Women and Birth
Volume 19, Issue 1 , Pages 23-28, March 2006

A midwife program of newborn resuscitation

  • S. Graham

      Affiliations

    • John Hunter Children's Hospital, Locked Bag No1, Hunter Regional Mail Centre, NSW 2310, Australia
    • Corresponding Author InformationCorresponding author.
    • ,
  • A. Gill

      Affiliations

    • John Hunter Children's Hospital, Locked Bag No1, Hunter Regional Mail Centre, NSW 2310, Australia
    • ,
  • D. Lamers

      Affiliations

    • Belmont District Hospital, Croudace Bay Road, Belmont, NSW 2280, Australia

Accepted 6 December 2005.

Article Outline

Summary 

A very small proportion of newborns fail to establish a normal respiratory pattern without some assistance at birth and newborns requiring resuscitative measures at birth should have a skilled practitioner able to provide it. In this small hospital midwives felt unskilled in newborn resuscitation and paediatricians were not always immediately available. A stakeholder group gathered to discuss the problem. A training program was implemented that improved the skills, confidence and support of the attending midwife to resuscitate the newborn effectively. The aim was to improve the outcome for the infant whilst maintaining the mother's choice of birthing in a small local hospital close to family and friends.

Keywords: Resuscitation, Education, Skill, Support, Midwives

 

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Introduction 

Due to modern obstetric practices and socio-economic changes in the western world most babies establish a normal respiratory pattern with no intervention.1 However, approximately 10% of newborns require some assistance to begin breathing and about 1% require extensive resuscitation measures to survive.2 Perlman and Risser3 agree that cardiopulmonary resuscitation requiring chest compressions and medications in the delivery room is a rare event. There is a paucity of information in the Australian population however Tudehope and Osuch4 state that professionals all agree that newborns requiring resuscitative measures at birth should have a skilled practitioner able to provide it. The common aim is to deliver a healthy breathing pink baby to the parents or if this is not possible, resuscitative measures are taken to ensure the compromised baby is transferred to the neonatal unit in the best possible condition.

Over the past few decades there have been considerable improvements in the practice of newborn resuscitation, which has impacted on the outcome of those babies who require some assistance to begin normal respirations.1 Drew et al., describe having a balance between highly trained medical staff intrusively present at every birth and having the same doctors attend the birth only when problems arise. Having a paediatrician present at every birth medicalises what should be a natural process and can also be seen to waste time and resources. In New South Wales, Australia babies who may require resuscitation measures at birth are identified as ‘high risk’ and managed in a tertiary referral centre thus minimising high risk deliveries in the smaller hospitals. However, not all low risk births are uneventful and paediatricians are often not ‘on site’ in these smaller hospitals. The United Kingdom Department of Health5 states that a woman giving birth at the smaller hospitals or at home should feel confident that an expert is able to provide help efficiently and effectively in an acute emergency situation.

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An identified problem 

A woman in the low risk category should have the choice to birth her baby in an environment in which she feels comfortable and confident. If she is not having a home birth she should be allowed to choose her location of birth and it should be as close to home and family and friends as possible. The identified problem in this small Australian hospital was the response time of paediatricians to the call for assistance. The hospital is 12km from the tertiary referral hospital and does not have paediatricians on site. When the paediatrician was called to provide assistance at a birth the time to respond depended on various factors including traffic congestion. In addition, the midwives at this hospital believed that the training in resuscitation, although performed regularly, was inadequate to equip the midwife with confidence and skills to perform adequate resuscitation in the compromised newborn.

To seek a solution to the problem a stakeholder group was developed consisting of: the Area Health Service, visiting medical officers, Paediatricians, Division of Obstetrics, the neighbouring tertiary referral hospital and midwives and senior nursing staff from the hospital in question.

In order to ensure adequate, immediate and effective resuscitation to the small number of babies requiring resuscitation at birth the decision by the stakeholder group was made to train a group of midwives in advanced life support of the newborn. This was to be done utilising an American program developed by the AHA and the AAP. This program had already been evaluated in South East Queensland and Ireland. It utilises a team approach to newborn resuscitation. Ryan et al.6 evaluated the dissemination of this neonatal resuscitation workshop in Ireland and found that 85% of participants indicated an improvement in skills and confidence. In addition McDermott et al.7 found that midwives who received intensive education and training scored significantly higher in the practical demonstration of resuscitation than midwives who did not receive this training. The stakeholder group proposed that the midwife resuscitation team would undertake this one-day workshop in addition to other learning and skill development strategies in order to provide a confident and immediate response to neonatal resuscitation in the delivery suite. This education program was designed to enhance existing skills of the midwife whilst awaiting the arrival of the paediatrician.

