Tuesday, March 08, 2011

Neonatal resuscitation

Where/How/Why/Who
Several people have asked questions about how and where they can obtain training in neonatal resuscitation. If you're in the States, visit the AAP's NRP page. In Canada, visit the CPS' NRP page. You can find links to current NRP guidelines and search for instructors or courses.

I took my NRP course from Karen Strange, who travels all over the country teaching NRP workshops. She teaches everything required for the NRP certification and addresses how to adapt these to the realities of an out-of-hospital setting (cord usually left intact, resuscitating baby in place with a portable heated surface rather than removing baby to a warmer, etc). She's hilarious, quirky, and has a last name that totally fits her personality.

Nothing replaces actual hands-on experience gained at NRP workshops. But if there are no NRP courses near you, you can of course study on your own. Do what you can with the resources available to you. Buy or interlibrary loan the latest NRP manual. Watch videos. Read textbooks. Learn more about the fetus-to-newborn transition.

Who would benefit from taking a NRP class? Besides the obvious (midwives, physicians, nurses), I feel that doulas should also be certified in NRP. Sooner or later, most doulas will attend a precipitous birth where the mother has the baby before she can make it to the hospital, or where the midwife doesn't arrive in time at a planned home birth. In addition, I'd strongly recommend NRP for women planning a home birth or with a history of fast labors.


What about Inga's birth?
There is disagreement, even among NRP instructors and NICU/L&D nurses, about whether or not I should have done more aggressive stimulation (drying with towels, rubbing the back, etc) before proceeding to mouth-to-mouth. I am aware of the NRP flow chart (pictured below). During Inga's birth, it was clear to me that she needed mouth-to-mouth at that point, rather taking more time to get out of the tub and dry her off first. Inga was born with color and tone and then started losing it, which indicates secondary rather than primary apnea. In that case, stimulation is less likely to be effective than positive pressure ventilation (either by mouth-to-mouth or bag-and-mask).

If you read the comments on Inga's birth story, part 2, you'll see a conversation going on among L&D/NICU nurses and NRP providers about whether I should have done more stimulation before proceeding to PPV. Some suggested doing a bit more stimulation/clearing the airway, while others felt that moving to mouth-to-mouth at that point was most appropriate. For example, Sarah, a NICU nurse, explained:
With primary apnea (a baby born without tone and color) rubbing the baby and clearing the airway will often work to stimulate breathing. With secondary apnea, where the baby loses tone and color, stimulation will not work. The baby needs PPV/ rescue breaths. Stimulation is really irrelevant in these cases.
From cileag:
I think it's intimidating for people to see a baby "crash" like that. Like Housefairy said, mostly it's the "perfect" homebirths that get shared. As an OB nurse and practitioner of NRP, I know that the good thing about NRP is that it almost always works.
My nurse-midwife, who herself is a NRP instructor, wrote to me:
Stimulation [in the form of giving breaths] and a moment for the cord blood to return to baby again...and baby was clearly just fine. She had no additional need for support, not even blow-by oxygen, which is evidence that this was an acute scenario [i.e., temporary and quickly reversible] and she had a good reserve. 
Okay, now I'm really tired of talking about neonatal resuscitation, since Inga's was such a minor part of her overall birth. There are all sorts of ridiculous things being said on the internet about me and about her birth. Just to give you a few examples:
  • I am a bad, unfeeling mother because I remained unnaturally calm. A good mother would have panicked more and shown signs of distress and remorse. This reminds me of when I was engaged to Eric. People worried that I had made a bad decision "because I wasn't glowing enough." Apparently there's an engagement smile-o-meter that I failed to pass. Just as I failed the precipitous birth panic-o-meter.
  • Because I didn't follow the NRP flowchart to the letter, I was ignorant and uninformed. Never mind that Inga responded almost immediately to the mouth-to-mouth and had an Apgar of 9 or 10 by time she was 2 minutes old. 
  • Everything turned out fine, but YOU OR THE BABY COULD HAVE DIED! Yes, I could have had a hemorrhage, even though I lost only 10 cc of blood. Yes, the baby could have needed more extensive care, but it didn't and skilled help was on the way. Yes, I could have had a heart attack or an amniotic fluid embolism. But I didn't.
  • Inga's birth proves that home birth kills babies. Holy non-sequitur Batman!
I have an awesome response coming...stay tuned.
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89 comments:

  1. The only thing Inga's birth "proves" is that it's a great idea for (I would say everyone, but) home birthers to be trained in NRP.

    And good for you for being calm enough to be effective!

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  2. Love your response:) It's so easy to look at things in hindsight and decide what should or should not have been done:)

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  3. Oh, Rixa! Thanks for posting such great info, and I'm SOOO sorry you're having to deal with so much judgment for sharing your experience ... what a world.

    And FWIW, (because I just can't leave this part unsaid), the "not panicked enough" point is just TOTALLY bogus. Not panicking is common in high-stress situations - (although maybe not as common as panicking, if judgy comments are any indication) - we just do what's necessary, and then analyze/panic/vomit about it later.

    Here's to getting some rest from the cyber-war!

    *supportive, grateful hugs and thoughts and prayers your way!*

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  5. Love this!! We could "what if" all day long. I could "what if" just driving down the highway. Shoot, if I did, I wouldn't ever go anywhere. The fact is, you did a great job, mama. And this is why a mama who is left alone to her instincts and who is informed will be empowered to make the right choices in the moment. To me, my brain says the amazing outcome of Inga's birth is because you were left unhindered.

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  6. I love to read your blog, but almost never comment. This time, I feel compelled... The video of your birth was BEAUTIFUL and Inga is breathtakingly gorgeous. You prepared and informed yourself to the Nth degree, and it shows. You were cool headed and calm, and used your mama instincts. Those instincts are deeply powerful and I don't think enough people give them credit. Praising you for your strength. You are a beautiful mother.

    Blessings to you and your family!
    Heather

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  7. I was so impressed by your calm, quick response that I even made my husband watch the video in preparation for our next homebirth...just in case. I'm pretty confident that we both love our unborn child AND could remain calm in a similar situation. Congrats on your new baby!

