Benjamin Pugh's air-pipe: If you can't get a breech baby out, get the air in

English obstetrician Benjamin Pugh (1715-1798) is best known for inventing curved obstetric forceps and for his 1754 book A Treatise of Midwifery (PDF). He is less well known for innovating two ways to bring oxygen to a breech baby with a trapped after-coming head.

Pugh first created a flexible curved air-pipe, which would be inserted into the baby's mouth to the larynx. He next innovation was to create an airspace by manipulating the soft tissues inside the baby's mouth, with no need for the air-pipe.

Below is an excerpt from Benjamin Pugh: the air-pipe and neonatal resuscitation (PDF) by Thomas F. Baskett in Resuscitation May 2000;44(3): 153-155.

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Although it has received less notice [than his curved forceps], Benjamin Pugh made a considerable contribution to neonatal resuscitation. In his Treatise he describes and illustrates his air-pipe (Fig. 2):

‘‘The air-pipe, as a big as a swan’s quill in the inside, ten inches long, is made of a small common wire, turned very close (in the manner wire-springs are made) will turn any way; and covered with thin soft leather, one end is introduced with the palm of the hand, and between the fingers that are in the child’s mouth, as far as the larynx, the other end external.’’

Pugh initially advocated the use of his air-pipe in cases of breech extraction during delay in delivery of the after-coming head. He used the air-pipe in the manner quoted above as ‘‘I found many children were lost in this situation, for want of air…’’ Pugh then described an alternative method which he had developed making the use of his air-pipe rarely necessary:

‘‘You must then introduce the fingers of your left hand into the vagina, under the child’s breast, and put the first and second fingers into the child’s mouth pretty far, so far, however, that you are able to press down the child’s tongue in such a manner that by keeping your hand hollow, and pressing it upon the mother’s rectum, the air may have access to the larynx, you will soon perceive the thorax expand, as the air gets into the lungs.’’

Pugh emphasised the risk of asphyxia to the fetus during delivery of the after-coming head of the breech saying ‘‘…every operator must know there is difficulty, and grave danger of losing the child by its stay in the passage; by my method of giving the child air, I have saved great numbers of childrens’ lives, which otherwise would have died’’. Furthermore, Pugh goes on to give a remarkable early description of mouth-to-mouth respiration.

‘‘If the child does not breath immediately upon delivery, which sometimes it will not, especially if it has taken air in the womb; wipe its mouth, and press your mouth to the child’s, at the same time pinching the nose with your thumb and finger, to prevent the air escaping; inflate the lungs, rubbing before the fire: by which method I have saved many.’’

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Image from Baskett 2000

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Vaginal breech, ECV, and NRP Workshops

I have another announcement to make...Not quite as exciting as my pregnancy, but pretty close!

We are organizing another workshop with Dr. J. Peter O'Neill, the Canadian OB who taught vaginal breech skills last summer in Indianapolis. This time, he will be leading two full-day workshops: Vaginal Breech Birth and External Cephalic Version with Ultrasound Guidance. Both sessions include hands-on simulation.

On top of that, we have a NRP course tailored for out-of-hospital attendants, taught by Penny Lane, CNM, MSN, IBCLC. This course will cover full resuscitation skills, including intubation, medication administration, and umbilical line placement.

The workshops will take place in Niceville, Florida on June 7-10, 2013. We also have some fun free sessions for conference participants, including evening conversation circles and film screenings.

You can mix & match any of the 3 workshop days. We are offering deep discounts for students and for early registration; sign up now to take advantage of these fantastic prices.

Please spread the word about the Vaginal Breech, ECV, and NRP workshops! More information can be found at www.breechworkshop.com.

Ps--any of you coming to the Third International Breech Conference in D.C.? I'll be there!

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How and where to learn neonatal resuscitation

I've received some inquiries about how to gain neonatal resuscitation skills, especially for non-health professionals. If there's one kind of preparation I'd recommend for all pregnant women, it's learning the basics of neonatal resuscitation. Just like we all (should!) know how to perform infant resuscitation or adult CPR or the Heimlich maneuver, we should know the basics of neonatal resuscitation. Because--as Inga's birth story illustrates--you never know when you're going to need it.

Most likely your baby will be born healthy and will breathe on its own. Most likely you'll make it to the hospital or birth center on time, or your midwife will arrive before the birth. Most likely your baby won't be born in the car, or in the subway, or on your bathroom floor when you were planning otherwise.

But...what if the birth doesn't happen as planned? That's where having some neonatal resuscitation training can be a lifesaver.

So how and where can you learn these skills? If you can afford it, take a Neonatal Resuscitation Program (NRP) workshop. Before the course, you study the textbook and take an online exam. Then you come to the workshop--typically one full day--for hands-on instruction with life-size dolls and medical equipment. Since maternity care providers are required to stay current with their NR skills, the workshops are fairly easy to find. One problem a lay person might encounter is being able to register for the course; some are limited to health care professionals only.

