A neonatal resuscitation class does NOT mean that a midwife is actually qualified to resuscitate a baby

A helping hand

I received the following email from Susan O’Connor, a Board Certified Neonatal Nurse Practitioner and Neonatal Resuscitation Program (NRP) instructor:

I see so many comments about midwives being “trained” in NRP, but people not realizing that without the equipment necessary (ETT, bag/mask, oxygen, epinephrine, umbilical lines, saline, etc) you are not performing NRP. NRP is so much more than just the rate of compressions to breaths; … taking a class in NRP [does not mean] that a midwife is actually qualified to resuscitate a baby. And performing NRP correctly can make the difference between life and death in a neonate.

I invited her to share her thoughts and experience with you in the guest post below:

Neonatal Resuscitation Program (NRP) is a specialized type of resuscitation that was designed for neonates and their unique physiology and needs after birth. The American Academy of Pediatrics in a statement May 1, 2013 affirmed “there should be at least 1 person present at every delivery whose primary responsibility is the care of the newborn infant”. This is in addition to the midwife who is attending to the mother, in the situation that both the mother and infant need simultaneous resuscitation.

Many midwives – especially lay midwives – will claim they are trained in NRP and able to provide resuscitation to a newborn. Unfortunately, taking a class in NRP does not mean anything when it comes to the actual resuscitation of the infant. NRP is a systematic method of evaluating and providing support to a struggling neonate, which includes advanced life support.

NRP is set up in 30 second intervals: you have thirty seconds to determine whether your interventions are working and if they aren’t, to escalate care.

First you provide positive pressure ventilation with a bag/mask.

If that is not working, you must intubate the child to provide a secure airway – the first thing that most midwives cannot do. Intubation is not a skill you can perform infrequently and expect to be successful, especially in a stressful situations.

Once you are providing respiratory support, if the heartrate is still low (below 60) – compressions must be started.

But giving compressions in coordination with ventilation isn’t enough. At the point where you are doing this, epinephrine should be drawn up. It can be given through the breathing tube, but the most effective way is through the umbilical vessels. This is the next step in NRP that lay midwives cannot provide. They cannot have epinephrine for the infant, and they definitely do not have the equipment and training to place an umbilical line.

In a code situation, volume expansion [fluid] is frequently needed. Normal saline should be infused through the umbilical line, in order to be able to support circulation.

Occasionally, even other interventions are necessary, such as administration of surfactant, or the child could have a pneumothorax, a leak of air from the lungs into the chest and prevents infants from being able to breath/beat their heart well. In a hospital setting, you have all those supplies and trained personnel to be able to stick a needle into the chest to release the air. Some infants develop a pneumothorax spontaneously, without any risk factors or obvious cause.

All of these things happen in 30 second intervals. That means by 2 minutes of life if the baby is depressed, you are giving epinephrine and putting in lines while giving adequate ventilation. That’s a very short time-frame. It takes confidence, repetition and study to be able to provide adequate resuscitation to a newborn. Midwives are trained in the care of the mother and basic well-baby care. In the hospital, OBs do not provide NRP; typically, it is specialized nurses, nurse practitioners and physicians who do it.

This lack of ability to provide true neonatal resuscitation accounts for some of the morbidity and mortality that is seen with home births.

Bad things can happen at home and in the hospital, but in the hospital, you have a team of highly trained individuals who are dedicated solely to saving the baby’s life. That’s a huge departure from the care provided by midwives and that alone should explain why births are safer in the hospital.

280 Responses to “A neonatal resuscitation class does NOT mean that a midwife is actually qualified to resuscitate a baby”

  1. Heather
    November 20, 2017 at 4:50 pm #

    A note on the previous comment, it is recommended that two midwives attend births in the US. I am a Certified Professional Midwife (CPM) as well as a registered nurse. I also teach NRP. I currently practice midwifery in an out-of-hospital practice but have worked as an OB RN in hospital for 18 years (level 1 to level 3 centers). Completion of an NRP course does not confer competence to anyone that takes it, regardless of their profession. NRP is also not just about the advanced skills of UVCs or ET tube placement either, it is about the whole picture of resuscitation of newborns and recognizing those that need it. Remember that 10% of newborns need some type of intervention but only 1% will require advanced interventions (UVC, chest compressions, ET tube placement, etc.). The midwives in our state carry LMAs and are trained in placement. Yes we do not carry medications or IV fluids and cannot place ET tubes or UVCs but our clients are fully informed on these limitations. We also do not care for women that carry those risk factors that would lead to an anticipated resuscitation. These women get transferred to a hospital care provider as needed. Our goal in care is identifying women that are at risk and transferring their care appropriately. Also remember that the majority of the general population are delivering in critical care or level 1 or 2 facilities that also do not have neonatologists or pediatricians that are proficient at these skills either. There family practice providers or CNMs are delivering babies who’s level of experience at a resuscitation may be the same as an out of hospital provider. Yes we do deal with less resources when delivering out of the hospital but this is an informed decision made by the family that chooses this care and the providers caring for them are mostly trained professionals as well. Also, starting chest compressions does not mean that you will need to give medications either. In my experiences working at a level 3 facility in their labor and delivery unit as the charge nurse, labor nurse, and nursery nurse that got called to all deliveries, we rarely ever needed to use medications or iv fluids for babies that were not premature or had complications in labor that were not identified previously.

    • Claire
      November 20, 2017 at 5:09 pm #

      If you’re really a nurse, how come you don’t care that a CPM certification is a degree in baloney? This has to be addressed before anyone can go on here.

    • sapphiremind
      September 5, 2018 at 2:31 am #

      Hey, was just sharing this with a friend and saw this recent comment – So here’s a response:

      First, you are right, it’s not just about the equipment either, it’s about the team. I go out on transport and have been called to hospitals when kids are “coding” there. The more you do it, the better you are at it. Level 1 and Level 2 facilities, while they may not care for the babies, they do get a lot of deliveries and typically have dedicated NRP staff to go to those deliveries. Some don’t. I wouldn’t recommend delivering at those hospitals either. (Having heard people have to talk a less experienced group through a code was heart-wrenching. Not because they weren’t doing it enough, but worse, they refused to stop because of their inexperience. Over 45 minutes without any spontaneous circulation is too long. But they just didn’t want to give up and it was a terrible place for them to be in. I wish we could have been there in person to reassure them they went so far above and beyond) Anyway, I digress. The tertiary care centers can literally walk them through the code steps – they know them, just need a team leader essentially. We serve as their team leader from a distance.

      All deliveries have the same risk factors that can lead to the need for resuscitation. They have a baby, coming out of a person. Things can go wrong. Most of the time, you won’t need the epi and lines and needles and even ETT tubes, but when you do, you need them at that exact second, not 10 minutes from then.

      MANA’s own data shows your child is more likely to die or be neurologically damaged if you have a homebirth in the US. I hope the birth experience is worth it.

    • RudyTooty
      September 5, 2018 at 9:07 am #

      Heather, you are someone who has extensive experience working as a registered nurse in OB, and importantly, in in-hospital care of obstetric patients. Your RN experience is what creates the assurrance that you are a skilled and competent provider.

      You may hold yourself up as someone with this experience and skill – but you cannot represent CPMs or OOH midwives – because as you know, the skill and experience required for becoming a CPM/LM is far far less than what you have.

      One of the most dangerous and reckless things a midwife can do, is represent the entire profession when his/her individual skills and experience far exceed what is required for entry to practice.

      There are limitations that pertain to place of practice alone – a small, regional hospital is going to have fewer resources and staff than a tertiary medical center.

      There are also limitations that pertain the the person holding the NRP card – their skills, experience, and understanding of the limitations of the environment in which they practice.

      Most regional facilities are staffed with providers who understand the limitations of their environment, and refer and transfer higher-risk patients to appropriate facilities.

      CPMs have not demonstrated appropriate risk-status evaulation of their patients. They either do not screen for risk factors at all, or they deny the risk factors are worthy of referral for medical management and in-hospital care.

  2. Heather
    November 20, 2017 at 4:42 pm #

    So it is recommended that two midwives attend births in the US. I am a Certified Professional Midwife (CPM) as well as a registered nurse. I also teach NRP. I currently practice midwifery in an out-of-hospital practice but have worked as an OB RN in hospital for 18 years (level 1 to level 3 centers). Completion of an NRP course does not confer competence to anyone that takes it: midwives, doctor, nurses, etc. NRP is also not just about the advanced skills of UVCs or ET tube placement either, it is about the whole picture of resuscitation of newborns and recognizing those that need it. Remember that 10% of newborns need some type of intervention but only 1% will require advanced interventions (UVC, chest compressions, ET tube placement, etc.). The midwives in our state carry LMAs and are trained in placement. Yes we do not carry medications or IV fluids and cannot place ET tubes or UVCs but our clients are fully informed on these limitations. We also do not care for women that carry those risk factors that would lead to an anticipated resuscitation. These women get transferred to a hospital care provider as needed. Also remember that the majority of the population are delivering in critical care or level 1 or 2 facilities that also do not have neonatologists or pediatricians that are proficient at these skills either. Their family practice providers or CNMs are delivering them who’s level of experience at a resuscitation may be the same as an out of hospital provider. Yes we do deal with less resources when delivering out of the hospital but this is an informed decision made by the family that chooses this care and the providers caring for them are mostly trained professionals as well.

  3. Zoe
    September 26, 2014 at 2:08 pm #

    I just want to say that this is something that is unique to the US. In Canada, two midwives attend each home birth (one for mum, one for baby). They bring with them oxygen, a bag and mask for ppv (adult and infant), everything necessary to intubate the newborn, epinephrine, oxytocin, supplies to set up an IV etc. The US is one of the only developed nations that does not require midwives to have a university degree. The Society of Obstetricians and Gynecologists of Canada has recently issued a statement saying that home birth is equally as safe as hospital birth when a registered midwife is present and the woman is low risk.

  4. Sarah
    June 16, 2014 at 8:24 am #

    Really great article. I work in prenatal genetics and attend a meeting where the best obstretricians, fetal medicine specialists, paediatricians, cardiologists, etc discuss difficult cases. I am always in awe of how they manage some things which sometimes have never been described, their level of expertise and the compassion and genuine care they show for the mothers and the babies. The speed at which things can go wrong and the amount of times these doctors jump into action and smoothly manage complex cases blows me away!

  5. Sally RNC-NIC
    June 15, 2014 at 1:27 am #

    Standing.ovation. Excellent.

  6. Doula/Student
    June 13, 2014 at 1:20 pm #

    So true. I am a doula and who took NRP classes for the learning experience and as I prep to start an accelerated BSN-to-MSN/CNM program this fall. That does not mean I feel even slightly ready to do what I learned without even having my nursing degree yet. There is no way CPMs or CNMs who birth at home can follow the NRP algorithm because they don’t even have the equipment/meds to do so! Also, the statistics struck me in the learning modules – that 1% of babies who have no prior risk factors but end up needing resuscitation – is enough for me to know I will always value collaboration and trust with highly trained neonatologists.

    Drives me crazy that I will be spending several years in graduate school and in training to become a CNM (after I have already spent 4 years in undergrad) only to be called a midwife like the CPMs who have done next to nothing to earn that title.

    PS- among the doula community, it is obnoxious the lack of education there is about the difference between the two midwife credentials. I have so many stories about this I could go on and on…

    • AngryAtYourAttitude
      November 26, 2014 at 12:23 am #

      You want to know the difference between the two? You will be a nurse first and have a more structured training. I’m going the CNM route also but it was not my first choice it is just more readily available. Midwifery is supposed to be a traditional form of care so if you have an issue with being lumped in with traditional birth attendants who’ve done “next to nothing” other than basically work for free for YEARS to gain more hands on training than you will probably have at the completion of your program, then be an obstetrician. There is way too much shaming in the midwifery community today and it needs to stop. There are good things to say about both sides and quite honestly it is unprofessional and down right hateful to essentially label every person educated a certain way as less than yourself.

      • Samantha06
        November 26, 2014 at 1:21 am #

        “You want to know the difference between the two? You will be a nurse first and have a more structured training. I’m going the CNM route also but it was not my first choice it is just more readily available”

        If you are going the CNM route, you have to be a nurse first too. you know.. Certified NURSE Midwife? How is that more “readily available” than the CPM “education” when CPM’s only need a high school education, 20 births and an exam?

        • Bailey
          January 11, 2015 at 5:05 pm #

          Where did you get your information?