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  8. I applaud your decision to put your birth video online, even though I'm sure in the back of your head you realized you'd be dealing with some b.s. backlash.

    Also, your engagement smile-o-meter made me laugh. I am probably a bad mother because I didn't cry at my daughter's birth, and I know there's a cry-o-meter out there I failed. Come to think of it, I think you did, too! :)

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  9. I totally bombed the cry-o-meter. Didn't cry once at my children's births.

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  10. I've been following your blog for a year or so, but I'm not sure I've ever commented. I'm an L&D nurse, and while I'm not sure that I would make the same choices you do for myself, I *love* reading your thoughts and your birth stories. I just want to say thank you for sharing and for being you! I think you handled things perfectly!!

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  11. OB/nursery nurse here. I would have done exactly as you did, Rixa. I think we mess around too much with stimulation, esp in secondary apnea, when we ought to go straight to PPV. You aren't likely to hurt a baby by bagging him when he doesn't really need it; you might, however, if you diddle around doing other stuff when he DOES need it.

    I for one was impressed that you were so calm. I'm preggers with #2 and have had dreams where I deliver her and she needs breaths. I stay calm in my dreams and give her breaths. (I realize that it's not the same as real life, where I've also PPVed babies and tried to stay calm then too!) Really, who benefits if everyone is freaking out?

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  12. Oh, and I was going to say that the only mothering scale-o-meter you've failed is the one that says you should be nowhere near this coherent and intelligent in your responses at only 6 days pp!

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  13. You are awesome, Rixa!!

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  14. You were calm because you were informed. People who freak out show me that they are not as well informed as they could/should be. Your birth videos showed me the importance of knowing what you're doing and being prepared for things that could happen. I thought it was amazing.

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  15. I was actually way impressed with how you handled it! Made me think twice about getting certified myself! You are a great example of a home birth because most people only post the home birth videos where nothing goes wrong. You posted a video where you had a small problem, and handled it AWESOME! It makes it more real for me. Thanks!

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  16. I've never cried at a birth of one of my children. I feel too full of joy and peace to cry! I think freaking out the way those nay-sayers think you should've would have been detrimental to Inga's recovery! How lame of them not to realize such and know that you were doing what you were trained to do and led by the Spirit to do (probably, right?). Anyway... Absolutely amazing how absolutely ridiculous negative people can be! And looking in all the wrong places for validation of their faulty perspective!! Amazing.

    You are and were amazing. Thankfully you know it! ^_^

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  17. Hey Rixa, just another L&D and relief NICU RN here, who just got re-certified in NRP and based on what I saw you are ABSOLUTELY correct in your actions because secondary apnea does NOT respond to stimulation. IN FACT... I spent 2 weeks in rural Peru in April of last year teaching just that information (Basic NRP) to health-care providers in areas where there is no O2 or wall suction or intubation or meds.

    If baby comes out with good tone and crumps (loses tone and color and is not making breathing efforts) -> go directly to PPV. Do not pass go, do not waste time stimulating. We left a small ambubag and several infant masks at each rural health center to help them out. I am certain that they will see births like Inga's and know what to do and that babies will be saved, rather than being left to die because stimulation didn't work to get them breathing.

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  18. Panicking in an emergency makes you a good mom? Guess you'd better practice! You are so lucky to be the type of mom who stays cool and calm under stress! Amazing birth and video! I am planning our 3rd home birth this summer, and it never occurred to me to get training in this area, I mean, the midwife will be there, right... hmmm... :)

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  19. I'm so sorry you're having to deal with criticism for Inga's birth! You did an awesome job, and there is no criticism that can be rightly placed on any player in your birth. You were absolutely perfect! Good job, and ignore the trolls.

    Also, I fail cry-o-meters and panic-o-meters all the time. Didn't cry at my engagement, my wedding, or any time along the conception/pregnancy/births of my children. We can hang out together as cry-o-meter failures. :)

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  20. Rixa, Since I've read your blog for sooo long I know that your personality is reserve and common sense, such that your reaction to your labor and birth was totally "you" and "practically perfect in every way" as Mary Poppins would say. I've taken Karen Strange course of neonatal resuscitation so thought nothing of you giving your baby PPV (positive pressure ventilation) breaths.

    I love that homebirth families don't have to learn a strangers (nurse/doc) mannerisms, likes, mood during the work of birth. In my doula work I am very familiar with the awkward meeting of hospital providers, and the eye contact and verbal exhange that says, "who are you and am I okay, are you okay?" I love that at home we already love our attendants and they love us! that we can be ourselves and focus on greeting our work and our baby.

    Thank you for being vulnerable and sharing Inga's birth. I think you've taught more people more than you know.

    P.S. I'm signed up for Karen's course in June. I need a refresher.

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  21. Isaac was born with primary apnea and rubbing his back and drying him was my first instinct and that seemed to help (as he's still alive today!)

    I think it's funny that your lack of panic with the apnea situation was dissed. Just last month, I was eating out with some friends when Isaac started choking on an onion he tried to eat. I was pretty calm in sweeping out his mouth and getting him back together and the response from a non-mom was, "See, you're just made to be a mom! I would have panicked and made things worse!" It's funny how panicking or not is a way to gauge the love/effectiveness of mothering!

    I think you did exactly what you were "supposed" to and you are a great mom! :)

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  22. I really appreciate the further explanation. So happy you're both okay, and congratulations again!

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  23. babygirlwren3/8/11, 3:49 PM

    In response to the 'your a bad mom because you didnt panic' comments.

    What in the world does panicing achieve? Will it help your daughter breathe? No. Will it help get color back and blood flowing for her? No. Could it have resulted in you doing absolutely nothing and your baby possibly dying? Absolutely.

    Panicing solves nothing, there is no reason to do it. You did what needed to be done for your daughter in a calm, efficent way without resorting to hysterics. I applaude you!

    And remember. Yes, homebirth kills. We all have zombie babies. Mine is currently 19 months old and enjoying the afternoon with her grandparents :)

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  24. As someone who has had a super fast birth before, your posts the last couple of days have opened my eyes to things I should educate myself further on, just in case. Thank you.

