NRP with Karen Strange

I took the most amazing NRP class today (NRP stands for Neonatal Resuscitation Provider, for those who aren’t hip to all of the gazillion acronyms in this crazy profession) with Karen Strange of, and I am so buzzed from the class that I have to sit down and write about it tonight before I forget everything that I learned.  It was unlike any NRP class I have ever taken before (and trust me, at this point in my nursing/ midwifery career, having to re-certify every 2 years, I’ve already taken the class 5 times before).  This class is designed for out-of-hospital providers.  It’s meant to teach NRP to homebirth midwives and doulas, those who’re resuscitating babies without pulse oximeters and oxygen blenders and a NICU just down the hall, but it was without a doubt more informative, evidence-based and just plain helpful than any other NRP class I have ever taken before.  It makes me wonder how these other NRP classes can get away with just teaching the how-to of resuscitation when there’s actually so much else going on which needs to be addressed.  It was completely mind-blowing, paradigm-shifting, eye-opening, wow.  I’m going to run over the bullet points here, but if you ever get a chance to take a class with her, DO IT.

*  Remember the baby in all of this.  As midwives in particular we’re so focused on the woman–the mother, the mother, the mother–her experience, her birth, her power, her strength, her triumph, her fears, her labor, that we forget that there’s a second silent passenger traveling with her every step of the way.  Karen talked about treating pregnant women almost as if you’re treating siamese twins–it would be rude to talk to just one twin as if the other isn’t there, you have to talk to both, so in that sense, everything you explain to the mother you should also explain to the baby.  We need to treat them the way we would want to be treated; this includes telling the baby what you’re going to do before you do it, telling the baby what’s going on, telling the baby what you want her to do, and telling her the story of what’s happened.  And reminding the parents to do the same, so that the baby hears this from everyone, not just from the midwife or doula.

*  Think long and hard about what birth might feel like from the baby’s perspective; how emerging into the super-bright, super-loud, super-chaotic world can be incredibly overwhelming and traumatic, even in the calmest and gentlest of births, and that in births where the baby requires resuscitation and intervention, even more so.  And think about the baby’s story in all of this.  Their early cries may be their attempt to be heard, to tell their story to the world, and to know that they’re not alone, that someone is listening.  Being present at the birth means being able to slow down and listen to what your baby is saying.  As the mother, you are the emotional regulator of your child.  If your baby is crying, notice how that makes you feel inside (frantic, frightened, worried?)–your baby may be responding to your emotions, since everything they know/ feel is a mirror of what you know/ feel.  Then take a moment to calm and collect yourself–how do you feel now?  By telling the story and naming what is happening or happened, you are helping the baby integrate their story (experience). For example, tell the baby that they’ve been born–they might not realize it yet.  Yes, that was really scary, and really hard, and really long, but we hear you, and you’re out now, you’re safe now. And calm yourself down while you’re saying it; then watch your baby mirror your emotions.

*  Everything that happens to the mother during pregnancy is also happening to the baby.  Motherbaby is  completely undifferentiated, and because of this the baby feels the impact of every stressful moment the mother experiences, even if it’s just for a second (such as slamming on the brakes while driving because another car cut in front, only to realize a moment later that you’re fine), except that the baby continues to feel the stress and adrenaline of the moment without the knowledge or understanding that it was temporary and not really a big deal.  The only way to counter the release of adrenaline is with the release of oxytocin, the feel-good love hormone that calms and soothes and relaxes again.  So as in the point above, it’s crucial to teach pregnant women to take a moment when they’re feeling stressed to ground themselves, feel where their feet connect to the floor, breathe, and release oxytocin in the process.  The time in utero, more than any other time in the baby’s life, is what’s developing and deciding who they are; babies are forming (marinating) in their mothers’ emotional states, this is what’s setting up their personalities, beliefs, termperments etc..  Stress is ok (and unavoidable), but the baby needs breaks from the stress, moments when the oxytocin flows again and s/he can relax again; teach moms to release the adrenaline, acknowledge what happened, tell the baby everything is ok, and then get a hug or a massage or some ice cream (great for relieving oxytocin).  Interested in learning more about this? Check out Prenatal Parenting by Dr. Frederick Wirth.

*  Oxygen is TOXIC.  It causes free radical damage, especially at high amounts, and especially with preterm infants. The newest guidelines from the AAP recommend starting a resuscitation on room air and then titrating up from 21% O2 (room air) until the correct O2 sats have been achieved in the infant.  And remember that it takes up to 10 minutes for a baby to be satting at the correct level–this is all part of the normal newborn transition.  There is a new chart in the 6th Edition NRP book with suggested O2 levels for the first 10 minutes of life, based on 100% O2.  The idea is that table is there to help guide the use of 100% O2, but if you don’t have an O2 Sat, then you shouldn’t be using 100% O2. Use room air (and keep in mind, if you’re giving mouth to mouth resuscitation instead of bag/mask, you’re delivering approx. 16% O2).

*  Babies need their full blood volume.  It belongs to them.  Only public demand will change the length of time practitioners wait before clamping the cord.  The research is already there (has already been there for years) about the benefits of delayed cord clamping, and STILL practitioners will commonly clamp and cut the cord immediately after birth, despite the research.  Now the only thing left to do is to educate the public so that they will start to DEMAND delayed cord clamping.  If you need more proof, look up Dr. Nicholas Fogelson on You Tube and watch his grand round presentations on this.  If you need to resuscitate, keep the baby attached to the cord, keep the baby lower than the placenta so the blood can drain into the baby, and milk the cord or have the mom give a few small pushes to get even more blood into the baby.  None of the concerns about polycythemia/ increased bilirubin/ jaundice with delayed cord clamping has been confirmed by research.

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*  In the UK textbooks for neonatal resuscitation, there is a differentiation between inflation breaths versus ventilation breaths.  The first few breaths given to a newborn during resuscitation are inflation breaths. The purpose of these breaths is to expand the lungs and clear out the fluid which is there before birth.  These breaths need to be a little bit longer with a little bit more pressure.  In the AAP 6th Edition, no distinction is made between inflation breaths versus ventilation breaths, although they do concede that a little bit more pressure may be needed at the beginning to help clear the lungs of fluid.

*  The GOLDEN HOUR after birth is the most important time for bonding, and as a care provider we must do everything we can to help preserve this time.  The baby and mother have both been primed for the bonding through hormonal changes, and the blue print is there for this to occur, but the first hour after birth is when the gears actually align and the bonding is actually cemented.  This is the moment when the baby learns that after the stress of birth, there is a place of safety, rest and relaxation waiting for her/him.   This time is PRECIOUS, and you will never have this hour again.  Teach your parents birth etiquette. The Golden Hour is not the time to be sending photos or texting or emailing or being pulled away from your baby–it’s the time to be totally plugged in and PRESENT.  If for some reason the baby needed resuscitation or was separated from his mom, the Golden Hour happens whenever it is that mom and baby are reunited for the first time.

And that is just the smallest glimpse into everything I learned…not to mention how to correctly do mouth-t0-mouth resuscitation in a home setting.  Seriously, if Karen Strange comes to your city and you have a chance to take a class with her…run, don’t walk!

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