The stakeholder group discussed and defined the following roles and responsibilities of health care professionals at this hospital:

Role of the obstetrician 

Where possible births with the potential to lead to neonatal complications such as: preterm infants less than 35 weeks gestation and any infant with suspected foetal abnormality or compromise should be transferred to the tertiary referral hospital. Adequate warning should be given to the resuscitation team (including the paediatrician) when a possible compromised infant needs to be birthed at this hospital. For example:

•Infants less than 35 weeks gestation.

•Suspected foetal abnormality or compromise.

•Signs of foetal compromise.

Role of the paediatrician 


•Provide support and assistance to midwife who is performing active resuscitation when requested.

•Provide ongoing education and support to midwives.

Role of midwife 


•Administer resuscitation techniques to level of competence and within professional boundaries.

•Work as a member of the resuscitation team.

•Maintain a record of neonatal resuscitations attended that can be used as a continuing education tool utilising root cause analysis and enable reflection on practice.

•Call a paediatrician at any time for support, assistance and/or advice.

•The paediatrician MUST be called for any resuscitation that requires cardiac massage and prior to ceasing resuscitation.

Role of the hospital 


•Provide a supportive environment for midwives attending resuscitation.

•Ensure appropriate rostering giving due attention to mentorship and ongoing education.

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The midwife participants 

An expression of interest was displayed at the participating hospital seeking midwives interested in the advanced role. The advanced role was accepted and recognised by the Area Health Service, however there were no monetary remunerations for such a role. Criteria for inclusion in the program included:

•Ability to work in an emergency situation.

•Excellent communication skills.

•Well-developed problem solving skills.

•Demonstrated ability to work as a team member.

Thirteen interviews were conducted and nine successful midwives chosen for the training.

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The training program 

Historically education programmes have followed a ‘front-end loading’ model where professionals are provided with the knowledge, skills and attributes the program developers thought were required before beginning practice. The competent practitioner would then apply the theory they had learned in the practical situation.8 However real life situations are not prescriptive they are often complex. A problem solving approach would allow critical thinking and analytical skills to be developed therefore a program that focuses on the way practitioners think and act in a work situation was designed.

Newborn resuscitation requires practical skills, critical thinking and problem solving skills as well as a theoretical understanding of the changes taking place at birth. As the midwives within this hospital had stated that they felt the cardio pulmonary resuscitation (CPR) training they had received on an annual basis was very basic and did not provide them with the confidence to be the primary resuscitator this program was designed to increase knowledge, confidence and competence. The literature indicates that the retention of skills and knowledge quickly deteriorates if not used regularly or updated.9, 10, 11, 12, 13, 14, 15, 16 However if the program involves critical thinking skills and promotes life long learning, knowledge and understanding is retained longer.8, 17 This program was designed to ensure a hands on approach utilising modern training manikins, video or DVD scenarios to ensure a realistic training that mimics real life scenarios. As self–instruction has been identified as a means of increasing confidence and competence in training by allowing synthesis of the information received and self regulated practice in the practical skills17 the equipment was available at all times for the midwives to practice the practical skills at any time and the textbook containing the theoretical component of the course was retained by the midwife.

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Important components of the training program 


1.A one-day training workshop. Titled “Advanced Life Support (ALS) of the Newborn” based on the American Academy of Pediatrics guidelines for newborn resuscitation training.This training workshop utilised interactive pre-workshop learning. An intubation head manikin (by Laerdal) was made available for individual practice throughout the course and following accreditation. The workshop consisted of didactic teaching and interactive practice and assessment. The aim of the workshop was to highlight real life scenarios and assist the participant in problem solving. The proposed trainers for the ALS newborn workshop included a Neonatologist and Nurse Educator (NE) from the tertiary referral hospital and a Clinical Nurse Specialist (CNS) from the smaller hospital. In order to facilitate the training the Neonatologist, NE and CNS travelled to South East Queensland to participate in the workshop, as train the trainer, that had been developed there.18The ALS newborn workshop consisted of seven lessons titled; Physiology, Initial steps in resuscitation, Use of bag and mask, Chest compressions, Endotracheal intubation, Medications and Special considerations. Each theoretical component was followed by a short test. There were two practical sessions to allow practice and guidance combining theory and practice using resuscitation manikins which has been described by Halamek et al.19 as highly successful. A video of endotracheal intubation developed by the AAP was shown to further highlight the anatomical landmarks and the procedure before simulated real life assessments utilising case scenarios (mega codes) were undertaken.Following successful completion of the workshop the midwives were provided with a professional journal to record all deliveries attended that required any form of resuscitation and the remaining program was undertaken.