  7. Meerkat
    June 13, 2014 at 10:32 am #

    I have the fondest memories of all the wonderful nurses who took care of my son and I during and after my C-Section. They were not just professionals, but warm and compassionate people who clearly cared about their patients, and not just their physical state. I remember slowly making my way to the nursery to check on my son after my csection. He was sleeping, but I felt the need to check on him. My hormones were in a havoc, so I was crying for no reason, and I didn’t even feel sad. I must have looked terrible, because a nurse I met in the hallway calmed me down, helped me walk down the hallway to the nursery to make sure my son still sleeping, brought me back to my room, and brought me some jello. This is just one of many kind and sweet gestures that they made, and I remember all of them. So thank you! Thank you for taking such good care of us!

  8. Beth S
    June 13, 2014 at 2:14 am #

    OT but kinda not: I live in a city where there’s 10 hospitals, but only 4 have any sort of maternity services, these hospitals serve a huge area and all of them are usually too far away for a true emergent situation for the patients in the most far flung parts of the city. Even if a mother isn’t homebirthing and there’s a situation where a patient is having an issue where it’s closest available hospital do you think hospitals should be required to have at least and OB, Pediatrician and a full time anesthesiologist on staff?

    • Gene
      June 13, 2014 at 2:46 am #

      Paid for by whom? I don’t mean that sarcastically, but having a full time IN HOUSE medical staff (not just docs, but nurses as well) is expensive. Smaller hospitals that may have a Pediatrics floor might be covered by a PA or NP at night (if that), and the pediatrician is asleep at home. Most bylaws state on call physicians must live within 30min. One hospital near me is covered by in house Peds from 7a to 7p. From 7-11p, there is a PA. And from 11p to 7a, physician coverage is the ED. Our health care system is broken enough. But many many hospitals are unable to pay for full time IN HOUSE “specialist” staff there for “emergencies only”.

      • Gene
        June 13, 2014 at 2:50 am #

        Another thought: it is similar to people who recommend homebirthers have “an ambulance on standby”. It is economically not feasible.

        • Beth S
          June 13, 2014 at 3:12 am #

          You’re right, what you said makes more sense than my going without sleep for three days rambling and that’s not being sarcastic, that’s being honest.

          • Mishimoo
            June 13, 2014 at 7:22 am #

            Ugh, I know that feeling all too well. Hope you get some decent sleep soon.

        • Matt Garner
          January 24, 2016 at 12:11 pm #

          Not just economically not feasible, logistically impossible. Speaking for the service where I work, if the fecal matter hits the ventilation system, we can very quickly find ourselves in a situation where there are ZERO available units anywhere in the county. It doesn’t happen often, but I can guarantee you, in that situation, they’ll have no choice but to pull that truck off that standby to run a call.

    • Elizabeth A
      June 13, 2014 at 9:47 am #

      IT was my experience that ambulances don’t necessarily pick the “closest available” hospital, but the “closest appropriate”. When I showed up at a hospital with insufficient maternity services earlier in pregnancy (they had OB, but no NICU), they did a quick eval, loaded me in an ambulance, and sent me someplace that had what I needed.

      I have also heard of situations in which patients were lifeflighted from local hospitals to hospitals that had what they needed. The system we have is not perfect, but we have considerable infrastructure for patient transport, and can often get patients where they need to be.

      It is awfully helpful if they start in hospital, though.

      • Medwife
        June 13, 2014 at 11:53 am #

        My hospital with a level II NICU sometimes gets transfers from a local level I NICU, which got the transfer from a homebirth. Less than stellar outcomes that way.

      • moto_librarian
        June 13, 2014 at 5:21 pm #

        Our hospital is a tertiary, university medical center. There are two ambulances (called Angel 1 and 2, respectively) that are equipped and designed for neonatal transfers from the surrounding communities.

        • areawomanpdx
          June 15, 2014 at 2:30 am #

          Yes, my hospital (also a tertiary university medical center) has a pediatric team to transfer neonates who need help. They will fly or take an ambulance to the outlying facility, stabilize the neonate (or actually any peds emergency a smaller hospital can’t handle), and return to the larger hospital for intensive care.

    • Guest
      June 13, 2014 at 11:10 am #

      I guess the hospital do the numbers and figure it’s cheaper to lose a few babies than to staff 24 hour care.

      • pinkyrn
        June 13, 2014 at 11:29 am #

        If you factor in legal fees and bad press, it really is not cheaper.

        • Guest
          June 13, 2014 at 11:44 am #

          Then why not do it and save some heartaches.

          • pinkyrn
            June 13, 2014 at 12:15 pm #

            I completely agree.

          • Sue
            June 14, 2014 at 12:55 am #

            Here’s why: because an emergency department has to have enough attendances to be able to sustain a skilled workforce – both professionally and financially.

        • DiomedesV
          June 13, 2014 at 4:05 pm #

          Why should all the hospitals in an area offer duplicate services? Is that a good use of resources? Should all hospitals offer treatment for cancer? How about organ transplants? Specialization is costly, and as others have noted, there are not enough providers anyway. Why shouldn’t they be concentrated in places where the resources they need to work are concentrated as well?

          Most labors are not precipitous, and parents have some time to decide when and where to go.

          • pinkyrn
            June 13, 2014 at 5:20 pm #

            I think all hospitals in an area should provide duplicate emergency services. If they have an OB unit, pregnant women are going to come in emergently. I am under the impression it cost way more money to care for patients in the large teaching hospital opposed to the community hospital.
            Ob legal settlements are astronomical and they take their toll on everyone involved.

          • Melissa
            June 13, 2014 at 5:54 pm #

            Imagine we have 2 hospitals that have emergency departments. One has a specialized OB unit. The other has a specialized major trauma unit. Both of these are operating at suitable levels (if they were at or over capacity that would be a different issue). Let’s say they each get 200 patients a month just to make the math handy.

            Why would it be better to have both units in each hospital. That is twice the number of people and twice the number of equipment. We couldn’t cut it to half the number because, under this system, we aren’t directing patients equally to each location. Hospital A could get all 150 OB and 150 Major Trauma and Hospital B would only get 50 of each. But the next week the reverse could happen. You would end up with hospitals that were sitting empty. It would take up twice as many resources with no clear benefit other than the fact that people who walked in off the street could get the specialization at either location.

            Are there a lot of people walking in from the street for emergency care? I wouldn’t think so, but maybe I’m just not informed. The paramedics and first responders will take them to the appropriate location. If they do come in off the street then they will be transported to the appropriate hospital. Other than homebirth situations where midwives have lied about the availability of hospitals to take the cases, how common are these cases where people are coming off the street into a random hospital in labor?

            Having the staff to take care of the rare situations when that may happen (and PS, there wouldn’t be a legal case in the situation I just described because it isn’t malpractice to not have an OB unit in your emergency room) means that money isn’t used elsewhere, in a place where it is more likely to do good instead of just spending it in case a rare situation happens.

          • Gene
            June 13, 2014 at 8:18 pm #

            “…how common are these cases where people are coming off the street into a random hospital in labor?”

            Depends on the hospital. We’ve had more “parking lot babies” at my current hospital in the past year than I’ve seen total during my entire decade plus of training. I had two in my first month there. Classic car screeching to a halt, frantic family member screaming, “She’s having a baby!!!”, panting pushing woman in back seat, etc. L&D is on the OPPOSITE side of the hospital from the ED. So if they are on the ED side, I get there first.

            It’s the ED. Crazy shit walks in off the street without notice regularly. EMS is smart enough to divert what they can but sometimes they scoop and run to the closest hospital for stabilization. But the stuff that gets driven in without warning? Remember all the bizarre things that would show up on ER or Greys? Real life is weirder.

          • pinkyrn
            June 14, 2014 at 1:42 pm #

            I think it depends on the distance between the two hospitals. In Boston, there are plenty of hospitals so I agree that duplicating the services is not necessary. In the community, hospitals are not very close together. And it also depends on how rare is rare? There should be more placenta previas roaming around due to the increased c-section rate.

            Remember that the community hospital maternity ward has antepartum and postpartum patients on the floor with no OB in house. The Ob Doctors do not have to come into the hospital to rule out labor either. An RN can follow a protocol, contact the on-call doctor and discharge a patient they have deemed is not in labor. So besides the OB complications rushing into the hospital, patients already on the maternity can quickly become an emergency situation.

          • fiftyfifty1
            June 14, 2014 at 2:29 pm #

            “There should be more placenta previas roaming around due to the increased c-section rate.”

            Yes, and since placenta previa is known in advance through prenatal ultrasounds, this woman should be instructed that she is high risk (doubly high risk because of c-section + previa) and should NOT plan to deliver in a community hospital without 24/7 in house coverage and should be instructed not to vacation to rural areas in her last trimester.

          • pinkyrn
            June 14, 2014 at 2:53 pm #

            Yes she is given these instructions, however she cannot spend her entire pregnancy on the Antepartum floor at the tertiary care hospital. She will go home and home is usually located in a community. The day she has her sentinel bleed cannot be determined in advance. When she starts bleeding on the toilet at home, she will call an ambulance. The EMTs then brings her to the closest hospital with a maternity unit.
            The point I am trying to make is that we cannot plan for these things. They can escalate very quickly.

          • DiomedesV
            June 13, 2014 at 9:09 pm #

            As other commenters have stated, those emergent births will be dealt with in the ED if there is not enough time, and transferred if there is. That seems to be an efficient use of resources.

            Not all hospitals (I believe) have equal capabilities to deal with trauma, either. Those patients may be stabilized at community hospitals and moved elsewhere as well. This is not just an OB issue.

          • pinkyrn
            June 14, 2014 at 10:54 am #

            I am not suggesting all hospitals have all services. I am suggesting that hospital that provide maternity services such as labor and delivery have a mechanism in place so they can get a woman into their operating room and do a quick c-section. That mechanism could be a general surgeon and not an obstetrician. It could be a nurse anesthetist and not an anesthesia Doctor.

            There have been disagreements in my hospital about which doctor is responsible for doing the emergency c-section in the emergency room when a pregnant woman comes in and needs to be coded. I think it is better to have a discussion and a plan way before the situation presents itself.

          • Gene
            June 14, 2014 at 11:48 am #

            A nurse anesthetist is required to be supervised by an anesthesiologist. And I don’t know ANY general surgeons who want to be on call for sections. Trauma surgeon, maybe (since they MIGHT be required to do a peri-mortem section, but even ED docs are trained in those). But trauma surgery requires extra training beyond just general surgery and we don’t have any on staff at our hospital as we are not a designated trauma center. A coding pregnant woman who arrives at our ED could have a peri-mortem section by our ED doc (though it is so rare, I don’t know any docs personally who have done them). We have OB here in house, so they would likely do it, even in the ED.

            But believe me, I don’t know ANY general surgeons who want to do sections. And I’m honestly not even sure if it is part of their training… Link to the ACS description of general surgery training where obstetrics is NOT mentioned: http://www.facs.org/residencysearch/specialties/general.html

            Also, I checked several surgery residency programs (including the hospitals where I trained) and none of the rotations during the five years of training were obstetrical. ZERO.

          • pinkyrn
            June 14, 2014 at 1:23 pm #

            I agree it is not optimal to have a general surgeon do them. I am thinking any port in a storm. The reason I suggested a general surgeon is years ago I was directed to overhead page “any available surgeon to Ob” Which is even more inappropriate. Also I have seen many general surgeons come to first assist with c-sections.

            It is also not optimal to have a maternity service where pregnant women will come for emergency treatment yet have no physician in house who can do a c-section. You say that obstetrical emergencies are rare enough that an Ob is not warranted. Isn’t that the same argument that pro-homebirth folks use?

            Also, due to IVF and our culture, the women having babies are not the young strong and healthy population that they used to be. So the rate of complications should be rise.

      • Siri
        June 13, 2014 at 2:02 pm #

        That is an unbelievably offensive statement.

        • Guest
          June 13, 2014 at 2:28 pm #

          Sorry about that, I guess it does sound harsh. I’m just trying to figure out why on earth a hospital wouldn’t have a ob on premises while moms are in labor. Mistakes happen, and someone needs to be there if there’s an emergency.

          • Elizabeth A
            June 13, 2014 at 2:36 pm #

            Hospitals that don’t offer maternity services are pretty up front about it. If you go to a hospital’s website, they list the services they offer. If you call and ask, they say things like “we don’t offer maternity services.” The only laboring women they deal with are coming in through the ED. If there’s time, they’re transferred. If not, they catch, stabilize and transfer. It’s not a good scene, but it couldn’t be avoided by having an OB on hand, because L&D units have resources besides doctors.

            Hospitals that DO offer maternity services should have OBs on site while moms labor, and usually do.

          • Matt Garner
            January 24, 2016 at 12:05 pm #

            I can’t fathom the thinking of some people. We had to pick up a neonate from a hospital in the south end of the neighboring county which had no maternity services whatsoever. The parents had driven from the north end of the county, passed up three hospitals with L&D and nursery facilities, and intentionally chose this hospital, because when the baby’s dad had broken his wrist while working in that area the previous year, they had “treated him real nice.”

