The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.
Other excellent resources about avoiding toxins during pregnancy
These are easy to read and understand and are beautifully presented.
Stripping the cord (also called milking the cord) is the act of
gently clamping two fingers on either side of the baby's umbilical
cord, near the introitus, and quickly moving the fingers towards
the baby's belly so that the blood from the umbilical cord is
pushed inside the baby's body.
Cord stripping achieves the same effect as CPR, as it moves oxygen into the baby's body by moving oxygenated blood in the umbilical vein into the baby's circulatory system, and it actually pushes this blood to the heart, where it is probably most useful as a way of jump starting the baby's own spontaneous circulation of oxygenated blood. I used to think of it as a way of merely increasing the oxygenation of the baby's blood, but I hadn't thought about the effect on the baby's circulatory system. Most umbilical veins hold enough blood that emptying the vein into the baby's body will push some oxygenated blood all the way to the baby's heart through the liver. This is the quickest way of getting oxygen to the baby's heart and could well remove the need to do chest compressions at all. Of course it makes sense to leave the cord intact and keep the baby at the level of the placenta while performing any additional necessary resuscitation efforts until the baby has recovered fully. Then you can focus on helping the baby to complete a normal transition.
Cord stripping seems completely non invasive, although it's
clearly not physiological, and I wouldn't recommend it routinely
for that reason. Thus it is much gentler on the baby than
suction, PPV and especially chest compressions.
Cord stripping is not just about achieving normal placental transfusion quickly so that the cord can be clamped and the baby moved to a resuscitation table. Stripping the cord affects the baby's circulatory system as much as the oxygenation level and the blood volume. It is the perfect, least invasive form of CPR, and it's a heck of a lot quicker than standard resus. It can also be performed by one person, even if other supportive personnel have not yet arrived on the scene.
I note that the Cochrane Collaboration's WORKSHEET for
Evidence-Based Review of Science for Emergency Cardiac Care
does not show any studies on stripping the cord as a form of
neonatal resuscitation. I would like to see some studies
that add cord stripping as the first step in neonatal
resuscitation. It might even be beneficial to add an
additional step to the study of a significant infusion of pitocin
to cause a hard contraction in the uterus to squeeze more
oxygenated blood into the umbilical cord so that this new infusion
of oxygenated blood can then be infused inside the baby's body
through a secondary cord stripping.
I've been taking NRP classes for about 14 years now, and although I'd heard really fabulous things about Karen's classes, I found myself wondering what could really be that different from the standard course.
Well, I was extremely impressed on three counts:
1) Karen's teaching techniques are excellent; she makes it easy and non-threatening for experienced midwives and students alike to understand NRP.
2) The recommendations for adapting NRP guidelines to homebirth are evidence based and very sensible.
3) Karen includes a great deal of information and insight about how considering things from the baby's perspective will help your resuscitation efforts to be more effective and be less likely to cause long-term negative effects for the baby.
And, after 12 years of various continuing education courses, I was VERY grateful that this course was engaging and paced well. PLUS . . . Karen brings CHOCOLATE!
Even if you're not able to find a workshop near
you, you could read some of her handouts.
The Changes to the 2005 Guidelines for Neonatal Resuscitation reflect the uncertainty about the use of oxygen.
Here are the 2005
Guidelines for Neonatal Resuscitation in their entirety. [Here's
newborn infants with 100% oxygen or air: a systematic review and
meta-analysis. [Lancet registration is free] [PubMed
Davis PG, Tan A, O'Donnell CP, Schulze A.
Lancet. 2004 Oct 9;364(9442):1329-33
"For term and near-term infants, we can reasonably conclude that air should be used initially, with oxygen as backup if initial resuscitation fails." ... " "One death would be prevented for every 20 babies resuscitated with air rather than 100% oxygen"
on air: it is time to turn down the oxygen tanks?
Comments by Georg Hansmann
Oxygen, Should Be Used First for Neonatal Resuscitation CME
[Medscape registration is free] [Release Date: October 11,
2004; Valid for credit through October 11, 2005]
A meta-analysis suggests that 100% oxygen should be reserved for backup.
asphyxiated newborn infants with room air or oxygen: an
international controlled trial: the Resair 2 study.
Saugstad OD, Rootwelt T, Aalen O
Pediatrics 1998 Jul;102(1):e1
IN NEONATAL RESUSCITATION: IS IT STILL APPROPRIATE?
from THE NEONATAL RESUSCITATION
PROGRAM at Children's Hospital Foundation of Winnipeg in
There was no difference in mortality or moderate to severe
hypoxic-ischemic encephalopathy, but there were fewer infants with
low 1- and 5-minute Apgar scores, and the time to first breath was
shorter in the room air group. The authors postulated that 100%
oxygen might delay the onset of spontaneous respirations.
