We are now at the point after birth that we have determined that baby needs a little extra help. Why isn't the baby breathing? Sometimes the risk factors are obvious, sometimes they are not. Was there meconium, suspected gestational diabetic baby, early term, late term, distress during labor or birth, infection, maybe a undiagnosed heart defect, heart valve not closing, surfactant deficiency or just a slow transitioning baby? Sometimes we just do not know.
Risk Factors:
Meconium staining. I looked for some photos of the different types of meconium staining which can lead to meconium aspiration. I couldn't find anything worth sharing, but I don't have any opportunity to take them for the purpose of sharing. The majority of meconium I see at birth is what you would call terminal meconium. It is when the water breaks and it is clear, but as the baby comes through the birth canal, they poop. It is evident when you see a big dark blob on the pad. It is completely benign and is not associated with meconium aspiration. There are different degrees of meconium staining from light (this means it happened awhile ago and the baby has already broken it down) to very dark thick pea soup consistency. The later would be an automatic hospital transfer if birth wasn't imminent. One study on meconium and birth. https://www.semanticscholar.org/paper/A-study-of-factors-causing-meconium-stained-fluid-Kumari-Ashwini/b4d1598c282b5fb9930af32678e0decd2bfaa35e
Blood sugars. Even if a mom passes the gestational diabetes test and she continues to eat high sugar or carbs during her pregnancy, she may have a baby that has had elevated sugar levels in pregnancy due to the carb intake. This may create a diabetic baby. Diabetic babies may have trouble maintaining their blood sugar levels after birth and may struggle to breathe. They crash from their sugar highs. Hence, this is why a hospital monitors large babies. Though not all large babies are because of their mother's diet. We monitor the symptoms, like the UK does.
Other factors. For the sake of brevity. I will not go into other factors in this post.
Our first steps to help a baby breathe and transition into birth are to stimulate and bulb suction, though evidence is suggesting to just wipe the mouth, if possible. This works for most babies, but we wouldn't need a whole post for that and you probably assumed we already did that. So what's next. These are some of my tools, though each midwife may vary what she carries depending on her training and protocols. None of these tools are required to be carried by any midwife.
This tool is my favorite. It is a bag and mask. It aides us in giving Positive pressure ventilation (PPV) The valve enables us to give "breaths" to the baby without having too much pressure for their lungs. It can also be connected to oxygen, if needed. I have found this tool more effective in aiding breathing transition over any other tool I have. Remember, babies are meant to absorb fluid in their lungs. Giving FIVE effective CLEANSING BREATHS is the first step. I have started to let parents know ahead of time that I would prefer to do this earlier than later and it isn't necessarily a sign of distress. This is not the same as performing PPV, which will be covered later. I am only giving 5 breaths to help with those first breaths. Oftentimes, it is a preventative to transfer, and is used if transition looks a little slow. Thank you for BEST Emergency Skills workshop on NRP training that is relevant to out of hospital midwives. What if it isn't enough or what if the chest does not rise?
Assuming that I am constantly checking the position of the mask and position of the chin, I will move on to other tools. If I cannot get a chest rise, I will move to suctioning. My out of hospital tool is the DELEE .
I insert the tube in the oropharyngeal cavity - back in the deep part of the mouth or opening into the throat. I am suctioning into the throat deeper than I can get a bulb syringe. I am using my mouth to suction with the other tube and contents from the baby will enter the cylinder. The hospital has suctioning tools that can be inserted as deeply as the baby's endotracheal cavity - I cannot do that. That is out of my scope of practice. Anything inserted into the baby has risk of causing swelling or puncturing, too deep and you can puncture a lung, and must be used with caution outside of the hospital. Suctioning is not indicated if the baby is breathing with adequate chest rise. Reminder, I am only suctioning in the throat. If the throat is full of mucous, the baby's airway will fully or partially be blocked. For years, I used to suction all babies with a delee before transfer, I figured "why not use all the tools I have". Anecdotally, in retrospect, it never helped unless I heard raspy lungs or did not have adequate chest rise. NRP, Neonatal Resuscitation Program by the American Academy of Pediatrics, no longer recommends routine suctioning even with meconium stained amniotic fluid. I have listed a few studies below.
If I need to continue with NRP, at this point, I will be placing a pulse oximeter on the baby.
These two tools provide me with much needed information. This shows me the baby's heartbeat and frees my hands & tells me what the baby's oxygen level is. I reference that with what is should be.
