The new NRP guidelines

[Charmie981]

I took my NRP last week and was really astounded at the "new" guidelines. Maybe it's because I took the class with a group of hospital personnel whereas last time it was with a group of midwives, but it just seems that the new recs. really lean toward separation of mom and baby more than the old ones did! It really felt like a step backward.

Specifically, the change in the first step of resuscitation (which is supposed to be done to ALL babies) from "dry, stimulate, evaluate" to "dry, position airway, stimulate" because you don't want to stimulate all babies to breathe/cry until you've established an airway?

Is it me or does this just assume that every baby is on a warmer? I know I'm not going to be worried about positioning an airway when baby is on mom; it would be impossible, not to mention CRAZY to make sure EVERY BABY is positioned optimally for me to give PPV since very few babies *need* me to give them PPV!

I certified on steps 1-9 and don't even want to get started on the section about "when baby is born outside of the hospital" in step...8, I think?

Aside from the material changes, it was an interesting experience taking NRP from three NICU nurse-practitioners.

[courtenay_e]

Huh. How'd that work for you, Charmie? Did you nod, smile, and bite your tongue a lot, or did you talk to them about differences?

[Maggi315]

wow, yeah, i think if you took it with karen strange, you'd get a whole different picture how to do it.

I just had to do a full resuscitation recently and believe me, we weren't even worried about all that little stuff, we were just going at it to get him going, which, tg, he did and is doing fine now!

I think the fact you took it with hospital personnel is why you heard all that stuff, when I worked in the hospital, we did all that silly stuff.

when we called 911 for this baby, they asked a bunch of really dumb questions, like whether we had given vit K (uh, yeah, he's not breathing, but we gave him vit. k?), why I hadn't cut the cord (so, he, can, uh, get some oxygenated blood maybe?), and other stupid things because that's how they are trained to think.

[TattooedMama]

Originally Posted by Maggi315

wow, yeah, i think if you took it with karen strange, you'd get a whole different picture how to do it.

:

Karen rocks! Anyone who is going to be doing OOH birth should take her class instead of the hospital one. So many times the nurses teaching NRP have never even seen a natural birth.

[hottmama]

I'm taking it next week (with a midwife) for initial certification, so I'm reading the book and was wondering the same thing. Why would I position the airway (and how would I?) in a babe that's doing fine on mama's belly? There were some other things that seemed off to me, too, and totally irrelevant to a homebirth. I wish there was a NNR for homebirths book.

[hottmama]

Oh, I also had a big problem with the HUGE list of high risk groups, and the recommendation that those babies be separated from the mom even in the absence of problems.

[Stacymom]

This is a cool and timely thread!

I think, (hope!) that I'll be doing NRP with Karen Strange on Tuesday of this week. I've heard lots of positive things about her- I'm glad to hear that its midwife and homebirth friendly. I'm attending homebirths as a doula with a midwife in my area, and she is strongly suggesting that I take it. I'm excited though- just hoping that I'll be able to do a late registration.

[Charmie981]

Yeah, the thing is, no matter who you take it with, the NRP Guidelines are anti-homebirth, so either the teacher is going to have to teach something none of us do at homebirths or she's going to have to say "they say do this, but we all know that's crazy." There's no way to make these new recs homebirth friendly!

The last book seemed a little more adaptable.

Oh, and yeah, the guidelines for mec are ABSURD. I would be so, SO, SOOOO PO'ed if someone INTUBATED my baby for suction b/c there was mec in the water and (s)he didn't cry right away.

Really, I did okay. The teacher was quite accepting of the fact that I did things differently and would ask me during skills tests "if you were at home, what would you do now?" It was quite comical because for my final test, I drew a STAT c-section for fetal distress. "Baby" needed some supplemental oxygen (another one I don't agree with, but whatever ) and then I was like, "So now I'd give baby to mom and watch closely." So my c-section baby was back to mom in 60 seconds.

[mamaspirit]

I worked in the NICU and in labor and delivery for a while and had to quit due to my personal and moral and ethical beliefs... I had such a hard time biting my tongue with stuff like that. It is SOOOOO common for nurses to never have seen a natural birth, and to think homebirth is dangerous etc...

When I do my recertification, I just do what I have to to pass, and than continue doing things the way they feel right...