Ya know, folks forget just how controversial resuscing newborns with O2 was when it was first proposed. There were a number of studies showing that room air was superior -- it was noted that resuscing with O2 actually inhibited the breathing reflex. In fact for many decades resuscing was done with a mixture (this'll shock ya') of oxygen and carbon-dioxide in order to counteract the side effects of oxygen.
The controversy over O2 vs. O2-CO2 ran for years --- O2 finally winning out when compared to the mixture. But by that time many resusc units could only be used with pressurized mixtures --- and the use or room air fell into neglect in many regions of the country.
As someone said "My ambubag can't work with room air".....
Anyway, I don't want to give the impression that I do not approve
of oxygen! Certainly I do. It's good stuff. I just think
it's role in resuscitation should be understood as "secondary" to
ventilation (by whatever means). And that I think it's not a great
handicap if the law forbids a midwife to carry it.
This is of course very interesting info and worthy of further
research. Let's not forget though, that the use of O2 for adults
(ie the mother) in cases of hemorrhage/shock is NOT being
disputed, so it is still helpful to carry supplemental O2 if you
can get it and are willing to carry it depending on state
laws/personal convictions. The recommendations for 100% O2
for neonates still stands according to the latest NRP
manual. Perhaps by the next revision we will see the
recommendations change. Or perhaps further study will
determine that it is indeed a better thing to use 100 % O2 for
neonates also. We'll have to wait and see.
[From an NRP instructor, 10/04]
For a self-inflating bag, if you attach the O2 without the O2reservoir the baby gets 40%. If you remove both the O2 and the O2 reservoir the baby gets room air which is 20.9%. If you have both the O2 reservoir and the 100% O2 attached then the baby is getting 90-100% (depending on the type of reservoir the bag comes with) oxygen.
The guidelines have still not changed for the American Academy of Pediatrics at this time which states that that if you have oxygen available you should use it. The new NRP book will be out in 2006 and they will be addressing the issue of 100% versus room air. Here is a sample of what they are stating in their instructor updates:
A representative of AAP/AHA/NRP " recommended that O2 be administered by PPV using a face mask or ET tube if respiratory efforts are absent or inadequate. Blended O2 from 21-100% should be available in the delivery room and O2 should be administered and guided by pulse oximetry if possible. Lastly, judicious use of O2 is reco'd in premature infants. If O2 is not available resuscitation should be initiated with room air." They also quotes some studies outside the US that reco beginning resuscitation with room air first.
These guideline are going to take a while to get with the program and reflect what all the studies are showing. Nonetheless, the guideline are still what is being done in the hospitals.
As far as oxygen tanks go, regular oxygen is not heated or
humidified. That is done with other machines in the hospital
for long term use not short term. The only difference I know
of between welding grade and medical grade is that they both come
out of the tank exactly the same, medical grade is checked for
purity a second time. As far as aviation O2 is it the O2 in
the plane in cylinders or what come down from the ceiling if plane
does not maintain pressure? That is 21% or room air.
I use the Res-Q-Vac
for deep suctioning. I get much better visibility than with
the DeLee's. NOTE - At one time, the Res-Q-Vac's came with
an appropriately small fluid collection bottle. Now it's a
bigger bottle - about 7" - which is way too big. The folks
at Cascade told me they're trying to get them with the smaller
bottles. Fingers crossed!
Newborn & Mom Pulse Ox Kit Item # : 716266 $169.95
[6/13] - I don't know how accurate these are, but I like what I
see in the catalog. The manual says it can be used on the
newborn's finger, foot or hand.
I provide my assistant with a single-head stethoscope so there isn't a wrong side for her to use. I haven't been able to find a single-head neonatal stethoscope, but I did find a single-head pediatric stethoscope - the Adscope 618 Adimal pediatric stethoscope. It happens to come with cute animal faces on the non-diaphragm side, and the animal ears actually provide a nice grip if you've got goop on your gloves! I got mine from Moore Medical for $39.49.
Years ago, I was in a situation where a new midwife was assisting
me, and she inadvertently used the wrong side of a dual-head
stethoscope and then told me that the baby had no heartbeat.
Fortunately, the baby was nicely pink and conscious, so we didn't
start resuscitation. :-) But this would have been more
serious if the baby were unconscious.
From Henci Goer, Dec., 2007
My co-author, Amy Romano, has finished the chapter on newborn procedures that will be part of the new edition of Ob Myths. Routine suctioning is worse than useless; it's harmful. Evidence suggests that suctioned babies take longer to achieve normal oxygenation levels. Linda Smith has written about the adverse effects of suctioning on initiating breastfeeding. Suctioning c-sectioned babies isn't even logical. The problem is fluid in their lungs. Suctioning the nasopharynx isn't going to do a thing about that. Finally, it is now believed that meconium aspiration results largely from events occurring in pregnancy. Thanks to randomized controlled trials of suctioning for meconium, the sole remaining accepted indication is meconium staining and a nonvigorous baby--and that is probably because no one has yet performed an RCT on this issue.