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  25. Oh for heaven's sake. You're great. I was so touched by your calm, loving, effective response to Inga's floppiness that I tried typing up a comment on that post but ultimately gave up on articulating my admiration in a non-sappy-sounding way. It's just pretty great to see informed, child-focused parenting happening seconds after that child joined you in the outside world.

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  26. Can't wait for the Rixa Freeze smackdown!

    And boo to all those who say you don't care because you didn't scream and cry and freak out - WTF-ever! None of those things help the baby and what you did helped your baby. End of story. Piss on the naysayers - they're just jealous because they can't stay calm, cool and collected like you.

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  27. Actually, I thought the opposite. I thought "Wow. She is such a great mom; staying calm and knowing exactely what to do when her baby wasn't breathing."

    I still stand by that. Women in tune with themselves and their babies know how to give birth, know what position to be in, know if something is wrong. After birth, Mom's can know where the baby is on the bed even when the mom is sleeping, they can know when the baby needs to pee, when the baby is hungry and when the baby just needs some snuggles. GOOD moms know. It comes easy. You are a good mom, Rixa, don't let anyone tell you different. And thanks for the info! I'm going to go learn more about NRP!

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  28. I'll 2nd Jane of Seagull Fountain. With adequate training/knowledge many emergent issues of birth can be successfully treated.

    And really, not panicked enough? Who would have taken care of Inga if you panicked?

    I'm looking foward to your response. You are so witty and informed.

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  29. That was really upsetting. Thank god your baby is alive. Your baby turned BLUE honey. That is terrifying. I'm glad your birth is just how you wanted it, and I'm glad your friends think you are awesome because your baby almost paid for that with her life. I'm not jealous, I'm horrified that the example you are setting is going to result in a dead baby for some poor momma out there.

    And the implication (from you and K la) that good moms have live babies therefore only bad moms have dead ones is repulsive. What a terrible thing to say... I guess those moms with empty arms due to negligence, misinformation and inexperience were just "bad moms".

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  30. I wish people would just stop with the "YOU OR THE BABY COULD HAVE DIED" comments. First of all, there is a possibility for death EVERY DAY. But do people say, OMG I can't believe you drove a car, YOU COULD HAVE DIED! Or, I can't believe you burn wood in a fireplace, you could set your house on fire and DIE! Sheesh.

    Also, really not sure how panicking would have helped anything. Aren't we always taught that it's best to stay calm in an emergency?

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  31. It's actually very common to remain eerily calm in the face of something scary or tramatic. It's a beautiful piece of human evolution that allows us to think clearly and make the right decisions instead of freaking out and making the wrong ones.

    There will always be people who nay-say home birth, but usually the information they have is hearsay not research-based. Meh.

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  32. I watched your whole video several times because I thought it was so beautiful: your labour, your delivery and the loving way you cared for your daughter in exactly the way you needed to.

    There are always people who will disagree with you, but you can't change their opinions, only your own reactions. The anonymous commenter before me saying that you will be responsible for tragic events is terrible. People will say anything when they can be anonymous and aren't face to face.

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  33. I've been checking in, but not reading comments, and I'm pretty shocked that people are criticizing you for doing mouth-to-mouth. I was very impressed that you stayed so calm and knew what to do, and if it doesn't exactly fit some flow-chart ... your baby recovered very quickly and is doing great! How much more evidence should you need to provide that you did the right thing?

    And now I'm kind of sorry I didn't comment on the previous birth story posts. I had several thoughts that had nothing to do with the resuscitation, but when I saw that the conversation was mostly about that, I thought I would be off topic to talk about how I, also, hate pushing and have to do this mental thing of "Okay, this really hurts but the only way to make it stop hurting is to get the baby out even though that's going to make it hurt worse at first." And it makes me feel better to know that such a birthing goddess as you also hates pushing.

    And I didn't cry at either of my kid's births. But I still love them to pieces.

    And just as a little PS - I sent your birth story to a friend who is an L&D nurse and a student-midwife, and she thought it was great.

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  34. I guess any time you put yourself out there and share something so intensely personal, there are bound to be critics. I was impressed with how calm you remained- wondering if I were in a similar situation if I would have known what to do. I was impressed with how calm you were during your entire labor- not just when you were performing mouth-to-mouth! People can "what-if" all day long. People can say, "Well, I would have done such and such differently" etc., but in the end you ended up with a perfect, healthy, beautiful baby girl, and that is really what is most important! You did something right, obviously, because performing mouth-to-mouth worked.

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  35. Oh goodness gracious me, those comments! That last one especially *gobsmacked*

    Everyone has already said what I was going to and you already know it to: you knew what you were doing, it was a beautiful birth where everything went right and was done right.

    You've reminded me of a blog post that remains half written in my account about the comments online about Nell's birth *sigh*

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  36. Our baby died shortly after birth in May of 2010. She was born at a free standing birth center, transported immediately, but died shortly after arriving at the hospital. We have received a lot of negative comments - and a state investigation - about our birth.

    It makes me crazy when people use my birth as an example of out of hospital birth killing babies. Babies die in hospitals too, sometimes it just happens.

    You handled the birth and resuscitation very well. I don't think there's anything wrong with the way you reacted. At one point you tell your husband, "we still have time," - which shows how aware you were of what needed to be done and in what time frame it needed to happen.

    And like you mentioned in your post, the resuscitation was a few seconds of a very good, beautiful home birth and you are right to want to focus on that aspect.

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  37. I am uber impressed with what you did and how calm you were. I'm a fairly calm person and I was kind of freaking out watching. I'm a HB mom and a doula, and I NEED to take a NRP class.

    Yeah, how does that possibly prove that HB kills babies. Oh my word, that is so stupid. It answers the question, what if something happens? Well, something happened, you were ready, and it was FINE.

    Yesh. You're awesome, go kiss that baby for us and ignore all the trolls.

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  38. Saw the video today and was sincerely impressed. After knowing you for over ten years I have been continually impressed with your calm character and once again it's proved a wonderful blessing.

