These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
Resuscitation in Hospital and at Home
What sort of equipment is available in hospital which is not available at home, and how likely it is that a midwife would be able to use it?
What I have at a home birth for neonatal resus is:
Mum & Dad asked to have several towels, which we warm when we expect baby
to come.
Flat firm surface for resus (a large tea tray is portable, the floor will do
in an emergency, top of a chest of drawers or nappy changing station ideal)
in a warm, draft free room.
Anglepoise (or similar) lamp to assess colour of baby (not if it's breathing
and crying, just if it isn't)
Manual suction equipment in case of meconium or other obstruction of the airway
Ambubag & oxygen, with various different size masks for different sized
babies to inflate baby's lungs
Gudel airways (useful if baby's nostrils don't work, they enable baby to mouth
breathe during hospital transfer)
What I don't have, which is in the room in hospital:
Mechanical suction equipment
Laryngoscope and endotracheal tubes (ETs)
Drugs (although I can theoretically bring Narcan if the woman choses to use
Pethidine, and could bring any prescribed medication out with me)
Someone to come running in straight away when I press the emergency call bell
However, if I ever was at a homebirth where the baby didn't breathe within the
first minute, I would ask someone to call paramedics, who have mechanical suction,
laryngyscopes & ET tubes, probably drugs too. And they know how to use them
and are up to date.
I think there's a difference in my attitude to resuss at home because you know basically that the buck stops with you (the midwife), so you jolly well remember and revisit all your neonatal resuss training. In hospital, its quite easy to pass over responsibility to a paed.
There are several courses training midwives in advanced resuscitation of neonates, but it is (probably similar to adult resus) the quality and timeliness of early resuss that gives the advanced resuss a chance to be effective.
I think that one of the most important roles of the midwife in hospital resuss is to observe the junior paeds and call a senior immediately if they are struggling, either due to lack of experience, or to the complexity of the situation. Where I work there's a sleeping registrar at night, and an awake SHO (Senior House Officer - a junior doctor), so its perfectly possible to get someone senior very quickly.
There are portable mechanical suction units available, but our hospital trust doesn't have the funds to buy them for us. I guess if/when I went independent I would buy myself one.
Viv (midwife)
I am not a midwife, but I am an ITU nurse......
In hospital there are endotracheal tubes, which are breathing tubes to be put into a person's throat to maintain their airway if they do not have the reflexes to do so themselves ( ie cough and gag). These are also used to blow air/oxygen into the lungs with either a ventilator (not available at home) or an ambubag (available at home). As long as the ambubag has an extra piece of tubing attached (which I assume they would do) the ambubag can be used to give either air or 100% oxygen whether you are at home or hospital.
Endotracheal tubes tubes are used to maintain the airway in longer, more aggressive resus situations. Although I have known of a paediatrician who refers to them as "airway obstructors" as, if badly used, they can do much harm. A skilled person can maintain an airway very effectively with just a bag and mask (as available at home). But it is a skill, and I imagine not easy to do in the back of an ambulance if transfer is needed (haven't tried it myself) .
It might also be necessary to give drugs in order to intubate (to get past reflexes that might prevent it). Those particular drugs, and ET tubes, are not available at home. As well as the ET tube, you also need something called a laryngoscope to pass the thing. Intubation is a very specific skill, which anyone doing it needs to have been trained in, whether they are doctor, midwife or nurse. Correct me if I'm wrong, but I don't think it is a standard midwifery skill ( unlike basic resus of the newborn or mother) - although I expect it can be obtained. The drugs are doctor-only, as far as I know.
Also available in hospital is a suction machine, if the baby's lungs (as opposed to upper airways) need clearing. I don't "do" neonates (I'm an adult nurse - although I have on occasion cared for intubated older babies) so I don't know how likely it is that a newborn would need this (as opposed to a baby with, say, pneumonia)
A hospital would also have a defibrillator - used to shock the heart either into action at all, or out of an ineffective rhythm, and drugs to try to achieve/stabilise same. However, I know that when children's hearts stop, unless they are "cardiac babies" it is largely because of lack of oxygen - the heart stopping is a long way down the line. Again, I don't know how this pertains to neonates as opposed to older babies/children.
Also available would be equipment to do an emergency tracheostomy (which is a surgical hole in the trachea to enable breathing if there is a blockage/problem further up, for non-health-care readers). I don't think I've ever heard of one being done at birth - but I'm not a paediatric nurse. I suppose that might be done if there were some sort of abnormality in the anatomy of the respiratory tract. ( might it be needed in an oesophogeal/tracheal fistula? - that would be a hole connecting the breathing and eating tubes. The baby's own, not artificial ones)
I have to say that the figures for successful prolonged resus in adults, even in hospital ( measured by how many of them actually get to leave hospital, as opposed to surviving the inital resus) are depressingly poor. Can't lay my hands on the figures right now, but I don't know how much better they are for babies/children. If at all. However, if I *was* analysing the figures, I'd want to be distinguishing between for example newborns who needed a quick bit of help to get going with a bag and mask, and a bit of rubbing and gentle encouragement, and those who needed full-scale resuscitation and intubation, and a trip to NICU - and I don't know if the figures would make that distinction.