<<Among them, some will develop a meconium aspiration
pneumonia and will go on mechanic ventilators. Very few of them
will have residual health problems. The practice of suctioning the
mouth and throat of the baby just before the delivery of the
shoulders is now considered useless. The routine intubation and
suction of the trachea just after birth in the case of meconium
staining is also considered useless according to recent studies.
It does not improve the outcome.>>
practices for the fetal to newborn transition - Many common
care practices during labor, birth, and the immediate postpartum
period impact the fetal to neonatal transition, including
medication used during labor, suctioning protocols,
strategies to prevent heat loss, umbilical cord clamping, and use
of 100% oxygen for resuscitation. Many of the care practices
used to assess and manage a newborn immediately after birth have
not proven efficacious.
at birth associated with long-term risk for functional
intestinal disorders in later life.
Anand KJ, Runeson B, Jacobson B.
J Pediatr. 2004 Apr;144(4):449-54.
"Noxious stimulation caused by gastric suction at birth may
promote the development of long-term visceral hypersensitivity and
cognitive hypervigilance, leading to an increased prevalence of
functional intestinal disorders in later life."
About the Neonatal Resuscitation Program (NRP 2000) from the American Academy of Pediatrics
for Neonatal Resuscitation: An Excerpt From the Guidelines 2000
- Of particular note is the change in guidelines for meconium - "
Meconium-stained amniotic fluid: If the newly born infant has
absent or depressed respirations, heart rate <100 beats per
minute (bpm), or poor muscle tone, direct tracheal suctioning
should be performed to remove meconium from the airway. "
and "There is evidence that tracheal suctioning of the vigorous
infant with meconium-stained fluid does not improve outcome and
may cause complications"
The issue of when to suction for meconium has undergone major
revision - thankfully for the babies, they should be getting
suctioned a lot less than they used to be! See About Meconium.
I've been carrying that same bulb syringe and DeLee for
ages[Grin]! I just wipe the baby off. And if you put her/him head
down you can SEE the junk run out of his/her nose and mouth -- the
natural mechanism is for the baby to drain and "spit" and THEN
breathe, so i want to encourage it to happen that way.... (I
"suspect" that suctioning -with a bulb- might make a baby try to
breathe before it's cleared)....
How do I know whether to suction? The sign I use is real simple
-- I gently touch the baby when just the head is out. If he purses
his lips and looks like he's "trying to spit: then I figure all
the reflexes are there and I'm not going to need to suction....
I used to suction on the perineum. I used to suction automatically. I finally figured out that suctioning and stimulation are great first steps in a baby who is a slow starter, but that a baby who clearly getting it together on his or her own doesn't need me to suction.... the baby seems to be quite capable of dealing with secretions on its own, and thus the suctioning is being done to make me feel better rather than because it is necessary. Now I wait, unless meconium is present. Then I suction on the perineum and afterwards, of course. But this in not the normal scenario. Still, it has been a hard habit to break......
The thing of it is, is that suctioning isn't always such a benign
intervention. There is clear evidence that over vigorous
suctioning can cause babies to brady down which is not something
we want. The other thing is that in my work as a lactation
consultant, I have seen a few babies who seemed to develop oral
aversions after really vigourous, deep suctioning, and this
interfered greatly with the establishment of effective
Count me as one of the reformed "blow-while-I-suction" midwives. I don't routinely suction anymore even after the birth. I believe it also helps there to be fewer "sticky shoulder" births.
A crying baby (or even not crying, but pink and good nurser) will clear their own lungs in my experience. My former partner has a big time problem with rattly sounds in newborns and always suctions with a vengeance. When she quit, I got to do things my way and rarely found the need to suction anymore. At my own niece's birth this past year I intended her to have as gentle a birth as possible so instructed that there be no suctioning by my assistants (including my former partner). The kid didn't cry at all (gentle birth accomplished!) but she did breathe well and needed no help. She did sound kind of rattly and "mucousy" though for the first half hour. My partner was as nervous as could be and kept on me about it to suction her. When she was about an hour old (after everyone had held her and she got the opportunity to be at the breast a few minutes), I finally relented and listened carefully to her lungs. I heard nothing and asked my partner what she was so worried about. She said "You can't hear it?!" I said "No, show me where she sounds mucousy" So she listened but it was gone. She couldn't believe it because she had just listened to her lungs about 10 minutes prior and had found it "unacceptable". :)
I do still suction on the perineum for mec though. I can't break
that habit yet, but am not convinced it is necessary.
By allowing natural drainage/clearing, the mom can pay more attention to the clues to push the shoulders.
Just speculation at this stage, but she's liking what she thinks
When I spent a week with the NNR team at LA County (a very good
team), I was taught that once the baby is out and needs
resuscitation, the bulb is safer to use than the deLee since deep
suctioning can cause a vagal response and really put an otherwise
good baby into distress if used before 5 minutes. But this is
after the baby is out, not on the perineum. We were taught to
deLee on the perineum if there is mec (2+ or more), otherwise I
don't suction at all before the birth.
vagal response is pretty common; I think we must assume we should avoid triggering it if possible.