    Congrats on your darling daughter.

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  39. I've never left a comment before but to "anonymous" above....I've been in family medicine for over 10 years and have been delivering babies for just as long. Are you aware that most newborns are blue when they are born? AND, that many do require rescue breaths or at least some blow-by oxygen and therefore; what you are seeing in these video clips are completely accurate and safe. I just wanted to make sure you were aware that the majority of babies do come out blue. Not sure where you got your information from. This woman delivered a completely unremarkable appearing newborn that required ventilation assistance which happens all of the time---fact of life. IN or OUT of the hospital. In fact, she responded much calmer than the majority of most of my nurses over the years. I congratulate her for that and encourage you to become more educated.

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  40. Rixa, do you have some sense of where these people (the angry rude ones who largely appear to be new to your blog) are coming from? I'm curious about whether you ended up with an unkind link somewhere, or ... ?

    It just seems so odd to lurk around homebirth-friendly blogs waiting for your chance to berate a mother during the early postpartum days ...

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  41. Rixa, your calm resuscitation did work. It is excellent that you did something and didn't freeze in panic. I'm happy for you and Inga that everything worked out okay.

    It is still a fact that Inga did have complications and she could have died if more help was needed and it wasn't on hand, or she could have been brain damaged even if she did survive a transport to the hospital. A comparison: What if you did hemorrhage for a few minutes suffering a class 1 hemorrhage before the bleeding stopped? Wouldn't that still be a close call, and haven't other women died from hemorrhage after birth? Is a bit of nipple stimulation going to save all women from bleeding out? This is the same as Inga not being able to breathe properly and needing 5 breathes a couple of minutes to come around again. A complication resolved with minor help... but it could have been more serious.

    Even though I know you acted quickly and Inga began breathing properly again, watching the video still scared the crap out of me and changed my mind about homebirthing again.

    I've read Tuteur's blog and she does scaremonger and paint homebirthers as heartless and selfish whenever she gets the opportunity. She's offensive and insulting often, but she does speak some truth when it comes to the fact that some complications at birth need skilled help and it may come too late for some babies born in a setting that doesn't have well experienced attendants and the necessary equipment.

    Saying this doesn't make me a troll, it is just sharing my opinion. It is an important opinion to share because while so many seem inspired by your birth video, there are others out there who have changed their minds about homebirth after viewing the video.

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  42. Totally had mixed feelings about your video, initially I think I was a little bit turned off by the midwife first - maybe I could sense her panic in wanting to get started? I also held my breath through the rescus part - but I think it was mainly because I've never actually used my NRP training on a real baby AND many videos I've watched on youtube, on tv, etc where rescus has been used it seems to work eventually but it doesn't make it less scary. It's a rush to be part of any kind of resuscitation (I've given CPR to kids and adults) and watching it isn't easy either. But it's easy to critique from afar, from a keyboard, from an anonymous comment, or someone who considers themselves an expert on any given situation. Totally admire your moxy, your faith in yourself and in your births. I'm sure many people don't understand how much time and energy you've put into knowing how to handle situations like this and when to truly jump out of the tub and make the call. That - and honestly, we're all our own guardians of our own actions in the end anyway. Thanks for including us and allowing our eyes and inquiring minds to follow you through your births.

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  43. "I think I was a little bit turned off by the midwife first - maybe I could sense her panic in wanting to get started?"

    You have to remember this was the midwife's assistant, not the midwife. Her bustling around was exactly why I kicked her out of the room! The midwife herself arrived a minute or so after the video turned off, probably about 5 minutes after the birth.

    I think some of the commenters were assuming this was a planned UC and directing their criticism with that assumption in mind. But it wasn't--it was a planned midwife-attended birth with a precipitous labor. Which means that I had equipment and skilled assistance on the way, so if I or Inga had needed more help, it was there. The assistant carried a basic set of birth supplies & equipment, and the midwives a more extensive set.

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  44. Jessica Beaufils3/8/11, 8:55 PM

    Rixa, I am a long time reader (or lurker)of your blog, and I have to tell you that I find SO much inspiration from reading. I found this not too long after my own son was born in a traumatic hospital setting--and got me to think of childbirth in a whole new way.

    To all those neigh-sayers; how on earth could the human race have survived for millennia if human babies died left and right (or moms for that matter)? ALL women have the RIGHT to be informed about how to give birth, including looking at the not-so-pretty facts (like how to resuscitate your newborn). Life isn't a series of rainbows and lollipops, and having a baby is more that having a clean swaddled bundle handed to you hours after the fact.

    I'm so sorry people are using your amazing candor to bully you.

    Thank you so much for what you do--I am truly inspired by your life.

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  45. Rixa, much love to you and baby Inga (and the rest of the family)... as another OB/L&D nurse & student nurse-midwife... i likely would have done the exact same thing.

    in regards to "B"s post above and some of the other negative comments: homebirth *can*, on rare occasions, be complicated. that's why the presence of skilled, experienced attendants is always recommended, but in the end, we all need to come to terms with our own decisions. no mother or father should be berated or guilt-ridden for doing what they feel is best for their family, whether it is choosing to give birth in the safety of their home, unassisted, or with a trained midwife, or in a birth center or hospital.

    safety is relative. the choice to bring a child into this world is a momentous one, and we each are responsible to prepare ourselves to be become informed, educated participants in our care. sadly, we can't rely on or "trust" our care providers (be in a physician, midwife, or anyone else) to give us the right answers - we need to do the hard homework for ourselves, and be willing to take some accountability for outcomes.

    (i feel like this post doesn't make much sense - it's been a long week - but i hope it isn't as much nonsense as it now seems to me. i think that Rixa and her family are *very* well informed of the risks and benefits of a midwife-attended homebirth versus a hospital birth, and as shown by what happened here when Inga was born precipitously before the midwife arrived, they were also well prepared for emergencies. had something terrible happened - which is generally less likely in the homebirth population than the general hospital population - i have a feeling that they would not have been looking to cast blame on anyone...)

    thank you, Rixa, for the strength & beauty you've shared with us...