          • pinkyrn
            June 13, 2014 at 5:09 pm #

            An OB is not required to be on the floor if, nobody is labor. If the labor and delivery unit is empty of pregnant women, the OB doc can go home. Those are the rules for my neck of the woods.

          • areawomanpdx
            June 15, 2014 at 2:24 am #

            Not all hospitals have women in labor at all times. Some hospitals have thousands of deliveries in a year and some don’t even make it to 100. It would be a ridiculous waste of resources and not at all feasible for one of those with fewer than 100 deliveries to have a 24 OB staff, along with anesthesia, a scrub tech, and more than one L&D nurse.

      • Sue
        June 14, 2014 at 12:53 am #

        I wonder if this guest gets his/her idea of hospital staffing from television, where the Attendings are always available in every specialty.

        The fact is, if every community hospital had in-house specialists for every specialty (from urology and plastic surgery to renal and oncology), they would never gain enough experience to remain competent, and the costs would be enormous.

        FOr that reason, each hospital either has an on-call roster or a transfer agreement with a referral center.

      • Renee Martin
        June 14, 2014 at 8:15 pm #

        Cheaper? How about totally unfeasible?

    • pinkyrn
      June 13, 2014 at 11:27 am #

      An OB is not required to be on the floor if nobody is in labor. Ambulances with ?able bleeding previa or (insert obstetrical emergency here) do roll into community hospitals. The ambulance usually calls the hospital with a heads up that they are coming. Then we call the OB at home. The heads up call gives us time to get ready (set up operating room, notify anesthesia, notify pedi, set up code carts, notify blood bank, etc).

    • Ash
      June 13, 2014 at 11:52 am #

      That’s simply not possible with the resources available.

    • auntbea
      June 13, 2014 at 12:04 pm #

      At least where I live, there are simply not physically enough people to do that kind of staffing. We have a serious doctor shortage and almost everyone in my town is a family practitioner because of it.

      • Guest
        June 13, 2014 at 12:13 pm #

        Then the hospitals need to state that risk, and inform the public. I believe most moms think that there is always an ob on staff. I don’t think they realize that that means 30 min. away.
        There is no doubt that hospital births are soooo much safer than homebirths, but hospitals could be even safer.

        • Ash
          June 13, 2014 at 12:18 pm #

          How would an ad in the paper advertising what services they do and do not have help the issue? If you live in Wyoming , one of the most sparsely populated states in the USA, it’s unlikely that all the women living there will go to Cheyenne when they go in labor. Cheyenne is the largest city in the state and has 60K people. Hell, you’d probably have to go to Salt Lake or Denver for access to Level IV NICU.

          • Young CC Prof
            June 13, 2014 at 12:27 pm #

            3 hour drive to the nearest good hospital sounds like a great reason for “convenience” induction.

          • Elizabeth A
            June 13, 2014 at 2:32 pm #

            Well, yes. Yes. Every expletive I can think of yes.

            This is one (of many) reasons why it bugs me when people get all het up about evil convenience inductions. They generally haven’t thought inconvenience through.

          • Amazed
            June 13, 2014 at 2:36 pm #

            Personally, I think it’s worth for a mother to suffer anything in the name of her baby’s natural coming earthside. Of course, that excludes a C-section which is incredibly painful but somehow it’s the easy way out for those frightened chickens. And it’s so UNNATURAL!

            Of course, that’s my idea of what’s happening in Induction Evil Evangelists’ headspace.

          • Renee Martin
            June 14, 2014 at 8:14 pm #

            How about a 1.5 drive, PLUS a possible 10 min- 5 hour wait at the busiest land border in the Americas?
            Yes, thats me, and I was DENIED an induction at term, and an MCRS. I was lucky that I went into labor at 1am when traffic was light. Only took 2.5 hours to get there….

        • Gene
          June 13, 2014 at 1:22 pm #

          Are you actually under the impression that EVERY SINGLE HOSPITAL (in the US) has, on staff and in house 24/7 every single conceivable specialty? A pediatric neurosurgeon? A level 3 NICU with neonatologist? A closed bone marrow transplant wing? Even in a Podunk hospital with maybe 20 total patient beds?

          There are not enough doctors (or nurses, resp therapists, etc etc) in the US for this to be even possible. My community hospital has a 24/7/365 pediatric ED, but we are the only one in our otherwise large and well off county. There are maybe three true pediatric EDs in my entire state (dedicated to kids, staffed with true pediatric emergency medicine trained docs). But we don’t have a PICU and are only a level 2 trauma (level 1 is the most serious) center. So a massive trauma (adult or ped) gets stabilized and transferred to a regional trauma center

          • guest
            June 13, 2014 at 1:42 pm #

            I’m not in the medical field- so yes I did believe that a hospital would have OB care in the event there were an emergency while delivering a baby.

          • pinkyrn
            June 13, 2014 at 1:57 pm #

            I think most people do think that hospitals have OB doctors in house.

          • Renee Martin
            June 14, 2014 at 8:14 pm #

            I agree, I think this is common. I never would have thought there wasn’t one until I learned more when I was pregnant.

          • Gene
            June 13, 2014 at 2:54 pm #

            There are community hospitals that are closing their emergency departments because they don’t have the funds or staff to keep them open. Not every hospital can afford to offer obstetrical care, let alone 24/7/365 an in house obstetrician, pediatrician (let alone neonatologist), and anesthesiologist and the appropriate support staff.

            It reminds me of a young patient I saw once. He’d has surgery on his genitals (by a peds urologist) that day, was discharged, and then developed some complications. His parents called his surgeon who asked them to come back to the hospital for an eval. So they drove to ***my*** ED instead because they didn’t want to pay for parking at the other hospital. Kiddo was stable, but needed to be seen by his surgeon. So I started to arrange transfer. Family was FURIOUS. They didn’t understand why their surgeon didn’t drive 45 min to see them at a hospital where he had no privileges (not permitted to work there). And then they were pissed that we couldn’t just call our (non-existent) in house peds urologist. And then they were upset that the ambulance that would transfer them was not going to be there for at least two hours. It was bizarre.

            Seriously, though, you cannot expect that every hospital will have every specialty available 24/7/365. It is not physically or economically feasible.

          • Matt Garner
            January 24, 2016 at 11:58 am #

            Sadly, this is not the case. I’m a member of a neonatal transport team, and this is the reason our jobs exist. We work out of a hospital with a level 3 NICU and travel via a very large ambulance/mobile ICU that is capable of transporting two isolette stretchers. Our job is to travel to nearby hospitals that lack the necessary staff and facilities to care for newborns with a variety of health problems, stabilize the newborn on site as needed, and bring them back to our hospital.

        • auntbea
          June 13, 2014 at 2:49 pm #

          I think they should definitely make it clear to mothers, and I intend to ask about it if we ever have a baby here. But I don’t know what I will do. Take the risk that comes with having only an on-call anesthesiologist? Or drive 1.5 hours for all my prenatal appointments so I can deliver with a doctor at a bigger hospital?

        • Melissa
          June 13, 2014 at 3:54 pm #

          I don’t understand why this would be an issue. A woman who assumes that X hospital has a full time OB would discover the truth before giving birth when she would be deciding what hospital to use. Her own OB would be able to tell her which hospitals have what features so she could decide where to deliver. I haven’t had a child yet, but from what I’ve seen with my friends (who did tours of the hospital before picking one) all the features are discussed right up front. Picking one is like picking what college to go to. They have pros and cons and you select one you think is best for your situation.

          The only reason that someone would be in danger because of a misapprehension about an OB being on staff is if someone wasn’t having any prenatal care and was just going to pop over to the nearest hospital when they started labor. Otherwise their actual OB would have probably talked to them about which hospital had what and had them pre-register.

          In the even of an actual emergency the paramedics know which hospital to take a pregnant woman to unless it was so dire that they needed to take them to a closer hospital that didn’t have a full time OB.

          • DiomedesV
            June 13, 2014 at 4:00 pm #

            I think this exchange illustrates that there is actually widespread misunderstanding about the resources available for OB at any given hospital. People who are being seen by a regular OB have a different perspective. They will have had these conversations. But many people are not being seen by regular OBs. They may start seeing a provider relatively late due to lack of insurance, for example. Also, it sounds like lay midwives are deliberately giving the impression that hospitals are a ready backup in case something goes wrong. That is simply not the case, but it may be asking too much for many people to know that without being told by someone.

          • Melissa
            June 13, 2014 at 4:23 pm #

            Which is why better access to insurance and more public health social workers are needed. But to say that the solution to this problem is to staff OBs at all hospitals (and even the suggestion below that hospitals must not care about the lives of babies if they don’t do this) seems to be a poor allocation of resources.

            I guess part of the reason that this is all so surprising for me is that I am not afraid to seem stupid. So I’ve always been the type of person to just ask very basic questions instead of assuming that I understood something. I am slowly starting to realize that many people don’t have this. When I was having terrible abdominal pains (ended up being a gall stone) I actually called up the hospital before going into the Er to ask what I needed to bring and if I should go to them or the hospital on the other side of town. (Hi, I’m in pain and it hurts to move. My friend is bringing me to the ER. Should I, like, bring anything. I don’t know? Like a change of clothes or…like…what I had for lunch? Do you need my passport? I’ve never done this before.)

          • DiomedesV
            June 13, 2014 at 4:02 pm #

            Another thing to keep in mind is that for many women, giving birth may be their first real encounter with a hospital. Many people on this blog have experience with chronic health problems and so may have plenty of experience with specialists and hospitals. But that is not true for many, many people. Many patients simply have no idea how to navigate the health care system in the US and what to expect with respect to resource availability.

    • sdsures
      June 13, 2014 at 2:54 pm #

      I lived for 2 years in a village in Scotland, called Saltcoats. The nearest hospital with an ER (A&E) didn’t have a NICU unit, so since I will be high-risk when we do choose to have kids, and if we had chosen to have kids (hospital, of course) at that time and needed a NICU, we would have had no choice but to drive to Glasgow’s Southern General hospital, an HOUR each way.

      Not every hospital in the UK has an emergency department. Signs near hospitals on all major roads display whether or not they have one.

  9. Sue
    June 12, 2014 at 10:35 pm #

    Great article – thank you. Many people in the population are certified in CPR. That doesn’t mean we get passing citizens to run resuscitations in ED.

  10. Beth S
    June 12, 2014 at 9:48 pm #

    Wonderful post, and it gives me more to use when I’m posting to get signers to my petition sorry to harp on this but I need all the signers I can get: http://www.change.org/petitions/u-s-house-of-representatives-and-u-s-senate-and-president-of-the-united-states-reform-midwife-laws
    I know a lot of women on my birth board tell me their HB midwives are just as well prepared in Neonatal resus as regular docs, so this will help immensely thank you.

    • Ducky7
      June 12, 2014 at 10:57 pm #

      This is not a issue where you’ll gain much traction with the President or Congress- states regulate medical scope of practice. You’ll probably get more traction lobbying in person or over the phone with specific legislators, anyway. I would recommend to focus on your own state legislature and encourage other women to organize to do the same. You can see if there is any relevant legislature in your state here, tracked by National Conference of State Legislators: http://www.ncsl.org/research/health/scope-of-practice-overview.aspx

      Arrange for meetings with your legislator’s office or any other offices who have reason to be sympathetic to the cause (maybe a state rep is a former OB? someone concerned with maternal health?) Bring fact sheets that break down your data, and speak forcefully and clearly. And have your friends do the same!

      • Beth S
        June 12, 2014 at 11:11 pm #

        When I started the petition I was thinking more along the lines of reforming the Medicaid, Medicare laws pertaining to maternity coverage and the way Homebirths are covered, then going from there.
        I honestly can’t believe I even did it considering I’m usually the worlds worst introvert.

    • Ducky7
      June 12, 2014 at 11:01 pm #

      Lord knows the pro-DEM/CPM crowd knows their audience for lobbying. Check out this state-by-state breakdown: http://cfmidwifery.org/states/

  11. attitude devant
    June 12, 2014 at 8:38 pm #

    Beautiful post. Thank you, sapphiremind! I have to say, one thing that blows my mind, knowing all of this, is how slow the HB crowd is to call 911 when they DO have a sick baby. If a kid comes out depressed, you should call for help as you begin your resus. That’s what we do in the hospital. You don’t throw your bag of tricks at the baby and THEN call. Time is BRAIN.

    • Stacy48918
      June 12, 2014 at 8:53 pm #

      “I have to say, one thing that blows my mind, knowing all of this, is how slow the HB crowd is to call 911 when they DO have a sick baby. If a kid comes out depressed, you should call for help as you begin your resus. That’s what we do in the hospital. You don’t throw your bag of tricks at the baby and THEN call.”