Also I suspect that if a baby has no reflex to breathe, quite possibly spending x weeks on a ventilator is not going to change that :-(
Having said all the above, and even knowing what I know about resuscitation equipment availability and skills - and also being very at-home in a high-tech hospital environment - I strongly suspect that if I had/have a breech baby, I will be staying at home to birth him. But that is a very personal decision, of course, and I would have to live with the consequences, whatever they might be. For me it is a case of weighing up the probabilities of the baby both needing faster access to higher-tech resus, and also benefiting from it -cf the increased risk of my having a c/s and the pros and cons that would entail for both of us if I were to go for a breech birth in hospital. I can say with some certainty after my years on this list that a breech *extraction* would be bottom of my list of preferences .
Brenda W
Midwives at home can give oxygen by bag and mask, and of course CPR, and some midwives are trained and equipped to intubate at home. However, if very heavy-duty resus is required, wouldn't a paediatrician would be more experienced in giving it? I hope that midwives will correct me if I am wrong, but for instance, intubation is one procedure which comes to mind. I have read that the risk of complications with intubation is directly related to the experience of the person doing the procedure.
I understand your concerns, but when I was working in the NHS the paediatrician on call would be a senior house officer -- in other words very junior. In this case, experienced midwives would probably be more experienced. Although with a breech birth in a hospital you'd probably get the situation of loads of spectators, one of whom might include a more experienced paediatrician. I don't know if the situation has changed.
Meg (retired midwife)
Oh bloody hell - it does make you wonder what the point is..... and I imagine that in an emergency resus situation, nobody is going to want to say "Hang on, are you experienced enough to intubate my baby?"
We had a relatively recent case in one of our local hospitals where a baby sadly died shortly after birth. The poor paed who attended the resus was new, just after the Drs all traditionally change over. It was clear to all midwives present that she did not know what she was doing, and in the end one of the more senior midwives took over. The family were not aware that the outcome may have been different - not sure whether that is good or bad. The poor Dr will, I imagine, remember this incident for ever.
A friend of mine who is a midwife there was so insensed she spoke to the Supervisor of Midwives about how woman are being lied to about the relative safety of hosp v home, they go in to hosp believing that it is a safer place, but the system is letting them down. She felt they should be being informed of this. The set up has now changed, and I think there is always an experienced paed available, but it does make you think.....
Tikki
Would this still be the case if it was a known higher-risk situation? Would a senior paed not be alerted to the fact that her skills might be needed?
Even if that is the case, you are rather dependent on another baby not needing them at the same time. There's no real way round these situations sometimes, but it does show that hospital is not a panacea when things go wrong.
I think maybe one of the things we should be looking at in terms of campaigning is the unsafe rotation system for SHOs - even if 'patients' escape unscathed, I suspect it has an adverse effect on the personal and professional development of the doctors. I too know of serious problems which have arisen from this.
I do know that sometimes GPs have reservations about particular hospitals in terms of their facilities/staffing (and I do mean hospitals not birth centres)
In one local unit, if a baby needs resus someone has to run down the corridor to what appears to be a linen cupboard with a resuscitaire in it. (in fact the resus facilities appear to be more readily available in the attached GP unit than on the consultant labour ward....) Alternatively you can go to another unit where there are wood-effect resuscitaires in every room - but the staffing arrangements and facilities for poorly babies and mothers leave something to be desired. Ain't choice a wonderful thing?
My impression is that independent midwives are particularly diligent about getting themselves onto infant resus courses. I would in a way be more confident because you would know that she did not operate on the basis of getting any slightly higher risk pregnancy into hospital and so might well have more practice as well as theory.
Jennifer
I think most units are pretty vigilant about the mandatory training in neonatal resus and other emergencies that midwives get, especially since the advent of CNST (Clinical Negligence Scheme for Trusts - a scheme to reduce NHS Trusts' likelihood of being sued) as this makes it compulsory in order for trusts to get the highest level of CNST.
(A fellow independent midwife and I) have regular updates at the local uni in return for doing some teaching. I think the problem can be that IMs have to fund our own updates and this can be costly. However SoMs should be providing/accessing this for all midwives wherever they may work in order to offer equity.
Laura
Over-Enthusiuastic Resuscitation?
I was there at a ventouse delivery which by definition meant that a paed was
there too, babe came out screaming (as you would!), put onto mum's tummy straight
away, lovely,saying hello, then paed came over and wrenched babe away, put under
bright lights of resuscitiare and next thing I know she was bagging and masking
it! I went over and felt heartrate, was about 145...??! WHAT FOR?!
Sally
My clients avoid this over resus trend by asking that the cord not be cut until the placenta has delivered. Not difficult for a midwife to use as personal standard. Many a time the overenthusiastic nursery nurse has tried to take the baby away from the mother only to find that she cannot because the baby is still firmly attached to mum.
If there is a genuine problem that cannot be solved right on mum (an ambubag with room air is most often all that is needed to jump start a reluctant breather), it is a small matter to clamp and cut.
Angela C.
PS Surely the person who bagged a healthy baby needs to be reported? She could have caused pneumothorax. Also she needs more education about indications for neonatal resus. Primum non nocere.
Our unit have amended policies over past few years and unless there is a fetal reason for a paediatrician to attend, we don't have a paed called. So if ventouse is because the woman has an epidural and we've waited an hour or 2 for descent and then had an hour or so of pushing and the vertex isn't visible - there would be no paed.
Also the paed waits outside of room so if there's meconium (paed called) and babe cries/screams etc then paed is sent away without seeing babe...How cool is that. Same with our sections now - if it's elective or due to failed induction etc I may not call paed at all, but if there is a fetal reason and babe born screaming they just leave asap
Cheryl
ps just done NLS course and they advocate a hands off approach really - dry/stimulate reassess, only suction under direct vision etc.etc.
AH updated July 21, 2004