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  46. Your bravery and quick thinking are an inspiration. Yes, even I found myself panicing as you resuscitated Inga. Your calm, level head and quick response were an amazing example to anyhome (not just those considering homebirth.)

    This particular video showed me that homebirth is possible and successful, even though we may be faced with the dreaded "what if's" that paralyze many people from working to obtain their homebirth goals.

    Thank you!

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  47. Geez, I'm sorry you have to deal with the naysayers, Rixa.

    People, the OB unit in Rixa's town closed March 1. There is no way she would have made it to the nearest delivery unit (30 min away) or one with a NICU (45 or 60 minutes, depending on which one she went to).

    I applaud your calmness and preparedness. Inga is beautiful, and you have a beautiful family.

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  48. I don't think people should really comment unless they've been in your exact situation before.

    And while it is important to be educated in neonatal resus as you are (and as I am as a neonatal ICU nurse), I wonder how much your actions were a result of instinct? Instinct vs. education - a bit like the nature/nurture debate really. Probably a result of both.

    At the end of the day you're too clever and strong to let these negative comments bother you Rixa - I wouldn't even waste your energy entertaining the argument any further


    Lauren

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  49. Thank you for sharing your video and birth story. Not to criticize at all, but I've seen the term "precipitous birth" mentioned a few times now. From your description of labor though, Inga's birth was not precipitous. You said you woke up at 1 am with intense contractions, yet Inga was not born until a little after 9 am, so your labor was over 8 hours long. A precipitous birth is defined as a labor that is less than three hours from start to finish (from the very first contraction to birth) not less than three hours of active labor. I know what you mean, that the active phase was very fast, but since this blog is set up to educate people about birth I figured it would be okay to point that out.

    Congratulations on the new baby.

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  50. I'm sorry you're having to deal with peoples' ignorance and meanness during your babymoon. I, like so many of the other commenters here, think you handled the situation beautifully and appropriately. You did exactly what needed to be done because you were well-prepared.

    Congratulations again on Inga's arrival!

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  51. Love your post! I think I'm getting addicted to your blog, love your writing and it's very informative. Don't worry about what other people say, you did the right thing. It is very easy to criticize in hindsight and after you know the outcome!
    You say at one point that NRP always works. The question that crossed my mind when watching Inga's birth was what would you have done had she not responded. I agree with one of the commentators, it is very intimidating to see a baby "crash" like this, I had to watch it twice, and even knowing the outcome, found it very moving.

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  52. Oh, and have to say it again: thank you so much for sharing your wonderful birth story and all your knowledge with us!
    Nadja

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  53. Great vid!

    I am glad to see/hear the story of another precipitous HB. Mine was 40 min from 1st contraction to placenta... midwife arrived as she was out to the eyebrows. 10 lbs 4 oz. We are kinda planning a third... so I am very happy to see you with your third, its an inspiration as we do not live near family and no one I know has more than 1. (are there any rixa-esque support groups out there? )

    HB is no more dangerous than hosp. In the hospital the dangers are simply different. Such as being forced into a c/s.

    happy baby and big brother and sister!

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  54. congrats on the birth of Inga! Way to go, I think you did fabulously. Don't get too caught up in the resuscitation debate~you did beautifully and followed your intuition and knowledge. It was perfect.
    Enjoy your babymoon!

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  55. hebamme said "in regards to "B"s post above and some of the other negative comments: homebirth *can*, on rare occasions, be complicated. that's why the presence of skilled, experienced attendants is always recommended, but in the end, we all need to come to terms with our own decisions."

    I agree, and this has been my view all along, especially when having my second baby at home with a skilled attendant. And now I have changed my mind and will birth in hospital next time (no birth centre available to me). I realize that I have zero tolerance for a close call at home.

    Each to their own opinion and birth choices.

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  56. Thank you for sharing your´s & Inga´s birth story, I learned a lot! And I think you did a great job! All the best for you and your family &
    greetings from Sweden!

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  57. All the "what if" comments got me thinking about the time I fell thru an attic floor at work. I was storing boxes and stepped on an unmarked, non-reinforced trap door that was no longer in use. I fell 12 ft to the 2nd floor and came out of it with a mild concussion, a pulled shoulder, a couple stitches and bruising. Pretty amazing, right? I thought so, too.

    I was scared by what happened, but happy it wasn't worse. Then, over the next few days I was told countless stories about people falling from much lower heights dieing or being paralyzed. "You could have died or been left a vegetable." 4 days after the accident I broke down into wracking tears and had nightmares for many nights afterward.

    It's just really shitty to tell the survivor of any kind of trauma, no matter how small, that it could have been so much worse. They know it, and should be left to process the experience on their own terms.

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  58. Thanks very much for ALL of the information surrounding Inga's birth. I loved the video- honestly it reminded me so much of my own labor, except that we had planned a hospital birth and the last 30 minutes were rushing to the hospital.

    I understand what you mean about not feeling like you were in laborland- I also didn't feel that way when my daughter was born. I think that some women need to get to that place to give birth, and some don't. I had a perfectly lucid conversation about why my daughter might have been a little chilly when she was born with the nurse (hey, I have a low body temperature, and she just came out of me, so maybe that's why?), but I was treated like I couldn't possibly know what I was talking about- after all, I just walked into the hospital and finished pushing her out. Just because you've given birth doesn't mean that you can't think clearly!

    THanks so much for the NRP links- I need to take a course in that, for my future midwife training and for any of my own possible precipitous births. My first was 5 hours start-finish, so there's no telling what the next one will be like!

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  59. I cannot believe (well, I shouldn't be shocked, but somehow I still am) that you are being so strongly criticized for Inga's birth. My word! I think your calm and presence of mind in resuscitating her is a beautiful and informing example of how a mother who is in touch with her baby and her body, who has a birth uncomplicated by interventions and chemicals blocking her natural hormones and instincts, will react intuitively to protect and assist her baby. We're programmed to try and keep our babies alive! You did exactly what Inga needed without flipping out because if you flipped out, you couldn't have helped her so effectively.