      This is another negative for the whole “my midwife knows infant CPR” thing. It gives the midwife and the parents this false sense of security that they’ve got that time to start CPR. This extends the time to hospital too. Folks say “Oh I’m only 5 minutes from the hospital”. But if baby comes out blue and floppy with a HR of 60 you KNOW the midwife is going to try some kind of resuscitation first (and she SHOULD…some kind of O2 is better than nothing…though just “calling baby earthyside” is nothing but anyway…) so even if they try for just 5 min before calling 911 there’s 5 min resus, 5 min transport, few min waiting for ambulance. That 5 min EASILY turns into 20 before you hit the door of the hospital, much less actually get baby into the hands of the people he/she needs.

      There’s a great paragraph in Amos Grunebaum’s paper on 5 min Apgar’s of 0: “We emphasize that the increased risks of poor outcomes from the setting of home birth regardless of attendant, are virtually impossible to solve by transport. This is because total time for tranport from home to hospital cannot realistically be reduced to clinically satisfactory times to optimize outcome when time is of the essence when unexpected deterioration of the condition of either the fetal patient or pregnant patient occurs.”

      So even if they DID call 911 the moment the baby came out blue and floppy, it’s already too late. No matter how close they are to the hospital.

    • Young CC Prof
      June 12, 2014 at 9:03 pm #

      Let me say again, the single most disturbing thing in the MANA paper was the fact that, of the babies who had a five-minute Apgar less than 7, half were not transported at all. Not they dithered for a few minutes THEN called 911, not they drove the baby to the hospital themselves, the midwife apparently went, “Eh, close enough, call the ped in the morning for a checkup.”

      • Stacy48918
        June 12, 2014 at 9:04 pm #

        I didn’t catch that. That IS terrifying.

      • sapphiremind
        June 12, 2014 at 9:13 pm #

        That is horrible. Technically, you are supposed to keep assigning apgars until they are > 7. Some days that’s hard and we give up after 30 minutes. But an apgar < 7 is serious.

        • Young CC Prof
          June 12, 2014 at 9:32 pm #

          Specifically, out of 17,000 births, 245 had low Apgar. 69 of those babies had transported during labor and were born in the hospital. 66 transferred after birth. The other 110 were apparently NOT transferred.

          And then there were the 401 babies who didn’t have any Apgar recorded at all.

          • sapphiremind
            June 12, 2014 at 9:42 pm #


          • The Bofa, Being of the Sofa
            June 12, 2014 at 10:27 pm #

            Especially since “Apgar inflation” is already a serious problem with midwives, so if you have an Apgar< 7, that is some serious shit.

            "It's not unconscious, it gets a 9"

          • Sue
            June 13, 2014 at 1:34 am #

            One HB APGAR point is worth two normal APGAR points – didn’t you know?

          • KarenJJ
            June 13, 2014 at 2:34 am #

            They get at least 7 points for being born at home – any breathing etc after that is just a bonus.

      • The Computer Ate My Nym
        June 13, 2014 at 3:37 am #

        Especially disturbing when you consider that most of the Apgars are probably overestimates anyway. I wonder what a study of long term outcomes of children born by an “uncomplicated” home birth would show. In principle, MANA has the data to do such an evaluation, but I doubt that they will.

    • Sue
      June 12, 2014 at 10:36 pm #

      Fully agree with AD. That’s why we have ”codes” in hospital, so that the troops and equipment come running.

    • KarenJJ
      June 13, 2014 at 2:32 am #

      That’s exactly what my training is (I’ve just done some workplace CPR and safety stuff). Call 000 and then do whatever needed next. You don’t wait around to see if CPR works before calling for an ambulance.

  12. sapphiremind
    June 12, 2014 at 8:18 pm #

    Thank you Dr. Amy for allowing me to talk about a subject near and dear to my heart, and hopefully explain *why* hospital births are safer for babies.

    And an apology because I forgot to mention respiratory therapists as part of the team and they’re awesome and I love them and wouldn’t want to code without them!

    • Sue
      June 12, 2014 at 10:37 pm #

      And that’s the difference between professional team-players and those renegades who think they can do everything better themselves. Pure hubris.

    • Box of Salt
      June 13, 2014 at 3:13 am #

      Thank you, sapphiremind.

    • pinkyrn
      June 13, 2014 at 1:47 pm #

      NICU respiratory therapists are the bomb!

  13. OldTimeRN
    June 12, 2014 at 6:52 pm #

    As one of the “specialized nurses” I heart this blog so much. I’ve been doing this for a long time and trust me it doesn’t get any easier. Seconds feel like forever. But at the same time it’s what we are trained to do and we do it well. I feel like the NCB want to make less of our job. Feel we aren’t needed in the delivery room. We are trained to pick up the unnoticeable. Babies don’t scream out, “Help me, I can’t breathe” or “Hello my blood sugar is low”. When a mom thinks her baby is singing, I call that grunting. When I mom thinks her baby isn’t hungry and is just sleepy I call that potential hypoglycemia. We do this all with no monitors, just our assessment skills. Up until last year Pulse Ox monitors weren’t even routinely provided in the DR. Just our trained eye to notice changes, sometimes so subtle you might even doubt yourself and ask a fellow RN for their opinion.

    The NCB crowd taking over the hospital, while administration sits back and allows it to happen with things like immediate skin to skin without a quick assessment. Would you want to breast feed your baby before you knew it had an anal opening? I’m on the short side, it’s hard to assess a baby on my tippy toes with a mother doing the afterbirth shakes. How do I get in there to see if the baby needs intervention? Trying not to scare a mom if I need to take the baby? I think skin to skin is great if all things are going great. But immediate skin to skin, with pooping or peeing babies(on mom), lead to a big mess and cold babies which can lead to hypoglycemic babies.

    We do so much in the delivery room, and I feel like some want to reduce our role as we aren’t needed. Trust me, we are.

    • Trixie
      June 12, 2014 at 7:03 pm #

      I completely agree with the heart of this post, but for me getting a tiny bit of baby pee on me during skin to skin wouldn’t be a big concern compared to the general grossness of birth.

      • OldTimeRN
        June 12, 2014 at 7:04 pm #

        But it could mean the difference between a dry and warm baby and a wet and cold baby.

        • Stacy48918
          June 12, 2014 at 8:46 pm #

          Both my kids peed on me pretty immediately. I was happy at that point to pass them off to be clean and dry, but I still appreciated the first few minutes of them close and skin to skin.

          • OldTimeRN
            June 12, 2014 at 8:56 pm #

            Of course Mom holds baby immediately after birth. For a good 5 minutes or more. By then most Moms want to know the weight and would like their baby cleaned off and warmed up. As Mom is getting stitched or cleaned up. we do what we need to do(maybe 10-15 minutes) with the baby. Afterwards baby goes right to skin to skin for however long Mom wants it. What they want taken away are those 5-10 away from Mom.

          • Stacy48918
            June 12, 2014 at 8:58 pm #

            I see. Thanks. See my reply above about my confusion here. 🙂

          • Trixie
            June 12, 2014 at 9:07 pm #

            I should clarify, I got my baby back, still naked, after a quick assessment, and then she peed on me. But, she was wrapped up, and hatted. I didn’t even notice until later, and I don’t think it made her cold.

          • moto_librarian
            June 13, 2014 at 9:11 am #

            My oldest pooped on me as soon as they handed him to me, still attached to his cord. In retrospect, that pretty much summed up the entire day, lol!

        • Guest
          June 12, 2014 at 9:28 pm #

          Incorporating skin to skin can be a bit of a challenge when providers are used to completing routine care at a radiant warmer, however, with a little ingenuity it really can be done effortlessly with healthy term babies. Most babies are stable enough to be dried thoroughly and placed skin to skin to maintain warmth and transition, slipping a quick diaper on by the time 5m Apgar assigned prevents most messes. Parents really enjoy this time with the baby and it really does help the baby transition. Of course those kiddos needing assistance still belong at the warmer. Skin to skin has certainly become routine care, but I do caution providers preemptively have this discussion during antenatal care to ensure the minority who don’t desire this practice do not have it implemented. It doesn’t happen often, but some mothers do prefer not to incorporate this type of care and it provides an opportunity to ensure a warm wiggly little baby under mom’s gown doesn’t serve as a trigger from past experiences.

          • Jessica S.
            June 12, 2014 at 9:40 pm #

            I must be in the minority, I had and have no desire to be skin-to-skin and have no problem with them being looked over before given to me. Now, I had a CS with my first, and I was beyond exhausted, so there wasn’t much of an opportunity. I was really impressed that they let me hold him when the wheeled us back to the recovery/delivery room. (I guess I didn’t have shaky arms like some people talk about.) But it’s good that mothers who want the immediate contact are accommodated. I just hope the majority of them aren’t giant pains in the ass if it doesn’t happen exactly how they want it and when they want it.

          • Guest
            June 12, 2014 at 9:59 pm #

            Not uncommon at all, especially after an unscheduled CS…Mom is exhausted and has just come through an intense experience and often needs time to mentally adjust to all that transpired. We manage to get most scheduled CS skin to skin within a few minutes of birth and through first 2 hours IF that’s what Mom wants. That IF is the important part, making sure it is what Mom wants and ensuring she doesnt feel judged or pressure IF its not.

          • Jessica S.
            June 12, 2014 at 10:41 pm #

            That’s awesome that you make it a priority, especially since that’s a common trope of why CS are so damaging to the mother/child bond – if you have a CS you won’t hold your baby for hours!! Of course, one would think that NOT having a CS when indicated could be a real downer to the mother/child bond, if one or both doesn’t make it. 🙁

          • KarenJJ
            June 13, 2014 at 2:41 am #

            I was all for skin to skin until I realised it made so little difference to me. I didn’t bother with it for baby number two. Instead we had a quiet hour or two a few days later where he fell asleep on my chest (we both had clothes on – didn’t bother us) and I read a book. It’s one of my favourite early newborn memories.

          • Amy M
            June 13, 2014 at 11:50 am #

            Eh, I guess it wasn’t as in vogue when my boys were born 5.5yr ago, but I don’t feel like we missed out. The doctors/nurses wanted to check them out asap to make sure they were fine, because they were 36wkers, and I was totally down with that. After the first one was out, I still had to deliver the 2nd one, so I wouldn’t have been able to concentrate on the first one. After the 2nd one was out, I was shaking so hard, surely I would have dropped any baby I was holding, and the nurse wrapped me up in warm blankets so my arms weren’t free anyway. My husband went off with the babies while they went to be checked so he held them first I guess, but not STS, since they were so small, the doctors wanted them wrapped up and hatted (the horror!) to make sure they didn’t get too cold. We did STS later on, when I was trying to BF them, because the only way they’d wake up enough to eat was if we got them naked.

          • sapphiremind
            June 13, 2014 at 1:11 pm #

            Actually STS would have likely made their temp more stable than all the swaddling.

          • Guest
            June 13, 2014 at 2:04 pm #

            Roadside precipitous birth very early this am, early term babe. Dropped temp en route with EMS (wee bit chilly here this am), otherwise stable. Radiant warmer for eval on admission and minimal temperature improvement after 20 minutes. RN’s placed baby STS and took 30 minutes skin to skin and temperature regulated just fine. 96.8 to 98.1. How timely for this discussion to have that nice reminder, although my lack of sleep tends to make me ramble.

          • Amy M
            June 13, 2014 at 3:46 pm #

            Probably, but like I said, this was 5yr ago, and though they did kangaroo care at this hospital for preemies in the NICU, I don’t think immediate STS had really caught on yet. Luckily, the boys really didn’t have any issue maintaining their temps. To this day, they are warm little guys, running around in shorts, when I prefer to wear a sweater.

        • Elaine
          June 12, 2014 at 9:46 pm #

          My son pooped on me twice during the first hour. They just wiped it off. Didn’t bother me much, I was a mess already. Though I think somebody should have semi-strongly suggested they take the baby so I could make a better attempt to push out the placenta and reduce the number of attempts my midwife had to make to manually extract it in pieces, but that’s another story.

          • JustSayin'
            June 13, 2014 at 9:51 am #

            I find it interesting that OldTimeRN talked about the “difference between a dry and warm baby and a wet and cold baby,” and you replied with “Didn’t bother me much.” With the demand for skin-to-skin and insta-bonding, nobody worries about the baby’s comfort.

          • Guest
            June 13, 2014 at 10:18 am #

            How did Elaine not worry about baby’s comfort? Because he had two BM? Would have happened on Mom or in the diaper, either way easy cleanup and not sure how it would have made the baby uncomfortable one way or other. Please don’t make it sound selfish for Elaine to say it didn’t bother her much and that it was ignoring baby’s comfort.
            I get it. Change is difficult. I remember good ol’ days where babies went to NB nurseries for 2-3hour evals immediately after birth. We fed them sugar water to check patency, followed by an ounce of formula and a rectal temp for patency. Babies born by CS were considered medically unstable and stayed in isolettes for 2 hours after birth until cleared by pediatrician. Now we have practice guidelines based on research and EMR’s that take us away from the bedside far too much. But the simple fact is that STS isn’t some NCB oriented bullet point on a birth plan and it does have benefits for babies, as well as Mom. Besides that, parents enjoy it and in a healthy postpartum dyad, why would we take that away from them if it isn’t imposing any risk?

