Evidence-based Midwifery: The Case Against Newborn Suctioning

by Melissa Marks
ometimes old habits can be hard minimal (Waltman 2004). This raises the to break. When a brand new baby question, "If most of the infant's pulmonary is born, the very first question that fluid secretions are absorbed or squeezed springs to the mind of each individual in out of the body through birth, how much the room tends to be, "Is the baby breath- fluid is really being suctioned out, and what ing?" Understandably, humans have come is the value in using these devices?" to the conclusion that breathing equals Neither the American Academy of healthy. However, this is not always true, Pediatrics nor the American Congress of and especially in the case of the newborn Obstetricians and Gynecologists recombaby, not breathing does not always equal mend the practice of routine bulb suctionnot healthy. Fetal-to-newborn transition ing of the newborn (Waltman 2004). In does not happen with the snap of the fingers. addition, studies which investigated the Instead, it is a complex process of chemical, routine use of DeLee suction catheters to hormonal and physical responses that initi- remove lung fluid, mucus and secretions ates the infant's first breath (Harper 2000). failed to show any benefit in oxygnation. Some newborns take longer to transition There were also no statistically significant than others. Hearing the gurgling, splut- differences in Apgar scores in the suctioned tering, gagging sound of a brand new baby and non-suctioned newborns. These studcan be disconcerting to midwives, health ies recommended that the routine use of care providers and especially parents. It is oro-naso-pharyngeal catheter suctioning very easy to reach for the bulb syringe or at birth be abandoned (Waltman 2004). the DeLee to try to suction out thefluidin In 1971, a retrospective review of the an attempt to help the newborn transition records of all newborns with a heart rate faster. This is not evidence-based midwifery. of 120-180 beats per minute before bulb Research and studies show that oro-nasoor DeLee catheter suction showed signifipharyngeal suctioning (with the bulb or cant heart rate disturbances with or without DeLee) does not improve outcomes (Mercer apnea in 15% of the infants who received 2007), and it can actually be harmful to nasopharyngeal suctioning with the DeLee the newborn infant (Velaphi and Vidyascatheter. "[The researchers] concluded that agar 2008). blind suctioning of the nasopharynx with a nasogastric tube in the first few minutes of life is a hazardous procedure" (Velaphi The Infant Born through and Vidyasagar 2008). Clear Amniotic Fluid At term, there is approximately 20ml of lung In 1997, researchers studied 15 infants fluid in the respiratory tract of a healthy who received oro-naso-pharyngeal suction newborn. Studies on fetal animals indicate and 15 who received no suction immediately that lung fluid secretions begin to decline after birth. They discovered that the average toward the end of gestation, and pulmo- arterial oxygen saturation was significantly nary microcirculation is responsible for the lower in the suctioned group within the first absorption of these fluids. Chest compres- six minutes of life. It also took the suctioned sion during birth is thought to squeeze out infants significantly longer to reach oxygen most of the remaining lung fluid through saturations of 86% and 92% (Velaphi and the infant's trachea and oronasopharynx. Vidyasagar 2008). Thefluidsremaining in the mouth, nose and In 2005, researchers compared the pharynx that are traditionally suctioned out oxygen saturation levels of 70 suctioned with the bulb syringe or DeLee catheter are infants versus 70 non-suctioned infants.

Again, the suctioned group had lower oxygen saturation levels in the first six minutes of life and took longer to reach saturation levels of more than 85% than did the non-suctioned infants (Velaphi and Vidyasagar 2008). According to these studies, routine oronaso-pharyngeal suctioning, through bulb or DeLee catheter suction, did not improve lung mechanics or oxygnation, and instead, delayed reaching normal oxygen saturation levels and caused both apnea and heartrate disturbances (Velaphi and Vidyasagar 2008). Breastfeeding and bonding can also be affected by oro-naso-pharyngeal suctioning. Infants whose mouths are repeatedly traumatized with a rubber bulb or plastic tube often show signs of oral aversion and may keep their mouth tightly shut to protect from further discomfort, trauma and injury (Lothian 2005).
The Infant Born through Meconiumstained Amniotic Fluid (MSAF)

Twelve percent (12%) of live babies are born through meconium-stained amniotic fluid. Approximately 1/3 of these infants will have meconium present below the vocal cords. However, Meconium Aspiration Syndrome (MAS) develops in only 2 out of every 1000 live births. Ninety-five percent of babies who inhale MSAF will clear their lungs spontaneously. What, then, causes MAS? Recent research suggests that it is not inhaled meconium that causes pathologic MAS, as previously thought, but rather the primary cause is fetal asphyxia in utero. Severe fetal lung asphyxia causes pulmonary vascular damage with pulmonary hypertension. The damaged lungs of the fetus are then unable to clear the meconium (Katz and Bowes 1992). In one large, multicenter, randomized study that took place in 2004, researchers reported that routine intrapartum