2.A seven-day period of clinical experience as the “Resuscitation Midwife” in Neonatal Intensive Care at the tertiary referral centre.

3.A minimum of one day of clinical experience in paediatric theatres. Learning objectives for this placement included viewing and identifying the vocal chords.

4.A formal assessment process utilising case scenarios and clinical competency assessments. The assessment process was developed to ensure the participant had the ability to perform to the best of his/her ability in a stressful environment. The assessors are Nurse Educator and Neonatologist.

5.Discussion groups and reflective practice. Discussion groups were designed to be part of the program utilising real life cases to highlight, discuss and problem solve issues that may arise. The goals of discussion groups were both cognitive and affective. Discussion groups are effective in developing participants analytical capacity, while increasing their tolerance of opposing viewpoints.8

6.The development of ongoing report/debriefing/support for midwives who undertook the training.

7.A cycle of re-accreditation on an annual basis.

Within two months the midwives were recalled for a day of ‘mega codes’. A Neonatologist from the tertiary referral hospital and one from the hospital in South East Queensland conducted the ‘mega codes’. The midwives found the ‘mega code’ stressful. Of the nine midwives in the program seven passed the mega code and two failed. An opportunity to re-sit the assessment was offered with further practice with the manikins, compact disc (CD) and mega code format. One participant declined to continue with the program the other participant passed on her re-sit. Eight midwives successfully completed the program.

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Minimal requirements for successful completion of the program 

The stakeholder group agreed that the minimal requirements should be that each midwife would:

•Gain a pass in the American Academy of Pediatrics/American Heart Association ALS Newborn one day workshop.

•Demonstrate competency in the clinical area and be assessed using clinical competencies of the advanced practice nurse/midwife.

•Successful and competent intravenous cannulation of the neonate.

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Evaluation of the program 

There was an ongoing evaluation of the program throughout its course through questionnaires and discussion groups. The one-day workshop was evaluated utilising a questionnaire. This used a Likert scale asking the participants two questions for each of the seven parts of the one-day workshop such as:

1.The content was presented clearly in a manner, which held my interest.

2.The material was relevant to my level of knowledge and experience.

Participants were asked to score each question from 1 to 5. The lowest point in the scale (1) meaning strongly disagree to the highest point (5) meaning strongly agree. Seven participants strongly agreed on both these questions and the remaining two agreed.

The questionnaire also had a space for comments participants would like to make about the training. Some comments from the participating midwives were as follows;

‘I have learned more in one day and I feel I have more confidence to attend resuscitations’

‘The CD was good in the visualisation of the procedures’

‘Great course should be compulsory for all who work with delivering women’

In addition to the one-day workshop evaluation the clinical experience was also evaluated using a similar questionnaire where the participating midwives were asked if they thought the clinical experience met their learning needs and was useful to their practice. This was on a Likert scale as described above. The first midwife placement highlighted the problems as ‘resuscitation midwife’ in that the midwife could be on an eight hour shift attending as many as ten deliveries and all or most of them requiring minimal or no intervention. Although this was expected due to the small percentage of newborns who require intervention to begin normal respirations it was found to be very frustrating for the midwife who was seeking experience in intubation techniques. However on evaluation, following the first clinical placement as resuscitation midwife, it was decided to include one day in Paediatric theatres where the opportunity to view the vocal chords and possibly intubate would be provided. It was continually emphasized throughout the program that the skill of endotracheal intubation although taught in the course was not a necessary requirement of the course but the skill of maintaining an airway by bag and mask ventilation was.

As in all courses the evaluations of the clinical experience reflected how busy the midwife was or how many resuscitations were attended. The evaluations varied from enjoyable and meeting all the needs of the course to no needs being met. One midwife found it frustrating as she was at the tertiary referral hospital for her clinical experience when there was a full resuscitation of a compromised infant at her own hospital and she felt that would have been more experience for her, however these events cannot be planned hence the initial reason for the program.