          • pinkyrn
            June 13, 2014 at 1:35 pm #

            The difference between the warm & dry baby and the cold & wet baby, can transform a well baby to a sick baby. That is what my PCEP books says.

          • Elaine
            June 15, 2014 at 8:29 pm #

            Um, I wouldn’t have continued doing what I was doing if the baby wasn’t comfortable as well. And the poop didn’t get on him enough to affect his comfort level (i.e. wet/cold baby wasn’t an issue).

            Just because I worded my post the way I did, you shouldn’t assume that I wasn’t acting out of consideration for my baby as well as consideration for myself.

    • Stacy48918
      June 12, 2014 at 8:45 pm #

      “Would you want to breast feed your baby before you knew it had an anal opening? ”
      Is immediate/early breastfeeding detrimental to a baby with atresi ani? I honestly think I WOULD prefer a bit of time to bond with baby before getting hit with the knowledge that my baby had a serious complication that would necessitate surgery. Does 15-30min matter that much before telling mom this info? (assuming it’s not immediately life-threatening? If it WOULD hurt baby, then yes I’d rather know before breastfeeding) The idea of “hey here’s your baby and guess what he needs surgery” 1 minute after birth is a bit much. But I’m pregnant and hormonal. 🙂

      If you NEED to take baby I’m going to be scared because I’m worried about my baby but not in a way that looks down on you at all. I would be scared but I would still WANT you to take baby.

      • OldTimeRN
        June 12, 2014 at 8:50 pm #

        The immediate bonding wouldn’t be a problem but breastfeeding could be. You really wouldn’t want anything in the gut as it would have no place “to go”.

        • Stacy48918
          June 12, 2014 at 8:56 pm #

          I’ll keep that in mind this time. I still want immediate skin to skin (assuming all does well, otherwise, off he/she goes pronto!) but make sure there’s an exit before nursing. 😛

          I appreciate your thoughts on this. This will be my first planned hospital birth, so even though it’s my 3rd baby I still don’t quite know what to expect and what’s standard. 🙂

          • OldTimeRN
            June 12, 2014 at 9:01 pm #

            Look for the “wink”

          • Stacy48918
            June 12, 2014 at 9:03 pm #

            Haha…I actually had to think about that for a sec. I shouldn’t have since it’s part of my neuro work up in dogs…but didn’t see it coming I guess, ha!

          • Guest
            June 12, 2014 at 10:02 pm #

            Easily accomplished to see the wink when checking acrocyanosis of feet simply by lifting mom’s gown.

    • NoLongerCrunching
      June 12, 2014 at 8:59 pm #

      Just curious, would it matter if the baby with no anal opening got a little colostrum? His colon already has meconium in it, right?

      • OldTimeRN
        June 12, 2014 at 9:01 pm #

        Yes it does, but we wouldn’t want anything else going in to put pressure on the anus.

    • Julia
      June 12, 2014 at 9:30 pm #

      While I’m quick to grab a blue, floppy baby and take it to the warmer for closer observation, I don’t think it is that hard to do a quick assessment with the baby skin-to-skin. Baby is warmed and dried right on mom, and they get to snuggle while I give baby the once over. I don’t usually find that the babies get cold if you are quick to change out the blankets while doing your 1 minute and 5 minutes APGARs. You can diaper a baby on mom too. And, of course if mom doesn’t want baby until s/he has been wiped down, etc. I’m happy to do that as well. But most of the moms in the area where I live want their babies right away.

      • Young CC Prof
        June 12, 2014 at 9:35 pm #

        My baby got all the standard newborn stuff while my OB was sewing my belly back together, but then we got to stay together. He needed blood sugar checks, but that was no problem for the newborn nurses, one managed to get a heel stick while he was latched on! Without him even noticing.

        • Guest
          June 12, 2014 at 9:40 pm #

          Yep, one of the perks of STS. Reduces pain perception significantly! One of the nice first steps of parents learning that they can soothe and comfort the baby too. Letting parents know they can reduce discomfort during Vit K, Hep B and chems has gone a long way in my experience of helping those parents on the fence about routine NB med administration to agreeing to Vit K and vaccines!

          • JustSayin'
            June 13, 2014 at 9:47 am #

            The other thing that reduces pain perception is pain medication. I’d rather have that.

          • Guest
            June 13, 2014 at 9:51 am #

            Agreed, but pain medication for routine newborn medication isn’t feasible unless there’s something I haven’t heard about yet. If a simple intervention reduces pain, why NOT implement it?

        • Beth S
          June 13, 2014 at 1:29 am #

          Yeah that’s the way they did it with me, and I appreciated not having to see it.

      • Aussiedoc
        June 13, 2014 at 1:02 am #

        Agreed. That’s my routine practice.

      • staceyjw
        June 13, 2014 at 4:36 am #

        Eeeew, I just do not understand the desire to have a baby covered in slime all over you. Get it wiped off, it only takes a second.

        • MaineJen
          June 13, 2014 at 3:12 pm #

          My hospital puts the baby on you right away, that is how I ended up covered in “baby cheese” after my daughter was born. I didn’t care even a little bit, I was so in love with holding my baby! But damn, that cheesy stuff is hard to wipe off…

      • Medwife
        June 13, 2014 at 6:34 am #

        Yup. And taking the first temp rectally resolves the patent anus question 🙂 As for sewing up etc, some moms need/want someone else to take the baby while all that is done, and some moms do better with the distraction of cuddling baby (with assistance).

        I don’t see the point of making a fuss over things that people prefer and are within safety.

        • sapphiremind
          June 13, 2014 at 6:36 am #

          Eek – don’t do the rectal temp! Risk of perforation is uncomfortably high. Visual inspection is really enough.

          • Medwife
            June 13, 2014 at 11:47 am #

            Can you point me towards information on that? I am a CNM so the baby isn’t “mine” once it’s out, basically, but it’s the nurses’ protocol. I can see the logic- if the risk of perforation is higher than the risk of not detecting imperforate anus with visual inspection alone, then that’s not a good protocol we have. Certainly a lot of parents are distressed by it.

          • Isramommy
            June 13, 2014 at 4:51 pm #

            Very interesting. Thanks for the links. I’m in nursing school now and just had a course in newborn evaluation in which we were taught that we must take a rectal temp on full term babies (although we were told that with preemies the risk of perforation is too high). And part of the justification for the rectal temp was to check the anal opening. I’m not in the US though, so our guidelines may be different.

          • Medwife
            June 13, 2014 at 7:33 pm #

            Thank you very much. I’m going to bring it up at our next perinatal department meeting.

          • Guest
            June 13, 2014 at 8:33 pm #

            Take note CPMs. This is how real providers effect change.

          • pinkyrn
            June 13, 2014 at 1:38 pm #

            Most NICU docs I know discourage taking rectal temps.

    • Guest
      June 12, 2014 at 10:14 pm #

      But it isn’t NCB taking over the hospital and administration sitting back. While there are several NCB purporting the benefits of skin to skin, the original impetus for this practice change was originated by AAP and WHO after research on preterm infants led to additional research demonstrating benefits for term infants too, the NCB crowd just tagged along.

      • Jessica S.
        June 12, 2014 at 10:31 pm #

        Yes, but I assume the AAP and WHO are realistic about the instances where skin-to-skin is not possible right away or needs to be interrupted momentarily. The NCB advocates would not be so realistic, and therein lies the problem.

        • Guest
          June 13, 2014 at 7:59 am #

          Absolutely, if a baby needs assistance he/she belongs under a radiant warmer under the care of the experts. I have yet to hear even the crunchiest of NCB parents utter a word to disagree with taking a baby away when a baby needs assistance. There will be no ‘calling baby earthside’ in lieu of medical care in my delivery rooms, but then again…that’s a subject that is never up for discussion.

          I find that if parents understand routine care is skin to skin, that’s one last bullet point on the birth plan to contend with. Makes for less animosity AND they understand that if baby needs evaluation and care at the warmer, we’re not interrupting there bonding time, we’re providing their infant the care they are in the hospital for in the first place.

          • Guest
            June 13, 2014 at 8:02 am #

            Edit* one ‘less’ bullet point on the birth plan.

          • Elizabeth A
            June 13, 2014 at 9:52 am #

            Absolutely, if a baby needs assistance he/she belongs under a radiant
            warmer under the care of the experts. I have yet to hear even the
            crunchiest of NCB parents utter a word to disagree with taking a baby
            away when a baby needs assistance.

            You’re lucky. I’ve heard that. The assumption is that NRP is totally bogus, because all babies need is breastmilk and kangaroo care. These ideas are false and ridiculous and incredibly painful to shed when you have a baby in real danger. You should hear what they say about the evils of intubation. I concede that it looks like it hurts. I am pretty sure no one’s doing it for funsies. (Did not see my own daughter intubated, because I was busy being stitched up. DH seemed pretty traumatized, but intubation and subsequent procedures succeeded in making her not die, and she’s dancing in her first ballet recital this weekend.)

          • Amy M
            June 13, 2014 at 11:41 am #

            Yeah, look on MDC…there are women there saying that the evil doctors took their helpless babies away from them and “did things to them” wo/mom’s consent when “all the baby needed was her mother.” Odds are the doctors/nurses took the baby to check it over, and either administer aid or vaccines, or just make sure it was doing ok. Probably in most of the cases, the baby was handed back within minutes, but the outrage about the interrupted bonding is ridiculous. They really seem to think human babies operate like ducklings. Idiots.

          • sapphiremind
            June 13, 2014 at 12:56 pm #

            It doesn’t hurt so much as is uncomfortable. But if you can’t breathe, you don’t care as much about that.

            I once needed a catheter because I had a blockage in my urethra. I was in so much pain from not being able to pee. When they put in the catheter, it was honestly the best feeling in the world because it relieved the pressure and pain I was feeling. Now, I wouldn’t like them put in on a regular basis for giggles, but when you need the intervention, it is like a relief when it is done, even if it is painful in theory.

      • JustSayin'
        June 13, 2014 at 9:44 am #

        Wasn’t the research on whether babies are better off with skin-to-skin versus NOTHING? It was research in poor countries where they don’t have incubators. The skin-to-skin warmth warmed the babies that would have been in incubators in America.

        • Guest
          June 13, 2014 at 10:03 am #

          Yes, originally from Columbia in 80’s in resource poor NICU’s with premature infants as the impetus for the research. Obviously it would be obtuse to assume the impact of the intervention for premature infants would apply to term infants. Fortunately, there is plenty of research on its benefits for term infants to support its practice.

        • Young CC Prof
          June 13, 2014 at 12:09 pm #

          When the nurse recommended skin-on-skin, she said something like, “He’s doing well, so you can hold him, but because he is so little, we’re not sure how well he can regulate temperature. I want him either in a warmer or skin-on-skin with you or his father for the next few hours.”

        • sapphiremind
          June 13, 2014 at 12:52 pm #

          No, the research has been on STS vs isolette/warming table. Initial research was STS vs nothing, but as time went on, we found that the mother’s body is actually superior to our fancy isolettes.

  14. Captain Obvious
    June 12, 2014 at 6:24 pm #

    Also, oximetry for SpO2 measurements are commonplace when resuscitation is needed. Rather than relying on color or chest rise, the SpO2 is more accurate at evaluating the neonate. How many Homebirth midwives have this set up at home?
    Once CC and PPV is initiated, 2 people are required for the baby and a third should be with the mother.
    I still laugh at Rixa Freeze’s immortal Internet birth of Inga and her NRP trained skills. By two minutes the baby could have umbilical lines and have received epinephrine. Yet Rixa was still in the birth tub holding a limp blue baby with the neck hyperextended as she blew breath at her baby’s face willing her to come earthside a 2 minutes.

    • Guest
      June 12, 2014 at 6:35 pm #

      But don’t forget, Captain, she also thought “I have NOT done all this work for nothing–come on, baby!” Surely that must have helped.

    • NatashaO
      June 12, 2014 at 6:54 pm #

      Some may have portable sp02 monitors, but whether or not they use them is another issue (equipment at the bed/poolside is not affirming do doubt. Also, what is their oxygen setup? Probably just a tank, with not a very good way to control the L/FI02.

      I don’t remember seeing the NPR step- ‘blow on babies face’! Maybe with mouth to mouth they are transmitting some life essence (in addition to god knows what else)!

