Saturday, April 12, 2008

Neonatal resuscitation (updated with illustration)

Lisa Barrett just posted about resuscitating the newborn. I love the photos at the end showing how to resuscitate and evaluate a newborn without cutting the cord or removing the baby from the mother. She shows pictures of a breech water-born baby receiving positive pressure ventilation via a bag and mask. The baby remains with the mother, who is still sitting in the birth pool.

Here is an illustration of a resuscitation from Anne Frye's Holistic Midwifery Vol. II.
Resuscitating a baby without removing it from its mother is certainly doable, although of course much less convenient for the birth attendants. (One might ask, of course, why convenience so often trumps what is best for the mother and baby.)

The one time I have resuscitated a baby was after a water birth. The midwife was still en route when the baby emerged. The baby was floppy and didn't respond to stimulation. The parents helped support the baby in the water while I positioned the airway and did mouth-to-mouth, which was all the baby needed to come into her body. (I was at the birth mainly in the role of a doula, although I had also begun an apprenticeship with the midwife. This experience spurred me to become certified in NNR. I took the course from Karen Strange, who I highly recommend if she is coming to your area.)

Home birth attendants have devised a nifty & portable contraption that substitutes for a warming table if the baby needs a warm, firm surface for resuscitation (for example, in the rare occasion that chest compressions are warranted). You put a large plastic cutting board or cookie sheet and some receiving blankets on top of an electric heating pad, then wrap everything in a pillowcase. You simply carry the "warming table" to the mother & baby, rather than remove the baby to a warming table. Midwives will often place folded towels on top of their "warming table" during a labor. This warms up the towels and keeps the cutting board warm.


  1. Awesome post as usual Rixa. I have actually been doing a fair amount of reading lately about doing NRP with the cord intact. Aye, aye, aye... I WISH we could do that. Seems it would make the NRP so much more effective. But those cords are cut within seconds. Makes me sick. Love the cutting board idea. How neat!

    My NRP is up in December so in a couple of months, I'm going to be actively looking for a Karen Strange class. I've had the opportunity to attend one a few months ago, but it was so early to renew. I probably should've had just gone. I hope she comes back. I don't think I'd ever get enough people together to organize my own class. We'll see.

    Thanks for all the info. I highly recommend Karen Strange too... she is such an advocate of gentleness at birth.... not all the violence that occurs otherwise. I really, really want to learn from her!

  2. Rixa, Can you mention more about the board. I don't use anything. and on the rare occasion I've had to be a little more vigorous I have just laid the baby on the floor with a warm towel still attached to the mother who is sitting in front. I warm towels by wrapping them around a hot water bottle.

  3. ENLIGHTENING! Please tell me more about what NRP is. (?) THANK YOU FOR EDUCATING!!

  4. Rixa your killing me!!!

  5. Well, the board is there for instances where the mom isn't near or on a firm surface (on a soft bed, for example, or in the water). Honestly I've never seen it actually put into use when I was attending births because the need for a hard surface to do chest compressions is quite rare; it's there as a "just in case we need it" thing.

    There's a great illustration in Vol 2 of Holistic Midwifery showing a resuscitation of a 9-min shoulder dystocia baby, with the mom and baby still in the birth pool. The midwife hopped in the pool, and she and her 2 assistants are doing a resus while mom and dad continue to hold on to baby. Mom is stroking the baby's foot and dad is touching the baby's head. Cord intact, of course. Will try to scan and post it when I have time.

    NRP is another abbreviation for neonatal resuscitation training. NRP = Neonatal Resuscitation Program.

  6. Picking nits here...technically I did mouth-to-nose-and-mouth. But it's so awkward to type that!

  7. Rixa:

    I am happy to do the preliminary NRP on Moms abd/while mom holds baby. But when you need ppv and you usually do not, but when you do, time is of the essence.

    When I have had to do ppv, I usually only have to do a few puffs. But it is important to read how much volume is going into the baby's lungs. You can pop a pneumo and be in worse shape.