SO.... What magic thing happens after the baby is out? If suction can trigger vagal response once the baby is out, why should we think it doesn't when the baby is still in?
If one wanted to, one could see vagal response on most babies by watching it appear on the fetal monitor (if it's still reading) when you suction on the perineum.
The theory behind suctioning on the perineum is that the babies mouth. throat, nose are filled with gunk and the baby will breath this into his lungs. If suctioning on the perineum worked to avoid meconium aspiration, then I don't think we would have ever seen a case of MAS during the decade or so of obsessive suctioning on the perineum. Wouldn't MAS have almost disappeared with the introduction of the technique? It did not. The incidence hasn't changed at all has it? So... why are we still doing it?
That said, I would still wipe, suction and drain a heavy mec baby
-- starting on the perineum -- as the first step in anticipated
resuscitation. I think it has an appropriate use there. [Editor's
NOTE - the NRP 2000 recommendations would recommend NOT suctioning
a vigorous baby just for me.]
Just thought I'd mention that in the hospital where I am
currently doing my MW training (in Scotland), we don't suction any
babies routinely...even those with mec unless the baby needs to be
resuscitated. I have yet to see any negative results from this
A client was told by a lactation consultant that bulbing the baby
at birth could cause the baby to have "oral aversion" and might
interfere with latching or sucking. I rarely suction a baby,
unless the baby is particularly gurgly, but I was wondering if
anyone knows of studies that support what the client was told
about oral aversion?
No... Haven't heard about oral aversion specifically but... I
feel routine suctioning is so invasive! When a baby is
trying to catch it's first air breathing breath we suction and
suppress or interfere AGAIN! Argh! What a bunch of
nonsensical loonies we be! We need to ask ourselves WHY we
do such things!!!
I don't like to suction babies, and usually just make rather a
show of it (for the nursery nurse), but rarely do any 'real'
suctioning with it.
I'm just guessing that this is more of a "soft knowledge" thing -
probably mostly anecdotal. I seldom suction, either, and
virtually never have problems getting babies to the breast, but
I've also observed that babies who get lots of mouth suction, in
particular, seem to have a tougher time (these are usually
deliveries I'm observing docs doing). Perhaps its a
multi-factoral thing - maybe it has to do with maternal analgesia
which leads to less vigorous babies which leads to more
suctioning, perhaps both of which lead to lousier nursing.
Don't know. But I, too, have heard about "oral aversion" and
believe there might be something to it.
Well, if there are studies, I wonder where they are. If
this were true, we would have a couple of generations of "oral
aversion" babies out there. Bulb suctioning is common in the
hospital setting and often done excessively, IMHO.
We also have lousy breastfeeding stats as a nation, and perhaps
some of that results from moms whose babies just "won't
nurse." Many moms say that they "could not nurse" or "didn't
make enough milk," but let us consider the root of some of those
statements. An oral-aversive baby is exceptionally
frustrating, and many mothers will bottle-feed instead.
Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:
Cardiopulmonary Resuscitation and Emergency Cardiovascular -
Special Report - Neonatal Resuscitation: 2010 American Heart
Ringer, Wendy M. Simon, et al.
Pediatrics published online Oct 18, 2010; DOI: 10.1542/peds.2010-2972E
This document is well-written - clear, concise, not preachy, and includes a discussion and data on when it is biologically reasonable to stop resuscitative efforts.
In normal practice, that might not be very useful (as you would have already called 911) but if there were a major disaster (earthquake, volunteering in third world countries, etc) and transport was not an option, such info would be very helpful.
"Discontinuing Resuscitative Efforts: In a newly born baby with
no detectable heart rate, it is appropriate to consider stopping
resuscitation if the heart rate remains undetectable for 10
minutes (Class IIb, LOE C104 –106). The decision to continue
resuscitation efforts beyond 10 minutes with no heart rate should
take into consideration factors such as the presumed etiology of
the arrest, the gestation of the baby, the presence or absence of
complications, the potential role of therapeutic hypothermia, and
the parents’ previously expressed feelings about acceptable risk
to the 2005 Guidelines for Neonatal Resuscitation reflect
the uncertainty about the use of oxygen.
THE NEONATAL RESUSCITATION
PROGRAM from Children's Hospital Foundation of Winnipeg in
- An outline review
the NRP guidelines - another review, possibly outdated, i.e.
Consolidating everything I've learned about a resus setup:
I haven't been able to find a reference for this, but at the 2007
Waterbirth Certification class, one of the midwives was suggesting
that newborns born in water are sometimes slow to breathe because
the air is so warm. They said that one of the mechanisms for
triggering breathing is a cooling of the area round the mouth, or
any stimulation of this area. (Maybe this is why cats and
dogs lick their newborn's mouths?) So the thinking is that
you can trigger breathing in a conscious baby by dabbing cool
water around the baby's mouth or just blowing gently on the face
to create a slight breeze.
