and bag. If after another 30 seconds has passed with no improvement - no breathing, heart rate less than 60, tubing the baby and giving epi can be *considered*. So after 90 seconds of apnea and a severely low heart rate, you might consider epi. To me, 90 seconds is a lot different than 30 seconds. I really just don't see people, even in the high-risk, high intervention hospital I've been at, tubing babies that fast.

Epi is never stated as a requirement, so I don't see how you can be faulted for not providing it. Maybe it's better, but then, you have an excellent point about hospital births and drugs causing depressed babies. The chances of getting to that point in a hospital resuscitation are greater, IMO. Also, remember that preemie babies and term babies are essentially treated the same in this algorithm.

I am wondering if the epinephrin is standard resuscitation care now because the majority of the population is on delivery drugs and so babies need this kind of resuscitation and that is what the EVIDENCE is showing - because the study base is contaminated-- I have watched when epidurals are put in and the heart tones drop to nothing-- and with out any flipping out or anything already prepared as a matter of course they give mom a shot of epinephrin and the heart tones respond...( if you watch medical staff anything that they are not anticipating they tend to filp out- by their calm smooth unremarkable response to this I take it the expect to see the epidural lower heart tones- sharply)

Totally true. And an increase in the number of preemie babies also increases the number of babies needing more extensive resuscitation.

as for oxygen it is still being recommended because if you are doing resuscitation for longer than 30 seconds it does improve outcomes....

My materials say 90 seconds on room air is OK, then you should switch to 100% oxygen if there is no improvement.

[mwherbs]

so depending on state of the baby- it will be ASAP or after a evaluation period- and although it was said that no one in the hospital practice had switched over to the protocols except for certain babies the recommendation remains that after you have provided 30 seconds of resuscitation, add oxygen and you have a point it would be 30 seconds after compressions AND breath-- so depends on beginning heart rate--- if you start with compressions and breath or just breath--
so could not disagree with the 90 seconds but it was gone over and over with this teacher that after we did one round add oxygen--
not using oxygen is not disturbing to me as I have spent many years without access to it but I have also seen the uses- like a mec aspiration baby who would smooth out and maintain color with blow by but would strongly retract and loose color with-out the oxygen-the heart rate was also changing but we just didn't play with it long enough to see if we would need to fully resuscitate- kwim and due to a long comedy of errors on the part of the emergency services it was over 45 minutes- before they arrived

[cfiddlinmama]

Thank you for this discussion. It is very fascinating to me. I'm going to be taking my first NRP class on the 15th. Now I have lots of questions I want to ask the instructor. (She's a CNM and part of the class is resuscitation with an intact cord so that should be interesting.)

[CMcC]

Yes, thanks to everyone who participated in this thread. Not sure I understand all of it, but it has been very interesting and helpful. I think it's always a good idea to question what is "standard procedure" so those who are in charge of health care can give the best care possible.