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If a baby is born as an apparent still birth, the midwife should follow certain steps:
Neonatal Resuscitation (NNR) until responsibility of care is transferred to other medical practitioner.
PRINCIPLES OF INFANT RESUSCITATION
If the baby is born limp and floppy, with white body:
1. Provide warmth: Wrap the baby with blankets and cover the head.
2. Clear the airway: Suction mouth with bulb syringe or DeLee, if necessary.
3. Position the baby so head is not overextended: otherwise, the airway will be blocked.
4. Begin mouth to mouth resuscitation: Place the mask unit over baby's nose and mouth, puff your cheeks full of air, and give four short puffs to the baby. Do not use your lungs! If this does not initiate breathing, continue at the rate of 30 breaths per minute. Switch to your ambu-bag as soon as possible, hooked up to your oxygen tank, if you carry one. Watch the baby's chest - it should rise and fall as you work. If not, make sure you have a good seal over nose and throat with the mask, and that the head is level with the back.
5. Have your birthing assistant take heart tones: if pulse rate is below 60 beats per minute, begin cardiac massage. Apply pressure on the sternum bone midway between the nipples, pressing with two fingers about 1/2 inch into chest. Continue at the rate of 80 to 100 times per minute.
6. If performing cardiac massage, blow air into the baby with every fifth beat as you release pressure, without interrupting the rhythm of your fingers. This is full cardiopulmonary resuscitation (CPR).
7. After a full minute, briefly stop and recheck the pulse. If absent, or still below 60, carefully reposition your fingers and continue CPR.
8. Periodically re-check pulse, but never stop for more than a minute. Continue as necessary or until EMS arrives and takes over.
MoonDragon's Health Care Information: CPR Infant - One Person
Do not release any medical records without a release signed by the mother or guardian of the mother and/or infant. If a release is signed, the midwife makes copies of any medical file documents to be given to medical personnel, but must keep all original documents for herself. This prevents any alterations from being made by unscrupulous individuals that may wish to cause legal problems for the midwife, her attendants and even the parents of the baby.
It is very fortunate that the birth experience usually renders a positive outcome for the entire birthing family, the midwife and the birthing attendants. Everyone is overjoyed, refreshed and exhilarated with the arrival of a new, healthy infant. However, in a rare instance, a infant death may and can occur either before the birth or soon afterward and usually as a result of a severe deformity. If death should occur, it is important to keep the experience as positive and open as possible. This will be a time for greeting, acknowledgement, and letting go. If the midwife senses that the parents are in denial and she knows the baby is departing, then the midwife needs to tell the parents that their baby has such serious problems that it is going to die. This is seldom necessary since usually when death becomes a part of birth, everyone present knows it.
Many women considering becoming midwives become apprehensive at the thought of losing a baby at birth. There can be many fears associated with it such as the emotions that may surround the event, the fear of accusations, or simply the fear of death itself. Women working with either birth or death need to keep in mind that the two are similar, high-energy transitional states of being and moving through both are identical. It is tragic that the loss of a baby occurs, but it is easier if everyone stays together, offering support, comfort and stays open and connected to the event and to each other, especially if the parents knew the baby was to be a stillborn before the onset of birth.
It is different when a baby is unexpectedly stillborn, being so perfect, beautiful and lifeless. The genuine shock, plus the loss can create a reality break in which the mind must grasp the event, explain to itself the whys and wherefores and attempt to control the situation. The midwife and birth attendants need to try to set aside their thoughts and surrender to their feelings, focusing on the mother and family members. Help the mother to touch and claim her baby, encouraging both parents to look and caress the baby. The midwife and attendants should only bear witness to this important rite of passage and don't give consolations or suggestion at this time. This will come later. Allow the parents to have their moments with the baby.
When a stillbirth occurs, the coroner must be notified for any stillborn infant weighing 500 grams (about 1 lb) or more. An autopsy may be done at the discretion of the coroner. But usually, if it can be established that the baby has been dead in utero for some time, an autopsy may be optional. The coroner releases the body to a funeral home or the parent's choosing. With hospital stillbirths, the health care provider signs the death certificate, out of hospital, this is the coroner's task. (The midwife should be prepared in the event of a coroner's inquest. Unfortunately, in some states and under certain circumstances, there may be legal issues arise, again, the midwife needs to make sure all her records are in order and her actions are well documented in the event this happens. She should consider consulting an attorney. Meanwhile, it is her function as a midwife to make sure the parents are able to move through their loss with as much support as she can possibly give to them.)
Naming the baby is important to many parents. Parents may also want a memento of the baby, such as a lock of hair or a photograph. I also encourage the midwife and the birth attendants to attend the memorial for the baby, if possible. The extra parent and family support is important.
Postpartum, the mother may have some difficult times for the first few days or so. Her hormones will be fluctuating and her milk begins to flow... lactation can be suppressed with sage tea, or by binding the breasts. But the grief will be another issue. The midwife should plan on spending time with the parents daily for the first few weeks or so. Postpartum depression can be a major concern.
Friends and family will arrive to offer their condolences and look on the midwife for reassurance and support, not to mention the possibility of many questions.
The midwife needs to make sure that the mother has her privacy, sleep and any other physical and emotional requirements met during this time. Becoming a listening ear is important. The midwife may encourage the parents to make a scrapbook or other dedication to the baby as a lasting memorial. They should be called regularly and seen occasionally throughout the next several months. Grief is a long process and take much time to work with. Know that the basic steps in grieving will need to be worked through: shock, denial, anger, resolution... and be ready to share these phases with the parents. The steps may not occur or be in any particular order and the parents may fluctuate back and forth between them for awhile. Steps may need to be taken to approach and speak with siblings or other children about death.
The midwife will need to pay attention to her own well-being (sleep, nutrition, etc.) during this time to be able to offer the type and amount of support that is needed by the mother. This is especially important as she goes through any medical and legal issues that may surface. Expect possible negative publicity and from the media and from regional medical practitioners. A coroner's inquest can be stressful, to say the least. This is, unfortunately, the usual nonsense that many midwives must deal with, regardless of the facts behind the stillbirth or death of an infant.
RELATED LINKS
MoonDragon's MDBS Birthing Guidelines: Apparent Maternal Death
Dr. Cacciatore's Life and Death Blog
When a Child Dies
Changing the Way Our Culture Mourns
Dr. C's Research Page
Stillbirth Policy Advocacy
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