We often use those "gel packs" in addition to or instead of the
heating pad. Handy for places where there's no electricity. You
can either zap them in the microwave or put them in a pot of
boiling water to heat. Once they're hot they hold it approx 30
minutes, depends on the particular gel pack. Find them in the
sports section of stores or else at home health supply places.
They go where the heatingpad would go.
The ThermaCare warm pads for back/shoulder/neck are fabulous for
keeping babies warm for long periods of time, such as when you
need to transport the baby to the hospital. You can wrap
them over an undergarment and under whatever outer layers are
appropriate for the weather and/or room temperature. They
stay warm for eight hours!
Here is what I have experienced in regards to resuscitation. I
try to have a bread board or cookie sheet with a space blanket,
regular blanket or 2, towel padding underneath along with a
heating pad. Also a baby hat. This provides a surface to work on
in rare occasions it is needed (which is preferred to a wet
amniotic fluid filled floor with chux pads. Most of the time the
giving of oxygen can happen in mom's arms or just a rub/heel flick
helps the little beings come into their bodies. Always it is good
to encourage the mom and dad to talk to the baby and welcome and
encourage breathing. The beauty of homebirth is that resuscitation
measures happen quicker instead of the cord being cut and the baby
handed off to the pediatric team. Therefore less is required to
get a reluctant baby started. The last baby I helped get started
came out all floppy and white with good heart tones though. I gave
a few breaths mouth to mouth as the assistant got the O2 tank, and
then gave some puffs. It worked and he went from a 5, and then to
a 9 Apgar by five minutes of age.
One must be careful to not pump the bulb of the bag too hard as a
hole could be blown in the lung of the baby. The seal should also
not be too tight. Also, don't have the oxygen up over 5 liters per
minute as this could create blindness for the baby. The guy at the
welding shop where I fill my tanks said that I should bring it in
partially full but never completely empty as this could mean
contamination of the tank.
Another thing I like to do is to have the assistant at all births
put a cloth over the babies face when just the head is out. The
reason I think this is such a fine idea is that so often a gush of
fluid-whether it be clear or stained or blood follows the body.
Holding the cloth there helps prevent this intake into the lungs
of whatever substance it is as the first breath is taken. Blood is
horrible for the lungs of a baby, as it is sticky. Wiping the
mouth, then suctioning only if necessary is the sequence. If
meconium is there, I would hope to suction it sooner. Maybe I am
superstitious on this cloth idea, but I do it and believe in it.
I think that there are pros and cons to mouth to mouth and an
ambu bag. There is a transmission of life force with mouth to
mouth which I like. Also a risk of disease spreading. With an ambu
bag, the higher concentration of oxygen seems possibly more
effective than air from my mouth. You can observe the baby better
too. From my training, I have learned (in theory) that if you
start early in helping a baby WHO NEEDS IT to breathe, less is
required and outcome is likely to be better. A nice aspect of a
homebirth is that it can be done in a calm manner without panic,
in a directed way. The parents can help by talking to the baby or
rubbing him to get a breath. The cord need not be cut if oxygen is
coming through still and it is not excessively short. For the
babies with transient tachypnea or grunting/ flaring/ or
retractions, a little oxygen by mask may help. A Russian method
for slowing down tachypnea that my colleague taught me is this:
Take the bundled baby in your arms next to your body horizontally
and rock swiftly left to right, arms in a bit of a figure 8. It
Other important aspects to helping a baby breathe are:
I am curious about stories of babies that were not here and came
into there bodies when an ambivalent parent welcomed them or they
were told they were accepted despite their gender being the
For those babies that are a bit slower than normal to get going
following birth, stimulating the acupressure points either side of
the spinal column is spectacularly successful.
Are these specific or do we hit points by just running our
fingers down the sides of the spinal column? --- I ask because
"rubbing the back" is a traditional thing and one of the first
things we do - -sometimes just through a blanket. I assumed it
worked by skin stimulation, but maybe it was some other process
all along. It "does" seem to work though [Grin]...
What you are trying to do is stimulate the spot for the vagal
nerve--right below the head. Run two fingers up and down the neck
and you will see the baby respond really well. Turn him over your
knee to do it, that makes it easier to do. Birth is the first
subluxation and sometimes the neck needs an adjusting.
I certainly am not keen on hitting or flicking babies anywhere. I
saw an old GP once throw a bowl of cold water on a sluggish to
Well, when I say 'flicking the feet", I don't mean "hitting",
just jiggling and twiddling with them, maybe running my fingers
over the heal -- a little girl once called it "playing with the
baby's feet"; a good description..... The cold water? yeah, I've
seen that too. Though it was just cold water flicked from the
fingers -- not too traumatic. Still had to question whether the
baby needed "that" much stimulation.....
