People often question me, (and friends and family members of our mom's frequently express similar concerns), "Isn't is safer to give birth in the hospital? What if something goes wrong?" These are valid and real concerns and I find myself, as a midwife who attends birth outside of a hospital, addressing them almost daily. The bottom line is that we are highly trained, equipped, and capable of intervening to keep both mom and baby safe, if needed. Choosing to birth at a birth center does not mean that you have to sacrifice safety for comfort, as some people assume.

I'm not bragging because I am some kind of hero (although I may be), but I'm describing part of the responsibility of a midwife, especially a midwife who attends birth outside of the hospital. People often ask (and friends and family frequently express concerns) "isn't it safer to give birth in the hospital? What if something goes wrong?"

Even when we limit our clients to healthy well nourished moms giving birth to one baby at term without being induced, there are always things that can "go wrong", even if complications are rare. If you are birthing babies, you have to be ready to deal with babies who have breathing problems at birth and moms who bleed excessively after birth (hemorrhage). Midwives have great responsibility and must be vigilant to pick up on problems and take steps to manage them.

So, what happened this morning? It's a great example of what we do.

Baby girl and mom just before EMS took her. She looks really good in the picture, but she was showing signs of respiratory distress.

Mom was in spontaneous labor at 40+ weeks with her first baby. GBS negative. Water broke when she was about 9 centimeters and was clear. She had a fairly long labor, depending on your perspective. It ended up being 21 hours total, with 3 hours of "pushing", which is not actually abnormal for a first time mom, although we usually see much shorter labors in mom who are prepared with Hypnobirthing. During the final stages of birthing the baby, we noticed that the baby's heart rate was dropping when mom was pushing. We immediately started giving the mom oxygen to increase the oxygen delivered via the placenta to the baby and the baby's heart rate recovered. Baby was close to crowning at this point and we were listening to the baby's heart rate closely, as is our usual practice, because if a baby is going to get into trouble, that is usually when it will happen. There is a reflex called the Vagal response. When a baby's head is squeezed, its heart rate drops. This is normal. But sometimes, the baby doesn't fully recover from the drop in heart rate and when it is born, it is in distress. That is what happened this morning.

Baby girl was born in "secondary apnea" http://www.americanheartclasses.com/cpr/wp-content/uploads/2011/03/NRP-STUDY-2010.pdf

She came out looking OK, but a little bit shocked. I stimulated her with a towel and she gave a good cry. She was pink and had good muscle tone. I placed her on mom's chest and kept a close eye on her. At about 45 seconds of life, I noticed her color get dusky. I immediately stimulated her again and she responded with a cry and return to pink color with good muscle tone. 15 seconds later, she did the same thing. This time, I had to take it more seriously. I picked her up from mom and placed her on the bed next to mom. (This happened to be a bed birth, but our birthing tubs have a very wide lip with plenty of room to place a baby on a dry towel for resuscitation without having to cut the cord prematurely Research confirms numerous immediate and long-term benefits to leaving the cord intact while performing neonatal resuscitation in both term and preterm neonates, while doing no harm.)

Hooking up the oxygen sensor for the ambulance ride.

Her heart rate was about 60, which indicated that we had to start the steps of neonatal resuscitation. Because I had already stimulated her twice with the cord intact, it was time to move on. The student quickly cut the cord (no time for letting daddy do it) and I moved her to the flat warm surface that we have ready at every birth. The assistant had readied the ambu bag as soon as we caught the heart rate decelerations during pushing and got the suction ready. I told the assistant to call 911 to get EMS to us and started neonatal resuscitation on the baby. I positioned her so that I could get a good seal with the ambu bag and gave 2 "breaths" with the bag. She immediately let out a loud cry and her heart rate jumped up to 120. Her color and muscle tone also improved. The assistant had the oxygen with baby mask ready and I put the mask over the baby's nose and mouth. I suctioned clear secretions from her nose and mouth (only indicated when resuscitating a baby; routine suctioning has been shown to have no value and can do harm Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial).

She was now stable. Her heart rate was normal, her color was pink, and her muscle tone was good. She was, however, still laboring to breath. She was retracting her rib cage with every breath and I could hear "junk" in her lungs (fluid that she had not yet removed).

The transition from fetus to newborn is incredibly complex. Babies have never breathed before. Parts of their hearts have never needed to pump oxygenated blood.

Baby girl nursing at 30 hours of life.

The lungs have never been in charge of oxygen and are naturally filled with fluid. Valves have to open and close and chemicals are released to move the fluid out of the lungs. But, basically, she had not taken a really deep breath to open up her lungs. That had to be done manually, by me using the ambu bag. NORMAL CARDIAC PHYSIOLOGY TRANSITION FROM FETAL TO NEONATAL

By the time EMS got there at 10 minutes of life, she was stable, with a normal heart rate and respiratory rate and her oxygen saturation was above 95%. But she was still having signs of respiratory distress (retractions) so the right thing to do was to transfer her to the NICU for evaluation and care.

Baby did great and was not on oxygen or a ventilator in the NICU. She was released on day 4 when her blood cultures showed that she doesn't have an infection. Treating newborns with respiratory distress is tricky because most of them are perfectly fine, but the NICU staff has to be vigilant to make sure that a baby doesn't have additional problems.

It's always hard to separate a mom from her baby and it's hard to know for sure that it is the right thing to do, but we always err on the side of being over cautious. EMS and NICU are our safety net, along with our training in neonatal resuscitation.

Resuscitation

Happy story of a baby who just needed a little help to get going and was quickly back in mama's arms, which is how it works out 99% of the time. We are fully prepared to help babies who have trouble at birth.