    Mother's are amazing. I didn't cry when my daughter was born, either, though I weep watching birth videos. But at my birth, when my hormones were high and my instincts were primed for protecting her, I stayed calm and alert. I expect that my birth this spring will likely cause a similar reaction: joy, but calm.

    Congratulations again, Rixa: you had a fabulous birth (we should all be so lucky to have such a great experience) and you reacted with aplomb when things got difficult. Kudos to you, and a strong "tsk tsk"ing to those who are calling you names.

    Darlene

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  60. Just watched your awesome videos again--
    I would have probably given her a 3 for her 1 minute apgar, and probably an 8 or 9 (which is fabulous) for her 5 minute (it's hard to tell from a video). This reflects a very successful resus! If it makes you feel any better, if you were at a hospital, by the time the cord would have been clamped and the baby brought over to the radiant warmer, the baby would be already near the one minute mark. If following NRP guidelines, I would then dry/stim/reposition for a good thirty seconds before beginning PPV. Inga turned pink and perfect again at 2.5 minutes of age and you began mouth to mouth right after the 1 minute mark. I HIGHLY doubt that she would have come around any faster if this resus took place at a hospital. :)

    It sucks that you have to defend yourself.

    Please don't stop blogging. I hate that this whole NRP discussion was at your expense, but it really has been beneficial for me (and others, I'm sure) to reflect on my skills.

    Thanks again for sharing. These videos are truly invaluable.

    Blessings!
    -Sigrid (a neonatal nurse)

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  61. Just to clarify the discussion, my understanding is that the issue with the management of the emergent situation is not as Rixa has described it here. The concern raised was that if warmth and stimulation had been applied while Inga was still flexed (before she became floppy) that rescue breathing would likely not have been necessary.

    Inga was on a downward trajectory. The delay in breathing at birth (but while she was still flexed), followed by becoming floppy (primary), then (if NPR as provided by Rixa, an inexperienced provider without additional tools (intubation, etc.) was not sufficient) brain injury and ultimately death.

    So the concern is that the initial inaction (perhaps not realizing that the situation had started on the downward trajectory immediately following birth) led to the necessity of rescue breathing in the first place.

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  62. I'm so with Elsha. Everyone knows someone who has died in a car accident, yet we all drive. Home birth doesn't kill babies anymore than having a having a fatal heart attack at home meant living at home killed you. I find it interesting when women who have stillbirths at a hospital feel that homebirth is too risky...if someone has a fatal heart attack at a hospital, no one stops going there for chest pain.

    There's no guarantee either way. Some are fine with the risks because they've educated themselves, are prepared, and want minimal interventions. Other people don't care if the doctor takes over and follows his own course of action, even if that is not evidence-based or even necessary. That's what's great about living here. What I want people to learn from your birth is that a natural, unmedicated, unintervened birth IS possible and within reach of "average" women. We've been fed the "tie to bed, don't move, must count to 10 when pushing" crap for TOO long!

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  63. "Everyone knows someone who has died in a car accident, yet we all drive."

    I'm not sure that's the correct analogy. We choose to get pregnant knowing that mothers and babies die in birth. Our prenatal care and how we choose to give birth are parallel to whether you choose a one star or five star crash tested vehicle, do you wear your seatbelt, do you choose to speed or run red lights or drive under the influence.

    The risk in both scenarios (driving/birth) exist, the question is how much risk mitigation does each individual choose to use for themselves and their passengers who are along for the ride.

    Also, can we kill the "babies die in hospitals too" meme? That's not the point. The point is -- how many babies that would otherwise die in OOH births live in hospital?

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  64. @ jane: Also, can we kill the "babies die in hospitals too" meme? That's not the point. The point is -- how many babies that would otherwise die in OOH births live in hospital?

    I understand what you're saying here, but what many others are saying is the opposite: How many babies and mothers die in the hospital due to accidents or unnecessary interventions? The rates of maternity morality are climbing in the US and it isn't due to homebirths, for the most part. I'm not trying to be a fearmonger about hospitals (both my babies were born in hospitals, FWIW, and I don't personally think I would feel comfortable having a homebirth). People get sick and tired of the characterization of homebirth as intrinsically and significantly more dangerous than hospital births while hospital complications are ignored. If a baby has a complication at home it's a sign that homebirth kills babies!!! Whereas if an unnecessary - or even necessary - intervention leads to a maternal or neonatal death in a hospital, everyone says, "Well they did everything they could." I mean, maybe. Maybe not.

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  65. Thank you so much for posting where to learn NPR Rixa (and just after having a baby too!). And BIG thank you for including the Canadian information-it's often hard to find since there's a lot fewer of us.

    I love your blog, have loved it for years and you are fabulous. I hope that I can remain calm in situations like these when I'm a mom. I always admired my husband for his incredible ability to remain absolutely calm and coherent no matter the situation. I find it odd that anyone could criticize someone for that.

    I guess what happened was scary so people have to make themselves feel less scared by saying things like you were wrong or home birth is bad-because if it's those things then they can be reassured that it would NEVER happen to them because they give birth in hospitals. It's not about you, it's about them and their feelings.

    Good on you for being educated and relying on the spirit for guidance. Much love!

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  66. Congrats Rixa! Inga is beautiful. I love that you remain calm and do what you have to do to help your little daughter. Very very wonderful!! Thanks for sharing.

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  67. Rixa, I understand your frustration towards the "what if's," but honestly, shouldn't you at least prepare for those what ifs??? No one expects those things to happen, but they do!
    By the way, if your labor started at 1am you would have had plenty of time to get to the hospital, you stated early that you probably wouldn't have. Your labor wasn't THAT short.

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  68. I just want to chime in and also say thank you for blogging and for sharing so much. I've been reading for about two and a half years and never commented (though I did email you once after my daughter was born in a wonderful home birth).

    I'm grateful for the information, stories, and videos you post and I think you're doing a great job not only as a mother but also as a facilitator of important discussion about maternity care in this country.