Does anyone outside of Oregon "blow" on a baby to stimulate a
breath? Very common here... and often works! Just a quick
puff-breath near the head or chest will often trigger a gasp and
then a cry....
Should midwives be intubating at home?
The answer to that is "NO" -- community midwives should NOT intubate neonates.
We (two well-known birth professionals) were having lunch in a restaurant a few years ago while we were discussing the issue of intubation during PHBs. At that time, a popular criticism of PHB was our 'inability" to prophylactically intubate in case of thick mec or a severely depressed baby. She was wondering out loud if midwives should just get additional training in the skill and add it to our customary practices. Unbeknown to us, an anesthesiologist was sitting at the next table and listening to our conversation.
I also said "no" that day, because midwives have no opportunity to actually learn this invasive neonatal procedure on actual neonates, we have no on-going opportunity to practice regularly in order to maintain adequate skills, and during its use, you only have 20 seconds before you must withdraw the e. tube and resume PPV (and presumably try again after a minute of ventilating).
In addition to the difficulty of performing this procedure right under the stress of a resuscitation, you can also cause really serious anatomical damage. During the bad old days, when the protocol for even the lightest of mec was to intubate, one of our babies was unfortunate enough to suffer a pneumothorax (and several days in the NICU) after the pediatric resident at Stanford punctured the side of his brachia with the ET tube (and still never got in).
Last but not least, should you get sued, the first question the plaintiff's attorney will ask is how many times you have done the procedure under the supervision of highly skilled practitioner (none), and how many times you have performed it since your certification (none), at which point, you lost the law suit.
After reciting this, a male voice from the adjoining table interrupted us and said to her::
"I'm an anesthesiologist and I agree -- intubating newborns is one of the hardest and riskiest things i ever have to do and even though i intubate many times a day, I often have trouble with newborns because the anatomy is so small. It would be impossible for someone who had never done it before to do it right the first time out. If you had a bad outcome, no perinatologist or anesthesiologist would ever defend you".
Those are enough reasons for me not to train, equip or describe
myself as capable of intubating a newborn immediately after a PHB.
30 years ago the chief perinatologist at Brigham and Women's Hospital in Boston offered to teach neonatal resuscitation to a small community of lay midwives. He was brilliant, supportive, and a great teacher. He presented resuscitation in the most human, holistic way (not unlike what Karen Strange does). He also gave us the lowdown on intubation: how rare its necessary use, even in a high risk tertiary care center; how residents learned and kept up skills (intubating when not necessary, intubating deceased babies etc.); and the damage done to infants in the best of circumstances. I, too, had the chance to practice on anesthetized cats, at a local hospital when I worked with Family Practice physicians who attended home births. But cats are not babies, no matter how successfully I had intubated one on the very first try.
This is outside the scope of our practice. We should not
carry the equipment, nor let our clients think it is a skill we
Fortunately, intubation is very rarely necessary at home if you
transport for meconium or fetal distress!
From Doctor DeLee in "Obstetrics For Nurses" (1940 edition) pg 510 Treatment of Asphyxia Neonatorum:
This consists of removal of foreign matter form the air passage, preservation of the body heat, artificial respiration, and the treatment of shock." (He describes suction technique ...)"The infant is then placed in a hot bath (106degrees). Some physicians place the infant alternately in hot and cold water -- as severe shock to the little one, and a procedure the author has never found necessary. In mild cases these measures suffice to bring about normal breathing.He goes on to describe asphyxia pallida, which we now call severe asphyxia or secondary apnea and agrees with the current view that suctioning and "substitute breathing" --positive pressure oxygen -- needs to be done immediately.
Throughout all these procedures continual care is to be taken not to fool the babe too much. The skin is wet, the child shocked, and he refrigerates rapidly. In fact, sometimes the child dies because of too violent and prolonged manipulations intended for resuscitation. The hot bath, warm flannel receivers (blankets) and the warm-water bag, gentle friction with a warmed hand under cover, all tend to keep up the baby's temperature.These days we use radiant warmers or HEATING PADS (midwife trick) or moms own abdomen instead of "warm water bags (hot water bottles).
Also in Practical Obstetrics (Bland, Montgomery 1932) Under treatment for asphyxia "warm baths, gentle massage" -- though he also refers to "immersing it (the child) alternately in hot and cold water."
I REALLY Like what I've seen when we've tried the warm bath --
sometimes a night and day response. I agree with DeLee's opinion
that alternating hot and cold is too shocking and defeats the
[Ed: I can't imagine any mechanism whereby lobelia rubbed on the chest and back would help, but lobelia is sometimes used for asthma as an anti-spasmodic. Maybe there's something that needs to relax in the baby's chest in order to absorb the lung fluid???]
Lobelia, as a tincture is rubbed on the babe's back and chest. The babe is positioned on a side lying position for 15 minutes and then positioned on the other side for 15 minutes. By that time (and I am not kidding) the flaring, retractions, wet lungs are GONE.