    When the baby is in the tub and the cord is attached, the placenta is below the baby. This means the baby is losing blood. The baby is a high pressure system and the placenta a low pressure system. If you are squating and the baby comes out. Then the baby would be getting more blood. The problem most Neonatologists have with keeping the cord intact (unless it is a premie c-section and then we do delay the cord clamp but we put the baby below or at the level of the placenta) is that we cannot predict how much blood baby will get or lose.)

    For the past year, I have been teaching NRP and for the last 10 years I have been interested in delayed cord clamping because many parents want it but don't have a good understanding of the physiology of the transitioning baby.When I asked one mother why she wanted to delay the cord clamp, she told me "so the baby does not have to breath right away." According to the NRP book, the baby does need to breath right away.

    Rixa I read your blog because it is important for me to keep an open mind. Folks from all walks of life come into the hospital to have their babys. I read blogs like yours so I can better understand where they are coming from.

    I think someday we may in fact find that the cord should stay intact. When that day comes, I will gladly do it. However, no one has directed me to research that indicates we should not cut the cord right away. If you have some, I would be glad to go look it up.

    Medicine changes constantly. ACLS has changed way too many times to keep straight. Believe it or not, we do change practice with evidence based medicine. However, we need to see the evidence.

  8. Pinky, I understand that you can't take thousands of years of successful procreation as evidence that birth works. Birth hasn't changed, just the medical model. The baby is not losing or gaining blood but getting the exact amount for it's needs. There is in fact evidence to show that delayed cord clamping reduces anaemia and that outcomes are better, I'm sure you don't need to be directed there, it's in the public domain.
    "Do no harm" means if it isn't broke don't try and fix it because you are just making it worse.

  9. "I understand that you can't take thousands of years of successful procreation as evidence that birth works"

    I realize it works. However a natural part of Birth is death. Birth is a natural process that, if left alone will kill a certain part of our population. This is evidenced by taking a walk through any old graveyard. You see many graves of young women and their babies. It is also evidenced by the poor outcomes women in Africa and Afganistan are subjected to.

    So my main question is: how do you know the baby is getting the correct amount of blood? The Nicu Doctors don't seem to think that is the case. Especially if the placenta is below the baby.

    I have seen the BMJ study of delayed cord clamping and hematocrits in children 1 year. However, they do not specify the position of the baby and the placenta.

    The "research" I have been directed to has been very old research 1950's in some cases. I want to look up the research because parents do not come to the hospital to hear my opinion. They want evidence based intervention.

    I also have to check motivation. The Nicu Doctors are responsible for the health of the baby. They are learned folks who have spent years and years studying Neonatal physiology. They are the folks we trust with our sick babies. They also have to justify their plan of care. Parents want to know "why" are we doing what we are doing. They have a right to know.

    If I didn't care about the welfare of the folks I take care of, I would not be looking this stuff up. The reason I started reading blogs is that the internet is where a lot of folks are getting their information about birth.

    Another thing is that correlation does not equal causation. Please see chart about Global warming being a cause for a decline in Piracy.


    Here is the Pirate vs. global warming site.

  11. Pinky... I'm assuming that last link was posted here by error? I don't see how the Church of the Flying Spaghetti Monster has anything to do with this topic. Am I missing a connection?

  12. Pinky... to give you some places and references to look at, I'll include a list here. I apologize if some are repeats.

    These are two of my favorite sites. The info contained in these two sites is what spurned me on a few years ago to begin looking into the issue of the timing of cord clamping. There actually IS a lot of evidence for delaying cord clamping. And while I can appreciate that there are many old grave stones with infant names on them, I think we're missing the point. I think there is a lot more that goes into those statistics, including cultural practices, religious beliefs, disease at the time, etc.

    That said... here are my two favorite sites:

    You may also find useful information at these sites:

    And in the following link, click on the chapter titled, "Review of evidence on cord care practices":

    Let me know if the links don't work or if there is an issue. I'd be happy to email them if need be.

  13. Hmm, delayed cord clamping just plain always made sense to me.

    I've seen enough animals born growing up on a farm and I have yet to see a cow or a pig turn around and bite off the umbilical cord the second the calf or the piglet is out. The baby animal is born, they kind of fumble around a bit, and usually within the first ten minutes the cord sort of goes slack and detaches by itself. I know that human beings are not pigs or cows, but we ARE mammals and I really don't think that our cords are intended to be cut the second we hit air for the first time.