      • staceyjw
        June 13, 2014 at 4:43 am #

        I have read several stories where they didn’t have a mask, they didnt know how to use it, ‘or worst- the tank was empty. One MW recently said she only has it to calm moms, she leaves it in the trunk of the car!!!

  15. NatashaO
    June 12, 2014 at 5:23 pm #

    But who needs NRP?! This is never needed at home because the outcomes are ALWAYS so good. Besides, home birth midwives are trained in gentle resuscitation by their ‘colleges’:

    • Young CC Prof
      June 12, 2014 at 6:15 pm #

      Gentle, eh? So no chili powder (ouch)?

      • NatashaO
        June 12, 2014 at 6:54 pm #

        Chili powder… never heard that one. What the hell?

        • PrimaryCareDoc
          June 12, 2014 at 6:55 pm #

          That’s how Vickie Sorensen resuscitates newborns.

          • Mishimoo
            June 12, 2014 at 7:15 pm #

            The baby on the vent mentioned by one of the commenters here is still sticking in my head. I hope the poor darling is okay.

          • sapphiremind
            June 12, 2014 at 8:15 pm #

            My soul just died a little.

          • pinkyrn
            June 12, 2014 at 10:24 pm #

            WTF? How? Enema?

          • Stacy48918
            June 12, 2014 at 10:28 pm #

            Rubs it on the baby’s chest. In the post about Vicki someone linked to a blog post about another set of twins she delivered after the preemie she killed. Twin B flipped to footling breech and came out blue and floppy. Vicki used cayenne pepper solution on the baby’s chest to “resuscitate” it.

          • araikwao
            June 13, 2014 at 2:58 am #

            More likely the rubbing on the baby’s chest that helped rather than the substance used, hmm?

        • Mishimoo
          June 12, 2014 at 7:04 pm #

          Cayenne Pepper solution, some homebirth midwives use/promote/sell it as a resuscitative aid. It’s just cayenne pepper, glycerine and water; not even a homoeopathic solution. I can’t fathom the depths of idiocy required to think that is a good thing to have anywhere near a baby.

          • auntbea
            June 12, 2014 at 9:48 pm #

            I would be so pissed if I was struggling to breathe and someone pepper sprayed me.

    • PrimaryCareDoc
      June 12, 2014 at 6:52 pm #

      Wait. It looks like they just made up their own newborn resuscitation program and the state of Oregon is accepting it for the neonatal resuscitation requirement. That’s…unbelievable.

    • OldTimeRN
      June 12, 2014 at 7:01 pm #

      OMG, delayed cord clamping does NOTHING for lung perfusion. Nor does it help prevent anemia.

      I notice how they like to point out “most babies respond” and sure most do. But what about the ones who don’t? That’s what NRP is.

      I can’t believe pregnant woman are allowing this people to care for their baby. They would have no clue what to do after the initial steps failed to resuciate the baby.

      • DiomedesV
        June 12, 2014 at 7:03 pm #

        Everything they offer is for “most” babies. Homebirth midwifery seems to have little interest in providing for the children that don’t fall into that category.

        • OldTimeRN
          June 12, 2014 at 7:05 pm #

          Those babies aren’t meant to live I guess.

          /end sad sarcasm

        • Sue
          June 13, 2014 at 1:39 am #

          If ”most” babies can do fine on their own, and these people can’t do anything for the sick ones, why pay for them to be there at all?

          Better to freebirth, and save the money for any health care needed if you have to call an ambulance. At least nobody will try to convince you not to transfer.

      • araikwao
        June 13, 2014 at 2:56 am #

        I’m not an aspiring HB advocate, but in the interests of accuracy, delayed cord clamping does lead to lower rates of anaemia at 6 months of age, accompanied by a small increase in rates of jaundice requiring phototherapy. (Cochrane review from last year).

        • staceyjw
          June 13, 2014 at 4:50 am #

          If your kid is sensitized and already in need of phototherapy (and transfusions, and some med like Ivig?), I cannot see this improving it.

          I didn’t know with my first this was possible. Many NICU weeks proved me wrong on that.

          • sapphiremind
            June 13, 2014 at 6:30 am #

            It really shouldn’t affect too much kids who have hemolytic anemia (blood incompatibility) They’re going to need a lot of interventions for their jaundice most likely anyway.

        • sapphiremind
          June 13, 2014 at 6:31 am #

          Thank you, I alluded to that in my post but didn’t mention the specifics 😀

        • Young CC Prof
          June 13, 2014 at 9:59 am #

          I wonder how that works for term growth restricted infants, since they are already at risk of polycythemia?

          • araikwao
            June 13, 2014 at 5:58 pm #

            Hmm. I imagine this was just in healthy term infants, but would have to check

    • sapphiremind
      June 12, 2014 at 8:14 pm #

      *twitch. twitch*

      “Recognition that the fetal stress response continues through the fetal transition period” Yes. So does NRP.

      “Delayed cord clamping to optimize lung perfusion and avoid anemia”
      No. It does not help lung perfusion. It MAY help maintain some oxygenation when there is no gas exchange in the lungs because the placenta, if attached to mom, is still providing oxygen. There is some benefit of delayed cord clamping, and it is becoming the standard of care for neonates, but that is pending them not needing resuscitation.

      “Alternating six-second assessments with 30 seconds of
      care/action – NRP omits the six-second assessment between the inflation
      and the first set of ventilation breaths. Because field-based care is
      provided to newborns who have not been exposed to medications and who
      are generally low risk, most respond positively to stimulation alone
      while most of the remainder respond to inflation breaths. A six-second
      assessment at that point usually results in discontinuing resuscitation,
      as the baby has responded well.”
      Bullshit bullshit bullshit. In NRP you are CONSTANTLY assessing the baby. Once the baby responds, you start backing off. Once the HR is >60, compressions stop. Once they start trying to breathe, you stop PPV and give CPAP to allow them to breathe on their own. They clearly have no clue how NRP works.

      “Use of room air for the first 90-seconds/two ventilation cycles of resuscitation.”
      This is good – we start with room air too. Though we don’t necessarily wait 1.5 minutes before using O2. Depends on the situation.

      “Recognition of the importance of a calm resuscitation environment to minimize neonatal catecholamines.”
      Evidence please. And while occasionally we get loud as we communicate, most resuscitations are fairly quiet.

      “Requires little or no specialized equipment to perform.” Which means you can to Jack and Shit when the baby is truly in trouble.

      In a true code situation, no – it is not gentle. We are trying to force the baby to live when they are trying to die. Sometimes they try really hard. We try harder.

      Gentle resuscitation my ass.

      • OldTimeRN
        June 12, 2014 at 8:25 pm #

        How many times are you been in a code when compressions stop because the heart rate is >60 only to have to start again when they fall <60? Or you have a pink screaming baby who required no assistance suddenly start turning blue before your eyes? Yeah it's happens. It's not like NRP ends because you think the baby is stable. The baby might have other plans.

        • sapphiremind
          June 12, 2014 at 8:28 pm #

          exactly. But hit 60? we stop. you fall again? restart again. CONSTANT assessment. The thirty second intervals are for assessing whether your interventions are *enough*

        • pinkyrn
          June 12, 2014 at 10:46 pm #

          Babies are not to be trusted in this respect.

          • The Bofa, Being of the Sofa
            June 12, 2014 at 11:02 pm #

            Kids. Can’t trust them from day 1…

      • Sue
        June 12, 2014 at 10:40 pm #

        Sapphiremind is clearly brainwashed by her training, and drenched in scientism. Sparkles will never survive in that attitude!

        (Written in irony font)

      • pinkyrn
        June 12, 2014 at 10:46 pm #

        Isn’t epinephrine a catecholamine? Isn’t that the first drug you would think of in a neonatal code? Why would she want to keep catecholamine levels low?

        • sapphiremind
          June 12, 2014 at 10:58 pm #

          Meh, it is, too many can be bad, especially in a hypoxic brain. But, you are correct, catecholamines are actually associated with better lung function (they are higher in vaginal birth vs c/s) Hence needing evidence for why it was bad *LOL*

      • Sue
        June 13, 2014 at 1:37 am #

        A “calm” resuscitation environment ??

        It’s the providers who need to be calm, not the baby! We want that baby screaming not silent!

        • C-section, I'll have another
          June 13, 2014 at 9:07 am #

          Right. I was willing my baby to scream for a minute and a half.

      • Siri
        June 14, 2014 at 4:01 pm #

        Babies are rubbish at taking subtle hints. Come to think of it, so are most people in need of resuscitation. Is this a form of natural selection?

    • areawomanpdx
      June 12, 2014 at 11:30 pm #

      Dr. Amy, would you please find someone to debunk that birthingway “NRP” and publish it? Birthingway has “trained” most of the hideous midwives in Oregon…

      • Sarah
        June 13, 2014 at 9:40 am #

        I would echo this request. If I didn’t know better from reading this site, I would have been completely taken in by their description of NRP. They are very slick at marketing!

    • Bombshellrisa
      June 12, 2014 at 11:52 pm #

      What is an “overseas resuscitation model”? I follow PRONTO international, a non profit that strives to improve outcomes by training through simulation. They cover neonatal resuscitation and there is no “home brew” approach, it’s tried and true only. I should mention that they are focused on outcomes in low resource areas overseas and also have a special focus in Mexico. The group is headed by the amazing Dilys Walker, a practicing OB and professor at the University of Washington

  16. EM
    June 12, 2014 at 5:01 pm #

    OT: My dear friend and his wife are expecting their first child. The bad news: They’ve decided to give birth at a birthing centre in NYC (I heard that the one of their instructors is 81yo o_0) and baby is now 10 days overdue. I’m so scared that this is all going to go horribly wrong :'( and that the people who should be concerned are not.

    • Therese
      June 12, 2014 at 5:51 pm #

      An instructor or midwife? If it’s just an instructor, as in childbirth instructor, not sure why it matters how old she is. But maybe you meant midwife as that would be a lot more relevant to the point you’re making? Any case, hope your friend and her baby are okay!

      • EM
        June 12, 2014 at 9:06 pm #

        I’m led to believe she does both. My apologies for not clarifying.

    • attitude devant
      June 12, 2014 at 8:32 pm #

      Have the look at the Justice for Vylette page on FB. That’ll scare them

  17. Anna T
    June 12, 2014 at 3:58 pm #

    To tell you the truth, every time I try to read home birth vs. hospital birth studies, statistics of outcome for mother and baby, etc, my eyes kind of get glazed over. I’m not very strong at numbers.

    However, it’s really a no-brainer: in the hospital, you have a team of doctors and nurses, the NICU at hand, and all the medical equipment you might possibly need. Perhaps you *won’t* need it; I had two completely natural births in a hospital which were handled entirely by a midwife. However, there was no way I could have known it in advance.

    At home, you are attended by a midwife who might be very skilled, but is not a doctor. And she is only one person. She only carries rudimentary equipment with her, compared to what the hospital has. So what figures? If all goes fine, great; but if there’s a complication, you’re in trouble. Your best chance is a transfer, and it might be not anywhere near fast enough.

    You don’t need complicated statistics to work it out. You are safer where you have more, and better, professionals and better equipment. You are safer where help can be given to you AT ONCE.

    • wookie130
      June 12, 2014 at 5:29 pm #

      Oh, but all of the eeeeevil interventions!

      • Anna T
        June 13, 2014 at 7:51 am #

        It is entirely possible to have a hospital birth without interventions **if none are needed**. I did. Sure, you might have to be assertive about your birth plan, or have someone else with you who is assertive, but it’s feasible. Certainly the safety factor outweighs the discomfort and “foreign environment” one.

    • Box of Salt
      June 13, 2014 at 2:43 am #

      Anna T:
      Removing yourself from access to emergency care assumes you aren’t going to have one.
      There’s that comment about assumptions and you and me. . . .

  18. sleuther
    June 12, 2014 at 3:44 pm #

    Well this is fact-based. I’d actually like to see how the lay midwife crowd respond to this. Anyone? #crickets #tumbleweeds

    • Guesteleh
      June 12, 2014 at 5:25 pm #


    • staceyjw
      June 13, 2014 at 4:53 am #

      I say this all the time. They NEVER show up for factual posts.

      • The Computer Ate My Nym
        June 13, 2014 at 5:09 am #

        And even if they do, they do it months or years after the post is written and posted. Less chance of being challenged that way, I suppose.

  19. Elaine
    June 12, 2014 at 3:00 pm #

    OT: The CNM practice that delivered my children has, in the aftermath of the recent ACOG/AAP statement, suspended doing waterbirths. The crunchies on my Facebook are all bummed out about it. I’ve confined myself to “liking” the posts because I don’t feel like getting in another pointless Internet squabble today, but inside I’m doing the happy dance. Of course, this will probably drive more of them towards HB, so blah. I have one semi-crunchy local friend who is pregnant at the moment and I give thanks that she has talked pretty regularly about how much she likes her OB and hasn’t said anything negative about her first child’s birth in the hospital; if she’s got secret plans for a homebirth, she’s doing a really great job of keeping them under her hat.