In the States, the Neonatal Resuscitation Program is sponsored through the AAP; click here to locate a course or instructor. Canada's NRP program is sponsored by the Canadian Pediatric Society; click here to locate courses. Many instructors do not list their courses online, so also make inquiries through your local hospitals, birth centers, or home birth midwives. 

I highly recommend Karen Strange's Newborn Breath workshop. She travels all over the States teaching NRP from an out-of-hospital perspective. You'll learn everything you need to know to pass the exam and become certified, but you'll also learn these things with the assumption that you'll be in a home or birth center setting, that you won't be cutting or clamping the cord, that you'll be resuscitating on or near the mother, etc. Karen Strange is a quirky, fun instructor and keeps the class very lively. If you want her to come to your area, you can sponsor a workshop. Her workshop costs $220, plus the textbook (~$38 used/$55 new) and online exam fee ($23.50).

What if there is no NRP class in your area, or if you can't afford one? Hook up with local midwives and learn the skills from them. Buy or ILL textbooks and study as much as you can. At a bare minimum, learn how and when to perform mouth-to-mouth and chest compressions on a newborn--before your third trimester. Still, nothing can substitute for up-to-date, hands-on training, which is why I strongly suggest taking a NRP workshop.

My NRP baby...now in pigtails!

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Final reflections

To close the chapter on neonatal resuscitation, I wanted to share some final thoughts. I am still surprised that Inga's birth story took the turn it did. I never expected so much focus would fall on the mouth-to-mouth and so little on the rest of the birth! But that's the nature of writing and sharing our stories on the internet. We can choose the words and images but not the meaning that they take on once they are released "into the wild," so to speak.

To me, the two minutes where I assisted Inga in taking her first breaths were just that--two minutes, over and done with, and I moved on. They didn't dominate the birth experience (as they have the comments on this blog!).

I feel no need to create a tidy take-away lesson from my experience. I did not post Inga's birth story to advance an agenda or to teach about neonatal resuscitation. I simply wanted to share my experience of labor and birth with people I care about, and with those who care about me and my family, even if we don't know each other personally.

With those thoughts, I wanted to share these words from Tatiana of the Becoming Midwives blog (reposted with her permission).

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I don't have a punchline

There is just this: an unplanned unassisted (but planned home birth) to a mother who, when her baby grew limp and breathless moments after her birth had the resuscitation training to calmly position her, breathe into her mouth, and repeat until her little arms curled up, she sputtered, and she cried. When I first watched the baby's arms grow limp, even though I anticipated it, having read the word "resuscitation" in Rixa's post, I panicked. My own baby was nursing to sleep as I watched this and I startled harshly enough that he pulled back, opened his eyes and looked at me, surprised. As I watched the baby grow dangly, I said to the screen, "No, no."

That was the first pit of the last 20 minutes, that full-body rejection of the sight of an unbreathing baby. (Qualifier: I am a mom with a still-young baby and some unresolved junk around his birth - I know I have no business bringing all of that to anyone's birth, and I am not attending births. But I'm allowed to watch youtube.)

And then, as I watched the aftermath, mama settling into the tub, baby squirming in the normal fashion, the bustling attendant arriving and then being asked to leave, and the new baby girl seeming fine, I filled with joyful exuberance. That this one precious, tender, incredibly sensitive new little person could be born needing help and receiving that help from her mother in the warm safety of a tub is a transcendently beautiful departure of what neonatal resuscitation normally looks like. Nothing jarring, nothing painful or invasive, nothing panicked, nothing even as upset as my own response watching on a screen so many miles away. No, just family, breath appropriately applied, and the rolling of time into life here among us other breathing people. I felt buoyant and celebratory.

But now I'm sad again. Because this exemplifies what Adrienne Rich said. I believe every baby is that tender, soft, new, sensitive and deserving of such gentleness. Especially when it needs extra help. But in our world, such gentleness is not a universal right but a privilege that becomes available based on the constraints of social, cultural and demographic factors, including educational privilege and a willingness to make a choice that our culture largely regards as reckless. That is an awful lot to ask of people, who are social, dynamic beings in constant relationship and flux with the people around us, carrying with us the vestiges of that sense that certainly we can't know everything about this world, so mightn't it be wise to defer to authority?

I love Rixa's bold and unapologetic grasp on her responsibility for the choices she makes for her family. I'm so glad for her, and for that sweet baby girl who may have had the world's most tender resuscitation. I'm so glad for my own children's relatively peaceful births, and for the so many that are held in that remarkably rare spirit of reverence and respect in this slowly growing trend of gentle birthing.

But it is a bittersweet gladness, indeed, when I let myself broaden the lens to the larger world.

I wish I could summarize it all with... "And here is our clear answer."

But where? Where is our clear answer? I don't live in a world that has any of those. Not really, anyway. We like to assume the stance of certainty and conviction, but not one answer seems to stand firm against the onslaught of every possible experience, every possible shred of information, and every possible circumstance. And as much as I don't like to leave a bit of writing dangling with this feeling of conflicted joy-sad-ambiguity, it's what I have. There is no punchline.

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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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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.

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