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  69. Okay everyone take a chill pill and stop rehearsing the same old tired arguments about home/hospital birth and saying accusatory things and just...relax a little.

    And since there have been a gazillion comments here and on NGM's site about "you had plenty of time, why didn't you call the midwife sooner?", let me answer that and then please let's put it to rest.

    From 1-7 am, contractions were intense but not regular. I tried really hard not to look at the clock, but I did peek a few times and they were all over the place--10 minutes, 15 minutes, etc. They didn't become regular until I got up at 7. In my mind, no matter how strong the contractions, if I can force myself to stay in bed and not move through them, then it doesn't count.

    For my first 2 kids, the baby was born 12 hours (Zari) and then 13 hours (Dio) after I first saw bloody show. I first saw bloody show at 7 am with Inga, just 2 hours before she was born.

    With Dio, I had strong contractions all through the night that I made myself stay in bed for (hmmmm, sounds just like Inga's labor, right??). Then I got up at 7 am and had him at 2:30 pm that afternoon.

    Based on all of these indications, I did not at all anticipate that I would have the baby so quickly. Honestly, I'm still surprised that I called the midwife as early as I did!

    So yet, it technically wasn't a precipitous labor if you're using the narrow definition of under 3 hours from the first contraction till the baby was born. But it was definitely less than 3 hours from when I felt things really ramp up until the birth.

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  70. great now can you answer why you don't at least prepare for the unexpected....things that can't be solved with neonatal resuscitation?

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  71. Couple of thoughts:

    When watching the video I was overwhelmed by the desire to create a similar video to take with me when doing neonatal and birth education in developing countries. These skills are simple and effective. Increased global knowledge of this would go far in preventing neonatal mortality. Well done.

    As for the (few) negative comments, I feel it is important to remember homebirth in developed countries is a choice. There is plenty of tremendously strong evidence based data that supports it as an option. Judgement seems tremendously inappropriate in this scenario.

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  72. Congratulations on the birth of your beautiful daughter Inga. I loved watching your videos, and i think you were amazingly calm and brave throughout the labour, birth, and mouth-to-mouth. At the end of the day, whether doing mouth to mouth was or wasn't the 'right' thing to do (FTR i think you did great!), you followed your instinct and everything turned out ok. We could talk about the what if's all day long, but it wouldn't change anything. What if's are in everything we do, not just homebirth.
    I'm really sad for you that you're being expected to explain your choices....it's just not supposed to be like this. Enjoy your new family xo

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  73. Thank-you, Rixa, for sharing your experience. Congratulations on your new baby!

    My thoughts regarding the "what-ifs" questions:

    What if someone has a baby in a small town hospital (that routinely delivers babies and does planned c-sections), but they end up in an emergency situation the hospital can't handle, and get transported to a big city hospital? Should that person never have taken the risk of giving birth in that small town hospital?

    At what point has one done enough to prepare for the what-ifs? What is the "correct" level of tolerance for what-ifs? Should we only be allowed to live in the biggest cities, because they have the state-of-the-art machines and specialists?

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  74. Rixa, I will chime in, in agreement with you on not calling the midwife / not going to the hospital, because the contractions weren't in a good pattern. My 2nd labor was the same way. Even though I had about 24 hours of ctx, I still didn't call the mw in time, because I kept waiting for them to get *some* sort of rhythm, to make sure that this time labor wouldn't stop again, like it had a few days before.

    So, yeah, everybody who is getting onto you about not calling the mw sooner should back off and stop griping about the definition of "precipitous" and how you "really had enough time". [And I haven't read any of the comments except yours, so I'm responding to what you said, not anybody in particular.]

    -Kathy

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  75. @ Anonymous at 4:42
    Where on EARTH to you get the idea that Rixa didn't prepare? Have you read this blog? All the preparation that she did for Zari's birth, and then her thought processes having midwife care for her pregnancies and labours with Dio and Inga? If you're not going to actually bother using all the available information to form your opinion, it severely undermines your position.

    Rixa I think this might actually be my first comment here but I've been reading regularly since before I started my midwifery training, and I'm now only 9 months out from finishing. You're challenging and thought-provoking and I'm profoundly grateful for your posting the video of your lovely daughter's birth and the discussion that has ensued. I don't doubt that's it's exhausting and upsetting, but I think it's so important for people to realise that although there are risks involved in birth, for the most common problems, we are not purely reliant on high-tech hospital interventions to remedy them, and that some less common problems can't be remedied no matter where you are.

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  76. Rixa,
    Love your blog and your willingness to share your stories. Sorry there is so much criticism. Why can't we all just support and respect each others choices? There were no bad outcomes in this story for people to be upset about. Unplanned unassisted birth can happen to anyone planning to birth at home or hospital. I am an L&D nurse who has had two planned elective inductions that resulted in uncomplicated (well small postpartum hemorrhage with 1st) vaginal deliveries with healthy babies. I am sure everyone could criticize my choices too, but really who cares? I started reading this blog shortly after the birth of my second daughter. I already have a mental birthplan going if I have a third and have secret wishes for a homebirth so I could have a birth like Rixa's where I was in control. Congratulations on a beautiful healthy baby! Boo to all the negative commenters out there.
    Michelle
    P.S.Zari and Dio are beautiful too! Enjoy your family!

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  77. As I was watching your videos, I was reminded of my second birth - it was very similar! I went from 2cm to baby in 2.5 hours (7cm to baby in 17 mins) and it was SO INTENSE I couldn't think/talk between contractions. I laboured the same way, BTW, kneeling, with, generally, my head on my arms in front of me. One thing I'm sooooo not lucky to have is awful back labour :( From start of active labour to the finish, I need someone providing almost constant counterpressure to make it through the contractions.

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  78. Anonymous at 6:38, I think you summed up my feelings on the "what ifs" exactly. Should only those with access to a level 3 NICU in the next room give birth?

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  79. Jumping in again. I really want my husband to watch your video as a I want to have our second child in a birth center setting. I know he is afraid of the "what if's".

