Neonatal Resuscitation

Last week I attended the Newborn Life Support (NLS) update training day by the Resuscitation Council UK at Princess Alexandra Hospital. This is something we do every year as midwives in the hospital and so do we, independent midwives! The difference is that we pay for it, around £250-£300 per course to stay up to date! It’s been an amazing and inspiring day though, shared with other great professionals (pediatric nurses, neonatal registrars, consultants and midwives). We had a mix of theory and practice, and I’ve learnt lots, so I thought I’d share some interesting facts about how babies transition to breathing and when we step up to help them.

First of all, the terminology. We call it neonatal resuscitation, but really we rarely resuscitate babies. Resuscitation in adults implies that someone has had a cardiac arrest and the priority is to restart the heart. In newborn babies that have never taken a breath before, the priority is to inflate the lungs. Generally, once oxygenated blood circulates in their system the heart rate picks up automatically (if the heart rate was low, many times it isn’t). If the heart rate doesn’t pick up we know we have a very poorly baby that will then need chest compressions (or your more classical resuscitation). But chest compressions are extremely rare! They happen in less than 0.3% of all births. According to some studies cited in the Resuscitation Council manual “approximately 85% of babies born at term will iniciate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, and approximately 3% will iniciate respirations following positive pressure ventilation”. That’s 98% of babies that will require none or very little help to breath, the type of help we can provide at homebirths with the equipment we carry. Also, these studies have been done in hospital so think that there will be babies in those numbers that have been induced, are small or whose mothers have high blood pressure, gestational diabetes, sepsis, etc. Basically risk factors that increases the chances of babies not coping with birth that well. Then of course there are preterm babies who do need help more regularly, but these are not included in the above statistics.

So what happens during the birth process?

So what happens during the birth process that means that some babies will not tolerate it well? Other than the risk factors above, it turns out that the physiology of birth is a hypoxic event per se! Babies receive oxygenated blood from the mother through the placenta and the umbilical cord. Because of how the fetal circulation works, babies actually have an oxygen saturation level of 85%, rather than 97-100% that adults have. This is perfectly normal and their brains can cope with lower oxygen saturations. In labour, however, the contractions put pressure in the placenta and the cord and therefore babies receive less oxygenated blood for the duration of the contraction. This is perfectly fine as long as there is time between the contractions for the babies to “catch a breath” sort to speak.

However, during inductions where the contractions are increased at an artificial rate, or if there are medical complications where mum or baby are poorly (think trying to go for a run after you’ve recovered from the flu!), then the baby will not cope with the stresses of labour very well. We can usually see this by monitoring the baby’s heart rate in labour (intermittent or continuous monitoring and subsequently expediting the birth if the baby is not coping) and in rare circumstances a baby is born needing help with breathing without previous warning.

In my experience these unexpectedly unresponsive babies require very little help. These are the cases I have experienced in low risk settings such as birth centres or homebirths. As a matter of fact I recently attended a birth as an IM when we had to help a baby inflater her lungs, but that was all! I remember a couple of other times working in the birth centre where I’ve cut a cord as the baby was a bit floppy/unresponsive just to hear him/her cry the moment I put him/her on a flat surface ready to give inflation breaths. The breeze of cold air as the baby is wicked away can stimulate them to cry too. I have also been present in more extensive resuscitation cases in the labour ward, but these were high risk cases and the pediatricians were often present in advance.

Neonatal Resuscitation
NLS Resuscitation Council

What do we do as independent midwives?

Now as an independent midwife I find other ways in assisting with neonatal “resuscitation”. It is well recognised that delay cord clamping helps with neonatal resuscitation. The Resuscitation Council recommendeds to leave the cord unclamped for 60′ unless the baby is extremely unresponsive/very low heart rate. This is because the baby carries on receiving oxygenated blood from his/her mum. There has been studies about the benefits of neonatal resuscitation by the bedside, leaving the cord intact throughout the whole process. It makes sense! And this is something we will attempt in homebirths, to give your baby the best chance. After 5 minutes of delayed cord clamping a baby recovers 110 ml of his/her blood. And if the cord is clamped prematurely, the blood pressure will increase and heart rate decrease for a few second to minutes! What a way to meddle with physiology!

