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#1 of 28 Old 03-21-2013, 08:38 PM - Thread Starter
 
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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?)

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#2 of 28 Old 03-21-2013, 09:26 PM
 
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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."

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#3 of 28 Old 03-21-2013, 10:52 PM
 
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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.

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#4 of 28 Old 03-22-2013, 05:26 AM - Thread Starter
 
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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?
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#5 of 28 Old 03-22-2013, 05:29 AM - Thread Starter
 
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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?
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#6 of 28 Old 03-22-2013, 05:49 AM
 
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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.
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#7 of 28 Old 03-22-2013, 06:48 AM - Thread Starter
 
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Womenswisdom: I assume home birth midwives would have this face mask and suctioning devices with her when she comes for a delivery?
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#8 of 28 Old 03-22-2013, 06:51 AM
 
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Yes, that would be part of the normal equipment that a home birth midwife would carry.

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#9 of 28 Old 03-22-2013, 01:39 PM
 
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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.


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#10 of 28 Old 03-24-2013, 02:54 AM
 
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Originally Posted by Alenushka View Post

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.


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#11 of 28 Old 03-24-2013, 05:47 AM
 
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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.

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#12 of 28 Old 03-24-2013, 07:57 AM - Thread Starter
 
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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.
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#13 of 28 Old 03-24-2013, 09:17 AM
 
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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.  

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#14 of 28 Old 03-25-2013, 12:34 AM
 
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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.”

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#15 of 28 Old 03-26-2013, 06:50 PM - Thread Starter
 
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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.
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#16 of 28 Old 03-27-2013, 06:05 PM
 
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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.

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#17 of 28 Old 03-28-2013, 03:43 AM
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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 advertise@mothering.com to inquire about advertising opportunities. thumb.gif


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#18 of 28 Old 03-29-2013, 12:09 AM
 
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"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.

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I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#19 of 28 Old 03-29-2013, 05:48 AM
 
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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.
 


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#20 of 28 Old 03-29-2013, 06:04 AM
 
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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.


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#21 of 28 Old 03-29-2013, 11:38 AM
 
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Buzzbuzz - I don't know anyone who is trained in NRP who thinks that simply keeping the cord intact is sufficient to treat a baby who needs help after birth. That may be a layperson's interpretation of delayed cord clamping, but it's certainly not the professionals'.

Maybe it would help to explain the rationale of the midwifery approach to resuscitation. Keeping the cord intact and the baby on the mother is the norm and the standard, evolutionarily speaking. Thousands of years of refinement in the process of transition to extra-uterine life have resulted in a process that works well most of the time. Throughout this refining process, women and their attendants were NOT clamping the cord within 30 seconds of birth. I would have been at least several minutes before that was done. Immediate cord clamping is what needs to be justified, not maintaining the normal physiological process that is supposed to occur after birth. Up to 30% of the baby's (oxygenated) blood volume is transfused from the placenta to the baby in the first three minutes after birth. Unless there is good evidence presented that immediate cord clamping provides some benefit that exceeds the benefit of the infant receiving the full blood volume (and this blood IS oxygenated), then we don't do it. There are no steps to the NRP that cannot be done equally well with the cord attached as long as the provider is comfortable with the process. To hospital providers, who are trained and accustomed to doing NRP away from the mother on a warmer, in that particular environment, it must seem that it can't be done any other way effectively, but it certainly can. In a waterbirth, the baby can certainly be warmed and dried on the mother if needed, or other methods of stimulation such as the mother talking to and rubbing her baby can be done to counteract primary apnea, if present. If the baby is in secondary apnea, all the warming and drying in the world will not work, and you proceed to PPV and chest compressions (if needed), which can be done with no problem on or near the mother. If positioning for PPV is a problem, we use a pre-prepared firm surface with a shoulder roll, which is always nearby at the time of birth and can be used wherever the mother happens to give birth.

Furthermore, keeping the baby on the mother or near the mother during resuscitation is respecting the baby as a sentient human being having their own experience. That baby expects to be born and be in contact with the mother. Physically, skin-to-skin stabilizes the baby's temperature, blood sugar, blood pressure, etc. Psychologically, it's where the baby belongs and I believe it reduces stress. It's also respecting the mother as a vital part of the resuscitation process, in that she and the baby are a "unit", if you will, when the baby is born. Her role in speaking to the baby and touching the baby is an important one. Furthermore, it keeps the mother calm, reduces her adrenalin and keeps her oxytocin levels high, which helps the uterus clamp down appropriately.