If the heartrate is above 100 and baby is breathing or crying, I rarely will use a PPV mask. I will put oxygen on the baby. At this point if I have not already, and I am using oxygen or starting PPV, we are calling 911. Indicators that supplemental oxygen is working is obviously a rise in oxygen levels, stabilization of a heartbeat and color and breathing in baby. I have seen just giving baby supplementation of oxygen stabilize a baby until EMS arrives. Blow-by oxygen would be a starting point. If blow-by oxygen is not bringing pulse oximeter readings to the targeted levels, then you increase the oxygen until it does. If I am doing blow-by and the oxygen level is below 85, then blow-by is not indicated, a full-on oxygen mask is and then I slowly increase the amount of O2 until the targeted level is met. You have a risk of giving baby too much oxygen and it must be monitored continually.
If baby does not have adequate breathing movements and especially if the heartrate is under 100, I will be doing Positive Pressure Ventilation. This is not just the 5 breaths as I mentioned above. This is continual breaths given at 60 BPM and I will be monitoring if they are effective. THE NUMBER ONE INDICATOR THAT THINGS ARE WORKING IS A RISE IN HEARTBEAT. Chest compressions are indicated if the baby's heart rate remains less than 60 bpm after at least 30 seconds of PPV that inflates the lungs, as evidenced by chest movement with ventilation.
If PPV is needed beyond a brief period, I will insert an alternative airway and release gas from the baby's stomach. This is very rare, but I am trained to do it.
I want to do as much of this on mom's chest, as possible. I want to communicate what is going on. I am not very good at it at times but I am working on it. I tend to think inward and focus on my task with my head spinning through all the possibilities and probabilities. I am so thankful for good birth assistants that take over communication. I now practice doing my skills while pretending I have parents that are there and need information. So, I am getting better. This is one of the reasons that I like to educate parents.
Our purpose in NRP is to keep the baby breathing, heart beating and oxygen levels within range until EMS arrives. Our care ends when the ambulance arrives and EMS takes over care. The Texas Administrative Code states "(b) It is an emergency if, during labor, delivery, or six hours immediately following placental delivery, the midwife determines that transfer is necessary and the client refuses transfer. The midwife shall call 911 and provide further care as indicated by the situation. The midwife shall not provide any further care after the arrival of emergency medical service (EMS) personnel but may do so if requested by EMS personnel."
This code, while I understand the reason for it, can cause many midwives a lot of distress. At the birth center or a house in the city, it is no concern. EMS walks in and quickly assesses the situation and leaves very quickly with a baby. Most birth center births, if there has been a baby in respiratory distress right after birth, ambulance arrives, leaves and arrives at the hospital within 15 minutes of birth. Out of city limits, the results are not the same. Our co-care isn't needed within city limits. Our co-care is rarely wanted in the county and our instructions are often not listened to. I have had EMS come in and remove equipment I am using and not continue with NRP guidelines. I have pointed out over and over concerns and be ignored. I have seen EMS take an absurdly long time to leave. I have seen them transfer to hospitals twice as far away. I have seen them transfer babies inappropriately. My job is to start work that EMS is supposed to take over. This will be another post. I do not want to do an EMS bashing post. They do an incredibly necessary service, work in a lot of stress and are probably underpaid. I want to inform parents on how transfers should look. I want to give you the tools you need to feel confident in the next step of getting your baby help for respiratory distress.
I will have taken NRP for the 7th time this coming Friday. Some in a hospital settings, but the best have been given by some of the best instructors for out of hospital midwives. One of those has been teaching NRP type skills in a hospital before NRP was a thing. I have learned so much and hope that I have helped you understand the process as well. Did I leave anything out that you would like me to address?
Routine Suctioning:
International Liaison Committee on Resuscitation (ILCOR) guidelines from 2020 [13] recommended avoiding routine suctioning, even in the presence of meconium-stained amniotic fluid. This recommendation was supported by a 2022 systematic review that found no benefits of suctioning [14]. This study only recommend suctioning in the presence of obstruction. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10529279/#:~:text=International%20Liaison%20Committee%20on%20Resuscitation,benefits%20of%20suctioning%20%5B14%5D. NRP's latest guideline https://downloads.aap.org/DOICH/NRP%20Instructor%20Update%20Spring_Summer%202019.pdf