Another important element in assisting babies’ transition is to keep them warm. When I used to speak to mums about accidentally having a baby at home before help arrives I would emphasise how important it is to keep the baby warm. In so many BBAs (Born Before Arrival-of the health professional), the babies are found to be cold by paramedics. If babies are left wet and exposed, their temperature can drop to 33 °C in 5 minutes! It should be between 36.5-37.5°C. This does not mean that you need to use a hat in a well baby, there is controversy as to whether hats are needed at all, but making sure babies are dried, put skin to skin with mum and covered with towels/blankets is the best method. Babies that are cold do not resuscitate very well, hence the trend on some online videos of resuscitating babies on mother’s chest, skin to skin, but there are impediments to good technique with this method.

What about unassisted births?

 Is it true that babies can resuscitate themselves with time? Yes they can. The Resus Council manual says: “Most babies will breathe or cry within 30′ of birth and establish regular respirations by 60′. Without intervention, such as drying, stimulation and beginning ling inflation, up to 20% of healthy babies may take 60-180‘ to establish regular breathing. Gasping respirations are usually a sign that the baby will need help.” These gasping respirations are a whole body reflex the baby does to try and breath once they have been in a serious hypoxic state for around 10 minutes and the heart rate has dropped below 60bpm for 5 minutes. So they are trying to resuscitate themselves providing the airway is clear. If unable to do so (because they are in utero still or because their airway is not opening) they will carry on gasping for 10 minutes at which point chest compressions most likely be needed with good prognosis. This is why when a baby’s heart rate drops in labour and does not recover within 3 minutes, mum’s are rushed to theatre for a CS and the baby is usually born within 10 minutes. Often these babies can come out and cry and professionals present often wonder if they overreacted with expediting the birth, but it’s hard to know at birth at what stage of hypoxia the baby was and once air enters their system they respond quickly. Also, it should be noted that these numbers are drawn from animal studies subjected to deliberate hypoxia in utero, a very cruel way to do science. If you find yourself giving birth without a health care professional present know that mouth to mouth (with a few adjustments and considerations) is also a safe option that works.


Princess Alexandra Hospital
Newborn baby

So what is obstructing the airway?

The majority of the time it’s the state of the baby itself. Babies born unconscious tend to be floppy. This reduced tone makes the pharynx collapse (when babies are placed on their back) which in turn makes the jaw and the tongue fall back obstructing the airway (similar to someone under general anesthetic). The elongated head makes them place their chin too close to their chest and if the babies are not on their back then their own normally floppy head can close the airway. At this point a skilled trained professional help is recommended.

What is not necessarily obstructing the airway? Meconium. For many years we were taught that before inflating the lungs we should aspirate any meconium or any particular matter obstructing  the airway (vernix, blood, mucus). However, in recent years it has been recognised that this practice delays life saving manouvers. Plus it is very unlikely that meconium has been inhaled in utero except in the case of a hypoxic baby that’s gasping. The lungs and respiratory system are full of fluid in utero with as much as 100 ml. For meconium to reach the lungs the fluid would have to move and that’s difficult when there is nowhere for it to go. Some of it starts to get absorbed when labour starts, around 1/3 gets squeezed out when the baby is going through the birth canal, but the majority gets absorbed when the baby’s first breaths push the fluid into the sourounding tissues. It takes 4 breaths before fluid is absorbed enough that oxygen reaches the blood stream. The airways are fully cleared by 4h of life. In babies born vaginally, any meconium that has found it’s way to the mouth will be expelled during the birth. Still meconium aspiration syndrome (when the meconium reaches the lungs and causes an infection) can happen, but only in 0.5% to 3% of deliveries. The only scenario where meconium could reach the lower respiratory system in utero is when the baby has been hypoxic/deprived of oxygen for over 10 minutes and has started gasping in an effort to draw air in (but can’t as the lungs are full of fluid, so meconium could potentially then enter the airway up to the trachea)

Finally, do all babies need to cry?

Not necessarily although if they cry we know for sure they are well. Many waterbirth babies start breathing rather than crying. They take a bit longer to realise they have been born as they are born into warm water, the air around them is also warm and they are handled a bit gentler. Cold air will stimulate them to breath and will make the umbilical cord contract and slowly reduce the blood flow. These babies tend to do well but we observe them closely. Sometimes we may palpate the cord to feel their heart rate although this is only reliable if the heart rate is above 100 bpm.

So there you have it. A little introduction to how babies transition to breathing and some information about what we do as midwives.
How about you? Have you ever had to “resus” a baby or has your baby needed support transitioning to breathing?

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