So, in my opinion, giving the babe 30 minutes to see if the
Lobelia will prevent a hospital admission in those
borderline situations, is not excessive.
I've heard some people recommend some positive-pressure
ventilation as a treatment for TTN. They suggest five slow
inflations, about 3 seconds each.
of body position on the respiratory rate of infants with
Sconyers SM, Ogden BE, Goldberg HS
J Perinatol 1987 Spring;7(2):118-21
"The lowest mean respiratory rate occurred when patients were in
the prone elevated position"
We had a baby who was fine at birth, but then at the 18-hour
checkup, his resps were over 100; everything else was perfectly
fine. This baby had had a nuchal forearm, and I wondered
whether there might have been some mild inflammation from this,
which caused some neurological TTN. Then, in thinking about
it some more, I realized that the 2 other babies I'd seen with TTN
had also had shoulder issues. Could it be possible that this
is something that would be corrected with a chiropractic
Years ago I had 2 primips, 2 days apart with long hard labors. The first I sent to the hospital and after a few hours they finally c-sec'd. The other I did at home. Both babes, after 16 hrs developed TTN. babe in hospital, as I found out later, wound up with some major problems in NICU for over a week. The second I sent out our local Amish adjuster as she had just read a circle letter from another amish midwife that had run her thumbs up the spine of a baby she had had with similar respiratory problem (hope that is not too confusing of a sentence). Anyway, she went out and adjusted babe and ran her thumbs up the babes spine. Babe still had problems and 2 hrs later the dad called me out. by the time I got there all was resolved.
So my answer is yes. In fact, during the newborn exam I run
my thumbs up the the babes spine after any hard delivery.
In thinking it over . . . yes, both times I've seen TTN have been
big boys with delayed shoulders, so maybe they were torquing in
the pelvis in a way that caused some irritation of the spinal
nerbes controlling respiratory rate.
Good-sized babies often have a tight squeeze for the shoulders and body to be born. Sometimes the bones in the upper spine get a little out of whack, and that can cause "transient tachypnea of the newborn", i.e. fast breathing without any kind of true respiratory distress. And it makes sense that it could also cause swallowing issues. I would recommend getting a referral from your midwife to someone who adjusts newborn spines or does craniosacral adjustments.
Or you could use some national referral lists:
How To Find a Chiropractor
One of my clients with a similar situation was a homeopathy, and she used lots of homeopathic arnica, and that seemed to help. If he were older and could understand, you could use some ice to reduce inflammation, but I don't think I would recommend that for a baby! Or you could do gentle massage along his spine in the upper back of gently stretch out his spine by laying him flat and lifting his lower body by the knees or hips (very gently, of course) and even hanging him upside down by his hips if he's OK with that.
If you're open to a professional adjustment, that would be my
Transient tachypnea means rapid breathing in the baby which lasts for a while and goes away... as opposed to "tachypnea" which does have some sort of cause and remains untill the cause is fixed.
It is true you can't exactly diagnose TTN untill it DOES go away,
but you get to that conclusion by looking at the symptoms and
going through a "process of exclusion".
It ain't heart defect, because the heart sounds fine and there is good color and good perfusion.
It ain't infection, because the temp is normal and the baby is alert, eating, sleeping etc.
It ain't hypoglycemia because the kid is alert, nursing and not jittery.
it ain't hypothermia because the kids color is normal and he is
it ain't aspiration because the breath sounds are quite clear
it ain;'t bloodloss because there was no bleeding and the color is good etc etc.
Ya go on down the list of possibilities untill you find no reason for the rapid breathing... and you get a "presumptive" diagnosis of TTN.
And then when it goes away you get a "confirmed diagnosis" of TTN.
We really should call it "tachypnia of unknown origen" untill it
My questions here are.... would percussion have taken care of
this fluid that was not audible? Could that have been the cause of
the grunting and tachypnea? Anyone been here before? How long is
too long to sit on something like this?
We have used percussion and steam for these big babies with good results. We turn on the hot water in the shower and let the bathroom get good and steamy and take the baby in and percuss with the mask from the ambu bag. So far it has worked well.
I really hate to take these big healthy ones in just for TTN. I
will transport a smaller baby faster though. Maybe thinking the
smaller baby will have less reserves? I have seen this more often
with the bigger 9-10 pounders and it tends to set off warning
alarms in me if a 6-7 pounder is breathing fast.
what percentage of babies do you have with "transient respiratory
distress" and the like in absence of infection or other
problem? How do you handle it?
I think about one percent would be really close.
I think we see it mostly in babies who are born extremely rapidly -- the kids who go from floating to to birth in a contraction or two. I've got a theory these are kids who just didn't get enough chance to drain out well and whose lungs are a bit wet.
It usually never gets bad enough to need anything more than observation - I think gentle handling and frequent nursing is all the treatment most babies need. we keep an eye on them; do nothing else unless they are deteriorating, or having more than very mild, occasional retractions.