    • moto_librarian
      June 12, 2014 at 4:10 pm #

      My CNM practice offered laboring in water, but no water births. They are probably really glad that they never did it, since they follow ACOG guildelines.

      • Elaine
        June 12, 2014 at 9:50 pm #

        Sadly, these ladies are all too eager to put together an experimental protocol so they can keep doing them. I like them otherwise but idk what’s up with that crap.

        • Sue
          June 13, 2014 at 1:43 am #

          What experimental protocol could they possibly come up with that would be powered enough to add anything significant to existing knowledge?

          (Rhetorical question font)

          • Elaine
            June 13, 2014 at 7:01 am #

            I don’t know, but they run a fairly brisk practice. There are only two CNM practices serving our metro area of a million or more, so there is a lot of demand for the service.

          • Sue
            June 14, 2014 at 1:00 am #

            Sure, Elaine, but meaningful research might require hundreds of cases – not likely even in a “brisk” practice.

        • Box of Salt
          June 13, 2014 at 2:38 am #

          Are these ladies going to write up a grant proposal, apply for funding, and get IRB approval?

          If not, they are NOT “put[ting] together an experimental protocol.”

          Anybody can pretend they know how to run an experiment ethically with human subjects.

          • Elaine
            June 13, 2014 at 6:59 am #

            Yes. Yes, they are. This is a practice of CNMs affiliated with a large teaching hospital, not some fly-by-night LM group operating out of some skeezy birth center somewhere. I suppose it’s better to have them doing waterbirth than the patients ending up doing it with some random HB midwife (afaik no CNMs do homebirths in my state). They say their stats are good so far. Maybe this study will add materially to the available evidence. There are certainly patients who are interested in taking part.

    • Sue
      June 12, 2014 at 10:42 pm #

      New evidence suggests change in practice, CNM group adjusts practice. That’s how professionals work. It shouldn’t have to be exceptional.

      • Elaine
        June 12, 2014 at 10:58 pm #

        What do you mean?

        • The Bofa, Being of the Sofa
          June 12, 2014 at 11:04 pm #

          She means, why is this even notable? It shouldn’t be, you would think this would SOP for anyone. However, with midwives, it is so unusual that their behavior stands out.

          • Elaine
            June 12, 2014 at 11:11 pm #

            That actually wasn’t what I was driving at with this post. I don’t think it’s notable that CNMs changed their practice standards in line with newer evidence (though I am irked that they are so eager to continue to do waterbirths). I was more bothered by the mass reaction of “Oh, what a bummer! That’s why I chose this practice!” from a bunch of people on Facebook, and I’m glad that there will be fewer waterbirths in my area for the time being–and hopefully better protocols if they do start doing them on an “experimental” basis.

          • Sue
            June 13, 2014 at 1:42 am #

            Bofa is right – I was making a slightly different point: contrasting what professionals do (change practice in line with evidence) vs what ideologues do.

            I was just chiming in with a related thought.

      • staceyjw
        June 13, 2014 at 4:55 am #

        The bar for MWs is set SO LOW that just doing normal stuff is seen as wonderful.
        (CNMs aren’t generally included in this other than the crunchy HB ones.)

  20. lawyer jane
    June 12, 2014 at 2:39 pm #

    Amazing. In a teaching hospital, how many of these emergency procedures would the average practitioner have seen and done?

    • Gene
      June 12, 2014 at 6:10 pm #

      Lots. I did them all the time as a peds resident.

    • sapphiremind
      June 12, 2014 at 7:59 pm #

      I’m actually the person who wrote this post 😀 When I was doing deliveries, we would only go to “high risk” ones: meconium, fetal distress, congenital abnormalities, preterm. We would go to about 5/day on average, though some days it was much much higher. We also would get called to respond to the well-baby unit if any of the babies started looking concerning up there too.

      Now, not all those deliveries required intubation/lines/epi. But in two years, I’d been to at least 15 that had gotten to that point (and that is just on days I happen to be working.) And then of course codes in the regular NICU, heck, even just caring for some of the critically ill babies is like doing a prolonged code.

      There are even code/birth situations where the most seasoned attending is terrified due to the severity or unusual nature of the problem the child has. But that’s where the constant repetition and knowledge of how to handle a baby going south comes in. You have the “vanilla” part of the code down pat, which allows your brain to work on troubleshooting and solving whatever is making this code/resuscitation unusual. It needs to be automatic. I don’t automatically freak out about a baby who is blue coming to the warmer bed. I’m assessing what their other signals are about whether they’re going to start breathing, or whether their heart is beating.

      Nothing is quite as terrifying as having successfully intubated a child, but not getting color change on the CO2 detector (confirms you are in the right place) because the lungs are not getting enough blood to exchange the air. You have to give compressions for a few seconds before the lungs can even work at that basic level.

      I loved going to deliveries. I loved that NRP properly done can turn a potential tragedy into a healthy thriving baby. I love when I hear a crying and vigorous meconium baby that I don’t have to intubate and suction. I love the terrible situations we find ourselves in, because I love having a plan, knowing what to do and making a difference to these babies/families. NRP is the backbone of my profession.

      • Atmtx
        June 12, 2014 at 10:38 pm #

        You’re amazing. People like you saved my life when I was born. I came out blue, not breathing, etc. I was quickly rushed to the NICU and put on machines to help me breathe. I was in the NICU for a few weeks. Today I’m healthy, educated and have a family of my own. My kids both came out healthy and screaming, but I wanted them near people like you, just in case they came out like me. Thank you so much.

        • sapphiremind
          June 12, 2014 at 11:01 pm #

          Yay for babies not dying!

    • Sue
      June 12, 2014 at 10:44 pm #

      That’s why I favor midwifery as a post-nursing specialty – recognition of a mother or baby needing resuscitation is not ”midwifery”, it is a core clinical skill.

  21. C-section, I'll have another
    June 12, 2014 at 1:01 pm #

    I would also argue, that unless you have done a resuscitation, or even adult CPR, you do not know how you will react when you have to do one.

    For many years, I was trained in CPR. A young coworker and a friend in his 30’s was found slumped over at his desk, not breathing, one day when I came back from lunch with other coworkers. There were five of us. Two of us were able to handle the scene although all of us had been trained in CPR every year. The other three were in such shock they couldn’t even move to call 911. We yelled down the hallway, which brought others to respond and call the paramedics while we tried to help.
    Perhaps expecting parents should start the interview with the question–“How many neonates have you resuscitated? What methods did you use? What was the outcome? ”

    I was criticized/pitied by quite a few acquaintances when they discovered I had to have a c-section after the low risk healthy pregnancy I had.Some went so far as to tell me what I should have done to avoid it (Why, oh why,, when you are holding an adorable sleeping child do people think you want to talk about whether you popped it out of your vagina or got it taken out of your belly?!) Most don’t know that she had to be resuscitated, because, though traumatic for everyone who witnessed those moments, it was done by a professional who trained for years to excel at that critical moment. And, they did such a perfect job just mom and dad (and now you!) know.

    Shame on these NCB’ers. I’m a feminist. There is nothing feminist about putting children and families in danger because you want to be special.

    • areawomanpdx
      June 12, 2014 at 1:41 pm #

      This is why people who work in hospitals have drills, over and over, so that their body will know how to go through the motions in an actual emergency. There are dystocia drills, code drills, rapid response drills…so not only do they occasionally experience the real thing, they have rehearsed so many times it starts to become automatic. Taking one class every 2 years just doesn’t have the same effect.

    • OldTimeRN
      June 12, 2014 at 7:13 pm #

      I work on neonates for a living. In addition to NRP I’m also Adult and Child CPR trained. Chances are you do not want me standing next to you when you keel over. Not because I wouldn’t do everything I could to help, but I can’t guarantee I could do it well. Babies in the DR, I KNOW I can do it well.

      • sapphiremind
        June 12, 2014 at 7:59 pm #

        I am the same way. I joke about it to my friends that the most help I am in an adult code is that I know to cal 911 😉

    • guest
      June 12, 2014 at 8:30 pm #

      Just to clarify, I absolutely do not think CPR/resuscitation of a neonate are the same thing. However, I do think more people claim training in CPR and without experience, cannot be guaranteed to act. A midwife with nrp would likely be even worse, since it seems so little of their mind is devoted to hoping for the best and planning for the worst. That they probably don’t even run the possibility through their minds once they leave.

      I would be dead and my baby would have been dead without the 14 people in delivery. Its not a job I ever want nor could I perform. Thank you.

  22. areawomanpdx
    June 12, 2014 at 12:49 pm #

    Even hospital CNMs, who could prescribe those medications, and are also required to have NRP training, do not consider themselves to be appropriate providers to resuscitate a neonate. They hit the code button on the wall, and the peds team comes in and does the resuscitation.

    • June 12, 2014 at 2:06 pm #

      In the early years of my career, even though I worked in hospital, where there was a “Code Pink” team literally next door to the L&D unit [newborn nursery wasn’t even 15 meters away], I had dreams that if some emergency happened, I would just freeze, while all around me people would be handling the emergency and saying to me “But you’re supposed to know what to do…!”

      Fortunately, that never happened in real life.

  23. The Bofa, Being of the Sofa
    June 12, 2014 at 12:04 pm #

    You forgot the part about not doing it on a soft bed.

    • Siri
      June 12, 2014 at 12:51 pm #

      Worked for me five times….;-)

      • The Bofa, Being of the Sofa
        June 12, 2014 at 10:35 pm #

        In that respect, it has worked for me like, every time (guy beneifts ;))

        • Siri
          June 14, 2014 at 4:20 pm #

          What, someone conceived EVERY time? Or are you saying you only ever did it twice? ;-b

  24. MaineJen
    June 12, 2014 at 11:51 am #

    “This lack of ability to provide true neonatal resuscitation accounts for some of the morbidity and mortality that is seen with home births.”

    Probably the most important–and damning–statement on this blog, and one which homebirth advocates CANNOT dispute.

    And they can’t say that these kinds of problems with newborns are ‘very rare;’ I personally know 2 people whose babies needed resus after birth, and I’m not even in the business. It happens, and they can’t deal with it.

    • The Bofa, Being of the Sofa
      June 12, 2014 at 12:06 pm #

      Yeah, but how often is it unnecessitation?

      (I’m almost hesitant to say that because the NCB are going to co-opt it as legitimate)

      • Siri
        June 12, 2014 at 12:54 pm #

        I hear those ebil OBs keep playing the dead baby card even on healthy babies, leading to unnecessinterments.

    • atmtx
      June 12, 2014 at 12:13 pm #

      I needed it, so that’s my n=1 right there. As I said below, there was no convincing me to give birth away from a hospital. Even if it’s rare, it was me.

      Add to that, I was acquainted with Liz Paparella in high school (different schools but mutual friends). I never got in touch with her after finding out her story, and I do regret not reaching out. She was a sweet, gentle person who was very generous and caring. Definitely didn’t deserve that (no one does), but especially did not deserve the treatment she received from her community. That said, it’s yet another strike for me with OOH birth. Screw that!

      • moto_librarian
        June 12, 2014 at 12:15 pm #

        Yup, it happens even when you follow the playbook. People bitch about c-sections causing TTN all the time, but my naturally-birthed son had it (probably because he was born on the early side of term after SROM at 38 + 3).

        • sapphiremind
          June 12, 2014 at 8:01 pm #

          We try REALLY hard to not take TTNers away from mamas. If they’re comfy and tachypneic, then let them be and transition.

          • moto_librarian
            June 13, 2014 at 9:17 am #

            He initially went to the newborn nursery (I was in surgery to repair a cervical laceration that had caused a pph). My husband went to get him when I came out of the OR, and they had taken him to the NICU because he wasn’t doing great. At that point, I was so exhausted and doped up from the drugs that I just wanted to sleep. I got to see him the next morning, and the NICU nurses went out of there way to help me try to nurse and hold him.

    • the wingless one
      June 12, 2014 at 7:34 pm #

      My son went from breathing on his own in an open air crib immediately after birth through day four of life (he was in the NICU because he was a preemie and some of his labs were a little concerning, a sign of things to come) to suddenly the neo coming to my room telling me they weren’t quite sure what had happened but he had clearly taken a turn for the worse and the next time I saw him he was in an incubator, on CPAP and basically comatose. Now I know the sequence of events that led up to him getting an umbilical line. And thanks to the experts around him at the moment he needed them the most he was discharged three weeks later and is now a happy, healthy (albeit small) 17mo toddler who is hitting all his milestones and then some!