    I've done delayed cord clamping with all but the first one (hospital birth, we just forgot to demand it in the heat of the moment); when my babies came out of me I was lying on our bed and the baby was either lying on my belly or next to me being talked to and touched by me and dh while the midwife waited for the cord to stop pulsing and watched me for blood loss. Usually within the first 10 minutes or so we cut the cord. My placentas have always come within a half an hour.

    I have also seen growing evidence that delayed cord clamping is beneficial, including less iron deficiency anemia later on in infants. I know so many EBF military moms who use WIC and their babies are considered anemic at 9 months at the blood test; could this be because we cut the cord too soon in so many births? (Of course, the medical community blames that "deficient breastmilk", of course@@. If something is wrong it is always nature's fault.)

    Of course, there ARE exceptions to the rule with anything. I don't think delayed cord clamping would be a good idea in identical monochorionic twins who share a placenta, for instance, due to the risk of Twin-to-Twin Transfusion Syndrome.

  14. Team Harris:

    Church of the flying spaghetti Monster has a great chart about Pirates and Global warming. The gist of it is, correlation is not the same as causation. Just because something appears together, it does not mean that one caused the other.

    Thanks for the information. However, I have read and I don't consider it a scientific inquiry. Some of it is flat out false. I do consider the BMJ study a good source. However, I wish they would tell me the position of the baby at the time of the delay.

    I will check out the other sites. In order for the reference to be adequate, you need it to appear in a peer reviewed Journal.


    I actually like the picture of the baby being resused on the midwifes lap. Surprize! I like that she can get the baby into a sniffing positon and her hands are free to bag and keep a good seal on the mask.

  15. Just looked at the WHO paper. That is about care of the cord after delivery. And yes, in the 3rd world you are probably better off not cutting it and introducing infection. It does not, however, give me any meat and potatoes facts about delaying cord clamping. I need a peer reviewed journal. Especially since I have 8 neonatologist telling me the cord should be cut at delivery. I do have one Neo who agrees with the BMJ and thinks delayed cord clamping is beneficial.

  16. Pinky... one of the reasons I like is because many of articles ARE backed up by scientific, peer-reviewed journals. Check out the references for some of the articles. I'm not saying all of the articles are peer-reviewed, but many of them reference peer-reviewed journals.

    I know that I part ways with some though. I don't believe that all of life has to be proven in a peer-reviewed journal. I know I will catch a lot of heat for saying that. But it's what I believe. I think there are just some things that you can't always prove on paper. It doesn't make them untrue (in my personal opinion). But I realize that much of the general population (especially in the scientific world) will disagree with me.

    I will always maintain that personal intuition and communication with a higher power can trump science. Please no tomatoes if you disagree with me. We can certainly agree to disagree.

    To some degree I also agree with anonymous' comment that if something is wrong it's nature's fault. I see a lot of that in medicine. I also agree that we need to take a step back and see how it is that the human race has survived for millions of years. I have also wondered about mammals in general... I just can't accept that for all these years, mothers found it necessary to immediately clamp off that cord. After a long and arduous labor, I just find it hard to believe that after they went through the intense work of birthing, their first thought was to sever the cord. I just can't. But I can't prove that so it will hold no water with most. I'd like to think she picked up her infant and held it first.

    In fact, "way back when" before string or other things were even invented, I wonder what they used. In the very early history of humankind, I am willing to bet they just left the cord intact (lotus birth). By so doing, it will fall off by itself. Yes, I'm sure some babies died this way.

    But that is a whole different discussion. I DO believe that death is inherent in birth and I know I won't make friends saying that. But we do live in a world where death is very unacceptable, even though it is a normal part of the human life cycle. Like I said... different discussion altogether.

  17. Pinky... looked at the "church" site... still having a hard time correlating the two! ;-)

  18. "After a long and arduous labor, I just find it hard to believe that after they went through the intense work of birthing, their first thought was to sever the cord. I just can't. But I can't prove that so it will hold no water with most. I'd like to think she picked up her infant and held it first."