I tried immersing one baby in a warm bath once and was surprised
at a very quick improvement. Don't know if it would be repeated --
haven't had the chance to try it again yet.
To determine if it is heart or true HMD (Hyaline Membrane
Disease), I see if they will suck my finger. If they are
weak with a heart defect or true HMD (also diaphragmatic
whatever), they cannot suck.
Another fairly good rule of thumb: if the baby pinks up when he cries then the problems is gunk in the lungs or something which is preventing full breathing (treatment is time or better drainage/suction).
If he gets duskier or paler when he cries, then he/she has good
air movement but the problem is in the blood circulation (this
means probably a defect which needs treated)
<Okay, I have heard of this 'wet lung' for some time and I always assumed that babe took in a little fluid, nothing major on a term babe. Is is something different?
The lungs are normally filled with fluid in the womb. The fluid clears during the laboring process -- both by pressure and hormone response. With those first few breaths the lungs expand and the little air sacs displace fluid. SOme of it is absorbed. Some of it drains. But some kids just don't displace well. They need a little bit more time or pressure. These are the kids who sound gunky or retract a bit but are pretty good color --- they seem to clear up somewhere in the first half hour or so. Some of them develop TTN a few hours later -- and it clears up too.
There are two schools of thought on this issue. One says the baby will recover faster if he is made to expand his lungs more quickly -- so the old treatment is to get the baby to cry really well (this is the idea behind spanking or the old watershock methods). There is a much newer hospital based idea which advises doing PPV (some say with and some say without O2) for a few minutes. The lungs are forcibly expanded for a short time and then the assisted ventilation is stopped.
The other school of thought says that the baby will clear on his own with a bit of stimulation or time and gentle handling will get him through -- as long as his color stays good -- and that it will resolve about the same length of time.
There is another idea out there that giving him mask or blow by O2 will actually prolong the problem. If the baby is a little low on oxygen he breaths more deeply and rapidly -- and this is the trick he needs to fully expand his lungs. If we give him O2 to "make it easier to breathe", then he has plenty of oxygen -- maybe even more than he needs -- and he breathes more lightly, gently, slowly and doesn't expand his lungs or clear the fluid as quickly.
No matter the treatment he will eventually get over the hump -- just about the time we're thinking of taking him in for evaluation!
Those first 15 or 20 minutes can be pretty unstable -- sometimes we just don't know which way a baby is going to go.
oh PS -- I forgot another old time trick. Putting the baby
into a bath of warm water is supposed to help pull fluid out of
the lungs by stimulating the circulation to pull the blood
into the limbs. I don't know if the theory holds water or not, but
I have seen it work.
We frequently have excellent experience with a homeopathic called Antimonium tartaricum, used when baby has moist lung sounds and tachypnea and in the absence of other more obvious, serious problems such as infection, etc. We usually use 30x potency, crush 2 tablets or pellets between two teaspoons with a tiny bit of water.
It hasn't worked every time, but I would estimate the
success rate over the last five years that I've used it for this
fairly common problem as >90%. Prior to initiating its use, we
found it necessary to use O2 and extended stimulation, percussion,
postural drainage, etc. more often. Basically our approach is (1)
auscultate the lungs and heart sounds right after birth and listen
frequently thereafter. Encourage breastfeeding after birth as soon
as mother and baby are stable and interested (usually 5 to 15
minutes at most). Auscultate lung and heart sounds unobtrusively,
observe infant feeding behavior. If baby is nursing well, continue
to observe lung and heart sounds. If baby is disinterested in
breast or lung sounds are not clearing quickly or tachypnea is
present, give Ant. tart. as above. Re-auscultate lung and heart
sounds. Administer another dose of Ant. tart. if lung sounds not
clearing within about 15 minutes or so. I have not had to use more
than 2 doses to achieve clear lung sounds. Ant. tart. even
favorably impressed the anesthesiologist/dad at our most recent
birth in which we had this complication. It was really quite nice
to have him there to confirm what we were hearing, although I was
a bit intimidated at first! [grin] Of course, we are assessing for
other more serious problems as well. Ant. tart. is "widely used in
the treatment of . . . respiratory ailments in babies and young
children [and is] reputed to be excellent for respiratory distress
associated with fluid accumulation and rattling in the lungs . . .
" (Homeopathic Medicines for Pregnancy and Childbirth, Richard
Moskowitz, MD, 1992, North Atlantic Books and Homeopathic
Educational Services.) It's certainly made our lives as midwives
easier these last 5 years! [grin]
I was at a birth where the baby's lungs sounded wetter than we'd liked, so I tried, for the first time, the homeopathic Antimonium Tart. Within two minutes, the kid stopped crying and started rooting - nursed well. After that, he was only quiet alert - didn't even cry during his newborn exam. His lungs didn't sound much better, but something seemed to really help him out. He weighed 9#1oz, by the way.
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