    Even with our daughter born in a hospital, she went in to cardiac arrest and I began to hemmorhage. I was told by an OB nurse I still 5 or 6 hours of labor left and was scared into taking something to help me rest (I refused pain meds) even though I thought I was going much faster than the nurse thought. I bled more than I should have becuase the doctor tugged beyond "gentle traction" on my umbilical cord.

    Hospitals can be very dangerous places for mother's and babies, people tend to forget that. Yes, my daughter and I ended up fine, but we almost died to the forced, unwanted interventions.

    I wish I had had the confidence you possessed to trust my body and myself. I won't make that same mistake again.

    Again, thank you!

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  80. Anonymous 4:42 PM -Can't you see that it is despicable to break in upon a new mother with criticism of her birth? Whoever you are, you are entitled to push your views on your own blog, but not to intrude on her here. IF she had just posted thoughts about birth in general, yes, it might be appropriate. But not about HER birth and HER daughter.
    And aren't you ashamed not to sign your name?
    I find that really cowardly of you.
    I think Rixa was well prepared. She had skilled people on the way, and she has studied birth and newborn resus. To be prepared for EVERY eventuality one would have to give birth where there is a level 3 NICU, and a high level adult ICU as well, with the sort of staff present at all times who can deal with embolisms and DIC, and multiple multiple units of blood available. I have heard of women who decided they would only have a baby in a hospital with all those facilities. People have different attitudes, different ways of thinking, about what lengths they are willing to go to to eliminate as much risk as possible in life. You don't have the right to insist that Rixa make this decision in the same way that you would!

    Susan Peterson

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  81. I found the entire birth video to be beautiful INCLUDING your calm way of dealing with the baby's distress. I am so glad you left that part and shared it with us. My daughter is planning a homebirth with her future babies and I couldn't be more excited!

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  82. Beautiful woman, beautiful birth, beautiful baby - amazing stuff, absolutely adored seeing it all, thanks so much for sharing!

    Ignorance and fear is what breeds all those negative, judgemental comments - just feel happy in the knowledge that you aren't living in fear and you're well-informed, you are a step above. Let people spit out their anger, they can't see past it, unfortunately.

    Congratulations on your little one and on a birth that made me say, 'yes, I can!' :)

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  83. Rixa you crack me up babe!-"Holy non-sequitur Batman!" After knowing you all these years, in the real world not just by blog, I think that what ever you would have done to the baby would have been the correct thing to do. I was reassured by your calmness on the video, cause even though I had talked to you on the phone, and heard the whole birth story first hand, I was still nervous watching the video! Thank goodness you told me about it cause I can't even go see a movie untill I know the ending! LOL. I felt you had enough concern and calmness! If I was Eric i would have been freaking out, and he stayed calm too! koodos to you both! I would have trusted you of all people to ases the situation and act accordingly, just as you did! BRAVO on saving Inga! She is soo cute!
    I am glad you are both safe and well!

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  84. Rixa, I think you were a rock star at Inga's birth. Yes, Inga was very lucky! She was lucky to have a mother that was trained in neonatal resuscitation.

    As discussed, a quick second stage can happen at any birth, whether planned at home or hospital. Without experience, those parents would have been coached over the phone by EMS or a midwife.

    I agree that all doulas should be trained in NRP. I douled a friend's birth and ended up catching her baby within 5 minutes of showing up at her house. Thank G-d her baby did well and we were both calm knowing that she was getting O2 through the cord until EMS arrived.

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  85. As a precipitous birther, I can agree with Rixa's comments on contractions. While I didn't notice any myself, when the contractions started they were 10 min...5 min...3 min..1 min...3 min...1 min...2 min... at what point would I know that the baby was coming? As in, halving the time between contractions with every contraction doesn't fit a good pattern. My sister never had a pattern at all, just five contractions total.

    So, while many people seem to think that you should be able to tell, there are many many examples of contraction patterns that never match the predetermined 3-2-1. (or 4-1-1 or whatever your practitioner has decided on)

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  86. Rixa, I applaud you for your choices. Not all of them are not the choices I would have made but they are certainly the right choices for you. I have given up blogging and reading most birth type blogs, but yours is one of the few I will still check in to. Reading Inga's birth story and your thoughtful response to the varied responses solidifies why your blog remains on my must read list.

    And you've also reminded me that I am taking my NRP recert class this coming week and best get reading through the text. ;-)

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  87. Hi Rixa, I'm a homebirthing mum and now midwife and I thought you did a superb job bringing Inga back to the world! The "no panic" thing is quite normal actually - in such a situation most people pump out the adrenaline which helps to them to focus - just another way our brilliant bodies deliver the goods! I only wish I had read your blog (and other pearls of wisdom) before I had my kids. I'm now encouraging many of my mums to watch your video as there is nothing like the real thing to teach us! You are great - keep up the good work!

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  88. "I am a bad, unfeeling mother because I remained unnaturally calm. A good mother would have panicked more and shown signs of distress and remorse."

    Wow. I just watched your video moments ago and my first impression was being incredibly impressed about how calm you were. You were EXACTLY how you needed to be at the moment. That makes you a good mother, not a bad one!

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  89. We are using your you tube video at our NRP recert drills. Inga's APGARs at 1 minute (7:49-8:49) was a 1! No one saw you feel the umb cord for a HR, but we gave the benefit of the doubt it was present. First little gasp was at 1:12 after birth. A lot of evaluation, warming (loss of body heat evaporation), stimulation, or preceding with PPV could have occurred during that first 1:12. Your first half hearted blow by breath wasn't til 8:46. First gasp by baby was at 9:03, thus 1 minute APGARs of 1. At 9:49, Inga still gasping poorly and coughing. Unofficial APGARs at 2 minutes, maybe a 4 or 5. First decent cries at 10:08 of your video, 2 min 19 sec after birth.At 5 minute APGARs appears to be 7 or at best 8.

    But you all ready know this and have gone over the good and bad comments already with posters. Just posting what our tertiary care facility, MFM, and CNM have rated your efforts. Glad that you had some NRP training. We agree all homebirthers should have it. Can you explain how you calculated an APGARS at an arbitrary 2 minute of life at 9-10?

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