    Thank you for being honest with me. I can understand your rational with delayed cord clamping here. It makes sense.

    My problem is that everything we do now we need to back up with Evidence and with out it we have not a leg to stand on. In some ways this is good because when I disagree with a Doctor, I can refer to research to back up my claim. For example routine epis, AROM, Epidural at 2 cm instead of 4cm. Women who come to my hospital do not want to know my opinion necessarily. But most want to know why we are doing the things we are doing. And if it is personal preference. I need to be honest and tell folks that.

    My job is to tell the families both sides of each argument and let them decide.

    Again, thanks for the information you have provided.

  19. I agree that we should have ample evidence before we do things at birth. That means any deviation from the physiological process should be carefully evaluated and researched before being adopted as routine. With immediate cord clamping, it didn't emerge because of careful research and studies comparing it to both delayed (usually a matter of minutes) and non-clamping until the cord is white & limp and/or the placenta has birthed. Like a lot of other obstetrical practices, ICC became adopted as a routine practice that became firmly entrenched into birth routines, professional identities, and even architecture & furnishing of birth spaces (i.e., the infant warming table which necessitates cutting the cord in order to get the baby to the table).

    Those who advocate delayed or non-cord clamping approach the intervention as needing thorough research and justification before doing it--no matter how commonplace or routine or accepted--rather than needing to justify physiology. Does that makes sense? I can see parallels between ICC and other obstetrical interventions that were adopted without adequate research and vigorously defended as necessary and beneficial for a long time, until research finally proved otherwise: things like episiotomy or AROM to "speed up" labor, for example.

    Although gravity does affect the speed of the placental transfusion, it's not like you're pouring blood back and forth between the baby and the placenta. During postbirth contractions, blood will flow from the placenta to the baby no matter how the baby is positioned. Between contractions, the blood can return back (but in increasingly smaller amounts) to the placenta for oxygenation. There is a finite amount of blood in the baby's circulatory system, including the cord & placenta. Leaving the cord unclamped after birth will allow the baby to receive its full transfusion of blood.

    Pinky, I think the best source for you to understand where we're coming from is an excerpt from Anne Frye's textbook Holistic Midwifery Vol II, pages 489-505. It's the section called "Placenta-to-Newborn Transfusion, Physiologic Closure of the Umbilical Vessels and Severance of the Cord."

  20. Re gravity:
    (from Karen Strange's Midwifery Management of Neonatal Resuscitation)

    "...within 45 to 60 seconds after the birth, as the oxygen levels begin to increase, the umbilical arteries, which take deoxygenated blood from the baby to the placenta, begin to close, starting closest to the placenta."

    This is why, when you check for pulsation, you need to feel right next to the baby and not further out on the cord. Also note this physiology is not as simple as water flowing through a garden hose. The closing of the arteries, preventing most natural backflow from baby to placenta, is as Rixa mentioned, a gradual process.

    "Each time the mother has a contraction, blood is pumped into the baby. The vein stays open (which is more than twice the size of the arteries)..."

    The vein's role is to bring oxygenated blood from placenta to baby, and it can continue to do so when left unclamped. Strange also mentions that the body is always striving for homeostasis and the open vein can also accept reverse flow if need be.

    "True physiologic cord closure occurs between 1 1/2 and 3 hours after birth...

    "The place where you put the baby matters only if you cut the cord quickly after birth."

    "If you need to resuscitate the baby, place it below the level of the placenta."

    Much gratitude to Karen Strange and Anne Frye for shedding light on what is already a perfect, physiologically sound system.

  21. I know I'm late to this discussion, but this is for Pinky - - please listen carefully to the WHO video, Active management of the third stage. Even WHO is saying that evidence suggests a one minute delay in clamping the cord is advisable.

  22. Karen Strange and her NRP class rocks!

  23. I am late too, but I just read this blog where a letter by Henci Goer was sent to UCLA about the immediate cord clamping of her granddaughter after a premature birth.



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