      This happened after four days of him SEEMING to be totally fine and nothing more than a late term preemie. Honestly I’d be terrified to bring a hypothetical #2 home after only a day or two even if we were at term. I guess that wouldn’t happen since I’d have another c/s so we’d be able to stay at least four days, but I’m not even sure I’d feel comfortable with that given our history…

      This is why I will never understand people who don’t want to give birth in a hospital. Thank God for the medical professionals who performed labs on my son, knew that they needed to keep a close eye on him despite him *acting* normal.

  25. Pilo
    June 12, 2014 at 11:49 am #

    I remember the first time that I was the primary nurse in a situation where resuscitation was needed at delivery. I hit the “NRP Code” button on the wall, and within 30 seconds, I had two pediatricians, an anesthesiologist, 8 highly-trained nurses, a scribe, a pharmacist, and two respiratory therapists in the room. That’s not an exaggeration. And it wasn’t at a giant hospital either–just a community hospital with about 120 total births per month.
    I’ve participated in many, many resuscitations since that time. My definition of a horrific nightmare would include being in an environment where NRP is needed and not having the equipment and additional personnel who are needed.
    You CANNOT perform NRP at home. You CANNOT perform NRP by yourself.

    • Therese
      June 12, 2014 at 11:58 am #

      120 births a month seems like a lot to me! My local hospital does 300 a year. What percentage of full term babies need to be resuscitated (since my hospital would transfer any moms in preterm labor)? I just wonder if 300 births a year is enough to keep up NRP skills? I suppose they would do drills to make up for it though?

      • Young CC Prof
        June 12, 2014 at 12:37 pm #

        According to CDC records, about 1% of full-term babies have a five-minute Apgar less than 7, but five minutes is a LONG time. I would imagine quite a few resuscitated babies “pass.”

        • sapphiremind
          June 12, 2014 at 8:04 pm #

          Yes – because if we are breathing for them, they are still breathing. and even if they need 90% oxygen, they’re still pink. A low 1 minute apgar isn’t a guarantee of a NICU stay or major problems – it is just a baby that has the *potential* to have major problems if interventions are not done rapidly.

      • Therese
        June 12, 2014 at 12:40 pm #

        Ok, so it looks like 10% of infants need resuscitation though that is for all births, not just full term. But even 10% of babies would mean my local hospital just would do a couple a month, which means any one nurse would probably not do more than one a month, if even that. I guess it doesn’t really matter because it’s not like I have any other alternatives to this hospital, but still reassurance would be nice.

        • Young CC Prof
          June 12, 2014 at 12:59 pm #

          Once a month is light-years better than a home birth midwife who’s never done it before for real.

          • Busbus
            June 12, 2014 at 1:27 pm #

            Once a month PLUS a team of medical professionals and equipment.

          • Therese
            June 12, 2014 at 5:43 pm #

            Yeah, but when people say things like “It also requires a lot of experience and muscle memory. It’s not something you can do correctly after just memorizing the steps or practicing on a mannequin” it doesn’t make you feel very confident that drills + once a month or less is going to be enough. Oh well, at least a real hospital is only a short 20 minute life flight away, so hopefully they can keep the baby alive until they transfer.

          • Montserrat Blanco
            June 12, 2014 at 6:13 pm #

            From my experience with adults: you do not forget how to do chest compressions. Once you learn that stays for life. You might forget medication doses if a long time goes by ( that is what drills are for, so you know the doses by heart in an almost real situation). Lines are easier if you get a lot of experience with them but this is something that might be needed for other patients. So yes, at the hospital the normal situation is that everybody is pretty well trained.

          • NatashaO
            June 12, 2014 at 6:59 pm #

            I don’t think the home birth midwives a)memorize the steps or b) have practiced in a sim lab, or c) have developed the muscle memory to begin with!

            The problem I have seen is that even though the hospital is close by… by the time they realize that there is a REALLY big problem, make the call to EMS, EMS gets there and stabilizes the baby, and then loads them up and drives to the nearest hospital, an hour can already be gone.

          • sapphiremind
            June 12, 2014 at 9:19 pm #

            Honestly, the bigger the hospital/more deliveries they do, the better the outcomes, it’s been shown in many studies. I would never birth in a community hospital personally, because I want the most experienced, most up to date people working on my baby. There are some community hospitals that I’ve received babies from that aren’t a *whole* lot better than homebirth.

        • FormerPhysicist
          June 12, 2014 at 1:32 pm #

          Don’t they drill fairly regularly? I vaguely recall someone alluding to that way back on another post.

          • NatashaO
            June 12, 2014 at 5:32 pm #

            YES we do!

        • pinkyrn
          June 12, 2014 at 10:29 pm #

          Some times small community hospitals do more mock codes so their staff can stay up to date. Also some of the nurses may have worked in a higher census hospital for years which helps .

      • NatashaO
        June 12, 2014 at 5:32 pm #

        Community hospital RN here. We don’t have a ‘NRP code team’, just NRP trained nurses. And yes, we practice a lot! We don’t just do a ‘self study’ either, we have a skills/sim lab with NNPs who we practice code after code after code with. Thankfully, most resuscitations do not require more than ventilation, and occasionally 02. CPAP is used a lot, but that can’t be done in a home setting. However, we do have the skills to do chest compressions, baby IVs/antibiotics, insert UV lines, administer blood/fluids/D10 etc etc. Of course the bigger hospitals have more resources, but what we have at the community hospital is FAR more than can be offered at home.

        • pinkyrn
          June 13, 2014 at 1:04 pm #

          And community hospital RN’s who are responsible for resuscitation are very motivated to keep up their skills. Fear is a powerful motivator.

    • NatashaO
      June 12, 2014 at 5:25 pm #

      Even with one other person, which is typically the home birth scenario… the more trained people the better, with a competent leader.

    • Fuzzy
      June 13, 2014 at 3:19 pm #

      I’m a trauma/PCU RN. I deal with seriously ill patients all the damn time. However, when my friend had a gi bleed and damn near bled out in her home, vagaled out on the floor in front of me, I had nothing i needed to even start fixing the situation. 10 min for an ambulance called for a nonresponsive, tachypneic, tachycardic adult with active bleeding. Any baby would be dead.

      • Karen in SC
        June 13, 2014 at 3:41 pm #

        Fuzzy, how horrible! Did your friend recover?

        • Fuzzy
          June 13, 2014 at 8:40 pm #

          Yes. I now have solid white hair tho…

          But my point is that training does damn all without equipment and personnel.

  26. atmtx
    June 12, 2014 at 11:43 am #

    Thank you for everything you do! When I was born, I couldn’t breathe. Luckily we were in a hospital with a fantastic NICU and after a few days of having a machine breathe for me, I was fine. In fact, today I have absolutely perfect, healthy lungs (they were recently tested and were awesome), and an intact brain.

    When it came time to have my own kids, various crunchies I know were pushing OOH birth. I just told them that my story and said the most relaxing place for me is one with a great NICU right down the hall. That shuts ’em up right quick!

    I also took no chances while in labor and wanted every machine that beeps trained on me and my baby. There were no concerning moments at all, and it was such a great feeling to have constant evaluation and feedback. Give me all the beeps!

  27. fiftyfifty1
    June 12, 2014 at 11:36 am #

    Exactly. Neonatal resuscitation is NOT the same as infant CPR. It is a set of very specialized skills and is a TEAM effort. It also requires a lot of experience and muscle memory. It’s not something you can do correctly after just memorizing the steps or practicing on a mannequin. You need to have learned “the touch”.

    • Amy M
      June 12, 2014 at 12:14 pm #

      Can the lay midwives even perform infant CPR correctly? I’d have my doubts.

      • PrimaryCareDoc
        June 12, 2014 at 12:15 pm #

        I doubt it, given that we story after story where CPR is performed on the mother’s belly or on a mattress.

        • Sue
          June 12, 2014 at 10:46 pm #

          On the mother’s belly? Of course – because skin-to-skin is a higher priority than having a cardiac output. Sigh.

      • areawomanpdx
        June 12, 2014 at 12:51 pm #

        No. In the recorded 911 call during Shahzad’s death, you can hear the lay midwives in the background, arguing about how to properly do it.

        • Hannah
          June 12, 2014 at 12:55 pm #

          That is just…heartbreaking.

      • Elaine
        June 12, 2014 at 2:55 pm #

        I have to take CPR for work every 2 years and it covers how to do CPR on infants. We probably spent all of 10 minutes on that. And since I have kids of my own, I was more thorough in making sure I felt confident in my own skills on the mannequin than, probably, most people in the class were. I wouldn’t imagine the average CPR-certified person would be the uber-skilled at this, and I doubt that these midwives have drilled it very thoroughly.

    • araikwao
      June 12, 2014 at 6:01 pm #

      Ohhh yes. I am a med student, not depressingly far from graduation. I have been trained in neonatal CPR. There’s no way in the world I would be safe to do it/lead it myself. I’ve observed a few, and assisted in one, but as the third person (i.e. not doing a whole lot!) under direction from an experienced paeds registrar.

      Do HB midwives even have the monitoring equipment to do it safely? And how cold & stressed is the poor baby getting whilst being assessed and worked on (i.e. in the absence of a warmer as found in the hospital)?

  28. Anj Fabian
    June 12, 2014 at 11:34 am #

    So many terrifying or tragic birth stories include midwives or birth attendants who fail to provide even the most rudimentary resuscitation properly.

    The assessments are inaccurate leading to delays in the resus attempts – and the resus attempts are often either outdated or done incorrectly.

    I think the closest thing I’ve read to a proper resus attempt at a home birth was in Ghostbelly, although she didn’t use any equipment she did move immediately to chest compressions and had the husband call for an ambulance.

    In Freddy’s Story, the two midwives (NHS midwives, not ‘independent midwives’) BOTH left their equipment in their cars when they arrived – and didn’t have it when the baby was born.

  29. moto_librarian
    June 12, 2014 at 11:16 am #

    Thank you for this. Both of my sons experienced some respiratory issues at birth. Our eldest had TTN and was in the NICU for two days. Our youngest passed mec prior to delivery, and the NICU team was on standby for delivery. There was some urgency in getting him delivered, and he basically unrolled out of his cord. He was a bit stunned, and he had deep suction and O2 via CPAP. Those were a scary couple of minutes for us, but we were grateful to know that he was in good hands. He was stable and in my arms within 20 minutes. Thank you for all that you do to keep our children safe!

    • Karen in SC
      June 12, 2014 at 11:39 am #

      One of my sons had mec, too, and an entire team was there. First Apgar was low. I didn’t see all that went on in the isolette. I had retained parts of placenta as well, so you can imagine a homebirth with baby struggling to breathe and my with PPH. Lucky for me, I was in a hospital!

      • Anon88
        June 12, 2014 at 5:30 pm #

        My son also passed mec and we had the whole NICU team there and waiting just in case. They all introduced themselves and explained what was going on. Very reassuring. And thankfully, my son didn’t need any of it. But I’m glad they were there!

    • Amy M
      June 12, 2014 at 12:20 pm #

      Neither of my boys needed any resuscitation, but there was an entire team of people standing there in the room, just in case, because they were (slightly) premature, and therefore at greater risk for some breathing issues. There were nurses for each boy, as well as one for me, so no one would’ve been left to bleed to death or suffocate. Once I was actually in the hospital, giving birth, I didn’t really fear for the boys’ safety because I knew that at the slightest hint of trouble, a ton of people would leap into action and the Level 3 NICU was right upstairs. No amount of money would have convinced me to have them outside of a hospital.

  30. June 12, 2014 at 11:15 am #

    Thank you so much!

  31. Zornorph
    June 12, 2014 at 11:11 am #

    Thank you for this post. To me, it’s like having a crash and rescue setup at the airport. In nearly every landing you aren’t going to need that, but if you are in the plane that crashes, you are going to be happy you are at an airport and not at some isolated landing strip in the middle of nowhere. Even if that does mean you have to put up with rude airport security and expensive, bad food.

    • Karen in SC
      June 12, 2014 at 11:42 am #

      Did you miss the 50 yr old surrogate mother who derails the post “How natural childbirth advocates exploit women of color” a few days ago. If you have time, it’s a compelling read. )Though some think it is all imaginary.)

      • Zornorph
        June 12, 2014 at 11:47 am #

        I did miss that one (LO has been sick and I’ve not had as much free time) but I’ll go check it out.

  32. Karen in SC
    June 12, 2014 at 11:07 am #

    Excellent guest post!

    • sapphiremind
      June 12, 2014 at 8:06 pm #

      Thank you 🙂

      • the wingless one
        June 12, 2014 at 8:12 pm #

        Thank you for all you do! It was a huge source of comfort to me knowing my son had amazing NICU nurses watching over him those weeks before he could come home. Our family will always have a special place in our hearts for all NICU staff everywhere 🙂

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