[mwherbs]

yes I was having some trouble with it too because if seems like you are going to need to intubate fairly quickly and deliver epinephrine -- made me feel like we are getting shoved out the door so to speak ...
but to note that they won't let the docs assist in resuscitations now and they try to avoid giving them a bulb syringe as well

in any case I took it with the birth center CNMs -- mind you I don't have the new book just handouts the instructor had
in any case what was done in our class was the only time you don't stimulate is if you have mec- you want to suction first if the baby isn't already breathing/crying...
also you don't turn the oxygen on for the first round (unless you are using a demand bag)

[GatorNNP]

It seems the tone of the thread is negative towards the NRP program. I think if a baby is born and breathing, by your judgement, you know it does not need "resuscitation". A baby born limp, blue, with low tone, is the baby who may need assistance with positioning his airway, which can easily close in a low tone baby. I think if a baby needs PPV, you may want to put forth the effort to position the airway since forcing air to the lungs will be more helpful than pushing air to the stomach.

[mothercat]

I am a NNR instructor and when I looked at the 2005 book my first thought was "Finally, guidelines that look more like what we have been doing in the OOH birth community." I thought that they were easier to use and very adaptable to OOH birth.

My regional trainer knew going in that I am an OOH CNM and she had no problem with how I would handle things at home or the birth center. I would just explain beforehand when doing the megacode what we use for a heat source for the baby, I won't cut the cord, baby doesn't leave mom's arms, and that there is a concern for the child's emotional well being as well as the physical when resus. is necessary.

When I teach the classes, there is a wide variety in the scenarios I present, many of which come from birth stories told by other OOH midwives.

I think the bigger problem is not the guidelines themselves, but how they are being interpreted by the instructors. My regional trainer was concerned about OOH birth because she has dealt several times with babies in NICU at the other hospital where she works, that were transfers from one particular OOH provider. And before you think that the babies were there for observation, the truth is they were longer term admissions for brain damage and other injuries related to improperly performed NNR, or a mother who was improperly screened for low risk birth OOH. Unfortunately, the nurses in that NICU refer to the OOH practice as "the vegetable patch" because of the brain damage these babies suffer.

So, before you take exception to the guidelines consider that it may be that the instructor's perspective is skewed because of past experience with an unsafe provider in our midst.

[maxmama]

Originally Posted by hottmama

I'm taking it next week (with a midwife) for initial certification, so I'm reading the book and was wondering the same thing. Why would I position the airway (and how would I?) in a babe that's doing fine on mama's belly? There were some other things that seemed off to me, too, and totally irrelevant to a homebirth. I wish there was a NNR for homebirths book.

NRP is really for babies that aren't transitioning on their own. Babies who are get dried and that's pretty much it. It's focused on baby on warmer because if a baby is having trouble transitioning, that's probably where they go.

Also, the airway thing is because that's in line with the ABCs (airway, breathing, circulation, in that order). Doesn't do much good to stimulate breathing if the airway isn't open.

[mwherbs]

so yes having a neck roll like a rolled up washcloth(taping it helps) as far as positioning a baby's head/neck so air can get through- but that comes usually after I have rubbed a baby up and it isn't breathing and heart rate is dropping or is already low and it isn't the same as intubation which I don't think I will ever be qualified to do - my comments had to do with how quickly intubation was presented as something that needs to be done--
honest and truly we rarely see completely floppy low tone babies - and just like NRP classes say PPV is probably going to be the majority of the resuscitation we are going to need to do- there is that 1% that will need more so most of the time the babies are not floppy but not breathing or possibly gasping(or atleast the ones I have been around)
the recent baby that was floppy and no effort and heart rate low low - yes I still dried off and tried to stimulate (no mec) suctioned but nothing there, got a couple responding gurgles and started mouth to mouth with chest compressions because the bag was in the other room- we went from one end of the house to the other about 10 x in labor and brought everything from room to room but the last time it hadn't got brought up yet and was in the other room-- when the bag got to us the heart had taken off/picked up I felt that under in my fingers bam firm and getting stronger- and we positioned the baby on the edge of the pool but one of the plastic storage boxes would have done (for the mouth to mouth baby was on my arm) this kido is fine and was fine blood sugar good- pulse ox good but we sent baby into the hospital the EMTs were there 10/15 minutes waiting on us to decide - we sent them in because just wasn't as pink or smooth as I am use to seeing -at the hospital baby was fine midwives faint and sick
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[cfiddlinmama]

So I took the NRP class in June of '07. Have they changed the guidelines again since then?

I took it with a group of CPMs. Our instructor was a CNM from Maine. (Can't remember her name right now.) She did a lot of "this is why such and such is impractical in OOH birth setting. This is what would make more sense for us." She talked a lot about not cutting the cord.

[mothercat]

The guidelines were last updated in 2005.
So, the ones you just learned are the most recent.

I haven't seen anything saying they are planning another update.

Linda
NRP instructor

[cfiddlinmama]

Thank you! :