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Professional journal review 

The CNS held discussion groups and during this time the professional journals of the participating midwives were reviewed. The experience recorded varied. The following is a brief outline of the recorded resuscitation documented in the professional journals of each participating midwife.

•Midwife 1 recorded two bag and mask resuscitations for the whole program. This was confirmed to be accurate.

•Midwives 2–5 have utilised bag and mask ventilation skills over ten times each. All were confident in performing this skill.

•Midwife 6 had intubated on four occasions three of these for meconium stained liquor. The remaining singular occasion was for a full resuscitation. The same midwife recorded twelve bag and mask ventilations. In the debriefing session held a month after the event the midwife stated that she was happy with her efforts and felt confident that the skills gained had enhanced her practice.

•Midwife 7 recorded four intubations undertaken. Two of which were for full resuscitations with cardiac massage and medications. Bag and mask ventilation was recorded in eight other occasions.

•Midwife 8 was on maternity leave.

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Maintaining skill 

Maintaining practical skills within any neonatal program has been recognised to be difficult at times. Recommendations were made that all midwives in the program be re-accredited on an annual basis as it is recognised that those who have received retraining in CPR with manikin practice were found to demonstrate increased levels of competence compared to those who had not received retraining.20

Reflective practice was also utilised. This was partly by the introduction of the professional journals and the debrief sessions which allowed the reflection of experience and also in the follow up of the midwives after the training session had been completed. It was thought that reflection on practice would begin discussion and analysis of the experience the midwives had encountered.

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The plan for the future following completion of the program 


•The midwives will receive support in their ‘new’ role from the medical and midwifery colleagues within the hospital and also from the initial Stakeholder group.

•Provide ongoing education and debriefing sessions by the Nurse Educator and Clinical Nurse Specialist (midwifery). Education and debriefing sessions should be on a regular monthly basis and more frequently offered if required.

•Provide re-accreditation of advanced skills on an annual basis.

•Support all midwives and medical officers in attending the one day workshop. As the ALS workshop was highly evaluated by the midwives the stakeholder group decided that the one-day ALS newborn workshop should be offered to all medical staff intending to work in the obstetric or neonatal area. In addition to the eight midwives with advanced resuscitation skills the management team of this hospital supported and encouraged all midwives and medical officers to attend the one-day ALS newborn workshop. This ensures a team effort at resuscitations where everyone has the same logical systematic approach.

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Two years later 

Simulation-based neonatal resuscitation through mega code scenarios was attended periodically throughout the two years. The mega codes were initiated within the normal shift of the midwife with no pre warning being given, hence highlighting the unexpectedness of an emergency situation. The aim was to enable the midwife to gain experience and confidence in performing the appropriate actions and identifies the correct responses in an emergency situation.19 Formal education sessions of one to two hours were also undertaken during the previous two years. One of these formal session consisted of a written examination on neonatal resuscitation with the average score of 98% being awarded and 100% in Mega Code practice scenarios.

Following this a program for re-accreditation was developed to re-assess the advanced skills. This program consisted of five hours of theoretical and practical revision. The five hours were split into three sessions consisting of:

Session 1 –
•Debriefing, reviewing what has been happening over the previous two years. Discussing experience and reflecting on practice.

•Theoretical component of adaptation at birth and resuscitation including the need for intubation with a DVD of case discussions and scenarios shown.


Session 2 – Practice mega codes

Session 3 – Mega code examination

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Clinical impact of training and support 

Midwives with advanced resuscitation skills that had attended births requiring intubation for meconium stained liquor or births where the baby required bag and mask ventilation described themselves as being more self assured and comfortable in their own practice. One midwife had been on maternity leave for twelve months and had returned on a part-time basis, this midwife felt less confident in her abilities to be the ‘resuscitation midwife’. Following re-training and accreditation of skills all of the midwives felt more confident and competent in their practice. They all agreed to continue to practice advanced resuscitation for newborns.

Since the commencement of the program at this hospital there have been a number of occasions where the skills obtained during the program have been utilised in full resuscitations. In the debriefing sessions held for these occasions the midwives involved stated they were pleased that these new skills were easily called upon when required and they felt that these skills were of great benefit to their practice.