To address the level of experience with NRP that most CPMs have - yes, it is definitely lower than someone who works in a high-volume hospital setting. However, I would invite you to compare the number of births a CPM attends per year with the number of births an average nurse, who would be responsible for for NRP, in a rural hospital might attend. I would guess they are pretty statistically similar and no one is calling for women not to give birth at smaller rural hospitals and instead force all low-risk women to travel however far to a large, urban hospital setting due to their increased experience with NRP. NRP is wonderful, but it's not rocket science. It's actually a pretty simple series of actions which, granted, the more you do, the better you will be at it. That's why the midwives I know handle their equipment regularly and have "practice runs" on a regular basis, not just the certification class every 2 years.

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#22 of 28 Old 04-01-2013, 07:04 PM - Thread Starter
 
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To be clear, this birth took place at a small hospital with no NICU and no pediatrician at te birth.

I cant remember his first APGAR score. I want to say it was a 2? Does that sound about right? The second score was normal. He is a healhy 2.5 year old now.
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#23 of 28 Old 04-01-2013, 07:29 PM
 
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To be clear, this birth took place at a small hospital with no NICU and no pediatrician at te birth.

I cant remember his first APGAR score. I want to say it was a 2? Does that sound about right? The second score was normal. He is a healhy 2.5 year old now.

Two is a very low Apgar. It is certainly possible to have a two at one minute and the an eight or above at five minutes but that baby will require active resuscitation in between. Best case scenario for a two, IMO, would be a baby who had a good heart rate but poor colour and tone and no respiratory effort. Some stimulation and oxygen can improve things by five minutes. I personally would be worried that it took so long to come up and i would be watching very carefully for milestones but i would be resssured if he is fine at 2.5yo.

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#24 of 28 Old 04-01-2013, 07:53 PM
 
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Well, we don't really know how long it took to come up. It could have been an 8 at two minutes but the apgar still would be done at five minutes. Just because the one minute was a 2 and the five minute was a 7 or more doesn't tell us how long the resuscitation actually took. I wouldn't assume it took the entire five minutes. Also, it's the five minute score that is associated with long term prognosis.

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#25 of 28 Old 04-01-2013, 08:19 PM
 
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Well, we don't really know how long it took to come up. It could have been an 8 at two minutes but the apgar still would be done at five minutes. Just because the one minute was a 2 and the five minute was a 7 or more doesn't tell us how long the resuscitation actually took. I wouldn't assume it took the entire five minutes. Also, it's the five minute score that is associated with long term prognosis.

Yeah I know, I actually meant that I would be concerned that it was so low at one minute not that I thought it took 4 minutes of resuscitation to come good. He should have had resuscitation before one minute so to have only a two by then would make me personally (as both a parent and a midwife) concerned even if he was an 8 by two minutes. I would still wonder what had happened to cause such depression. As I said though, I probably would have relaxed my eagle eye on milestones by 2.5yo.

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#26 of 28 Old 04-02-2013, 06:13 PM - Thread Starter
 
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I was a little scared at first but he is sharp as a tack. He counts to 10 in English and Spanish, knows all the letters and the sounds associated with more than half of the letters. He speaks clearly, runs, and tells me he loves me. He really seems fine. My concern is really more at being prepared in case this happens at my next birth.
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#27 of 28 Old 04-02-2013, 06:18 PM - Thread Starter
 
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And Katelove, I too wonder what made him limp and blue when he was born. It was a sad, scary, surreal few minutes. In my mind I told myself he HAD to be okay and could not fully entertain any alternative outcomes. But, a small part of me was horrified that I might have killed my baby by not having an elective c-section. After such a long labor and a previous c-section, the doc would have done it on a heartbeat. She told me later though that with all that meconium he could have easily been born blue with a c-section. That made me feel a little better. But, honestly, I think I am only now realizing how serious this really was.
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#28 of 28 Old 04-08-2013, 12:47 PM
 
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I thought this article was pertinent. Long but interesting, written by a care provider. Covers the normal transition to breathing with lungs. It really gave me a new perspective on the whole thing!
 



Mama to a bilingual (Arabic/English) and cuddly 3 year old, and planning another peaceful homebirth in June.
 

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