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The future 

As health care workers know change is inevitable in practice and this small hospital is no exception as this unit is changing to become a midwife led unit. This means it will be a low risk birth centre with no on site medical backup. The midwives who elect to stay in the unit are expected to resuscitate and stabilise the newborn. Calls for assistance will be to the Neonatal Intensive Care Unit who will retrieve the newborn as required. Skilled persons need to be able to perform the complete resuscitation with assessment, stabilisation, ventilation and chest compression, administration of medications or fluids. This program has shown that midwives can perform this skill when they have received adequate education and support to do so.

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Conclusion 

The education and support provided to the midwives in this training program solved the initial problems of lack of confidence and skill by the attending midwives. The outcomes of the program were met and indeed superseded. The management team of the hospital recognised the importance of training and education in newborn resuscitation by supporting all midwives and medical officers to attend the one-day ALS workshop. Thus ensuring an effective team effort at resuscitations when they are required. Change in practice is inevitable and as this midwife led unit evolves these midwives will have the skills and experience from this course to utilise in practice.

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References 

  1. Drew D, Jevon P, Raby M. Resuscitation of the newborn: a practical approach. Oxford: Reed educational and professional publishing; 2000;
  2. American Academy of Pediatrics/American Heart Association. Neonatal resuscitation textbook. 4th ed. America: Library of Congress Catalogue; 2000 [card no. 00-131686].
  3. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room: associated clinical events. Archives of Pediatrics and Adolescent Medicine. 1995;149(1):20–25
  4. Tudehope D, Osuch M. Practical aims to maintaining neonatal resuscitation skills. Journal of Paediatrics and Child Health. 2001;[Editorial]
  5. Department of Health . Changing childbirth. London: HMSO Department of Health; 1993;
  6. Ryan CA, Ahmed S, Abdullah H, McCarthy-Clark L, Malone A. Dissemination and evaluation of AAP/AHA neonatal resuscitation program in Ireland. Irish Medical Journal. 1998;91(2):51–52
  7. McDermott J, Beck D, Buffington ST, Annas J, Supratikto G, Prenggono D, et al. Two models of in-service training to improve midwifery skills: how well do they work?. Journal of Midwifery Womens Health. 2001;46(4):217–225
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  9. Boyd M, Wotton K. A review of nurses’ performance of cardiopulmonary resuscitation at cardiac arrest. Journal of Nurses Staff Development. 2001;17(5):248–255
  10. Broomfield R. A quasi-experimental research to investigate the retention of basic cardiopulmonary resuscitation skills and knowledge by qualified nurses following a course in professional development. Journal of Advanced Nursing. 1996;23(5):1016–1023
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  12. Durojaiye L, O’Meara M. Improvement in resuscitation knowledge after a one-day paediatric life-support course. Journal of Paediatric and Child Health. 2002;38(3):241–245
  13. Lewis FH, Kee CC, Minick MP. Revisiting CPR knowledge and skills among registered nurses. Journal of Continuing Nursing Education. 1993;24(4):174–179
  14. Moule P, Knight C. Emergency cardiac arrest. Can we teach the skills?. Nursing Education Today. 1997;17(2):99–105
  15. Sefron P, Paulus T. Resuscitation skills of hospital nursing staff. Anaesthetist. 1994;43(2):107–114
  16. Smith S, Hatchett R. Perceived competence in cardiopulmonary resuscitation. Knowledge and skills amongst 50 qualified nurses. Intensive Critical Care Nurse. 1992;8(2):76–81
  17. Davies N, Gould D. Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses’ competence. Journal of Clinical Nursing. 2000;9(3):400–410
  18. Osuch MJ, Liley HG, Weber M, Woodgate PG, Tudehope DI. Establishment of a neonatal resuscitation program in South-East Queensland. In Proceedings from Perinatal Society of Australia and New Zealand, 2001; 2001.
  19. Halamek L, Kaegi D, Gaba D, Sowb Y, Smith BC, Smith B, et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. American Academy of Pediatrics. 2000;106(4 Part 1 of 2):45
  20. Davies N. Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses competence. Journal of Clinical Nursing. 2000;9(3):400–410

PII: S1871-5192(06)00004-7

doi:10.1016/j.wombi.2005.12.002

Women and Birth
Volume 19, Issue 1 , Pages 23-28, March 2006

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