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oro-naso-pharyngeal suctioning of term infants born through meconium-stained amniotic fiuid did not prevent Meconium Aspiration Syndrome (Velaphi and Vidyasagar 2008). In a study conducted in 1994 in which 438 infants were born through meconium-stained amniotic fiuid, 38 (9%) of these infants developed MAS, despite DeLee catheter suctioning. It was concluded that DeLee suctioning at the perineum does not prevent MAS, and researchers speculated that MAS is an intrauterine event associated with fetal distress, in which MAS is simply the marker for previous fetal hypoxia (Falciglia et al. 1992). Research and studies present confiicting results in regards to endotracheal intubation and suctioning of infants born through meconium-stained amniotic fiuid. According to Velaphi and Vidyasagar, "Infants who are born through MSAF with an Apgar score of 6 or less at 1 or 5 minutes and who have meconium below the [vocal] cords are more likely to have MAS" (2008). Therefore, intubating depressed infants born through MSAF may reduce the incidence of MAS. One study compared infants born through MSAF who received trachal suctioning to those who had not received trachal suctioning and found that the non-suctioned infants were more likely to be symptomatic of respiratory distress and die than the suctioned infants (Velaphi and Vidyasagar 2008). However, the study did not indicate whether or not the studied infants born through MSAF were vigorous or non-vigorous. A number of other studies found no benefit at all in trachal suctioning of vigorous infants born through MSAF, and instead showed that it may actually cause respiratory complications such as stridor (a high-pitched sound made during inspiration usually caused by a foreign body lodged in the airway). These studies have subsequently supported the use of a selective approach to trachal suctioning, recommending that only depressed infants born through MSAF receive intubation and trachal suctioning. However, it is not clear whether trachal suction actually reduces the incidences of Meconium Aspiration Syndrome in depressed infants with low Apgar scores because no randomized studies have been conducted comparing trachal suctioning and no trachea! suctioning in depressed

infants born through MSAF (Velaphi and Vidyasagar 2008).

When Should an Infant Be Suctioned?

According to current Neonatal Resuscitation Program (NRP) guidelines, approximately 10% of newborns require some assistance to begin breathing at birth and only 1% will require extensive resuscitation. Vigorous infants who are breathing and/or crying, have clear amniotic fiuid and demonstrate good tone do not need to be resuscitated. One of the first steps in NRP for infants who must be resuscitated includes clearing the airway via oro-naso-pharyngeal suction. Therefore, according to the American Heart Association (2005), bulb or DeLee oro-nasopharyngeal suction of the infant should be reserved only for non-vigorous infants born through clear amnioticfiuidprior to administering neonatal resuscitation. Non-vigorous infants with low Apgar scores who are born through meconium-stained amniotic fiuid need endotracheal intubation and trachal suctioning. From my own research into unhindered birthing and experience in observing and assisting at human births, I have concluded that the healthy newborn is designed to clear, absorb and expel lung fiuid, secretions and mucus all on its own through the process of compression during birth andfiirtherby gurgling, spitting up, breastfeeding and crying. Yet, this does not mean all newborn infants must cry in order to breathe. Indeed, many infants do not cry at birth, especially those who are water-born or born gently into a dim, warm environment. These infants manage to work out theirfiuid,mucus and secretions by means other than crying. The literature supports this conclusion. Routine bulb or DeLee suctioning does not improve newborn outcomes. Oro-naso-pharyngeal suctioning of the infant born through meconium-stained amniotic fiuid does not prevent Meconium Aspiration Syndrome, because MAS is likely a result of fetal distress in utero. Normal birth has been designed through millions ofyears of evolution to result in a healthy newborn and a healthy mother capable of solely ensuring her infant's survival. For normal birth and normal babies, it makes the most sense to get rid of that bulb and give up that DeLee. Reserve your hands for soft caresses unless otherwise needed, and observe the miracle of birth.

References: American Heart Association. 2005. "Part 7: Neonatal Resuscitation." Journal of the American tieort Association, 112:111-99. Estol, PC, H Piriz, S Bsalo et al. 1992. "Oro-nasopharyngeal suction at birth: Effects on respiratory adaptation of normal term vaginally born infants." J Perinat Med 20 (4): 297-395. Falciglia, HS, C Henderschott, P Potter et al. 1992. "Does DeLee suction at the perineum prevent meconium aspiration syndrome?" Am J Obstet Gynecot 167 (5): 1243-49. Harper, B. 2000. "Waterbirth Basics; From Newborn Breathing to Hospital Protocols." Midwifery Todoy 53: 9-15. Katz, VL, and W A Bowes, Jr. 1992. "Meconium aspiration syndrome: Reflections on a murky subject." Am J Obstet Gynecol 167 (6): 1914-16. Lothian, J. 2005. "The birth of a breastfeeding baby and mother." J Perinat Educ 14 (1): 42-45. Mercer, J, D A Erickson-Owens, B Graves et al. 2007. "Evidence-based practices for the fetal to newborn transition." JM/dwi/ery Wom Heol 52 (3): 262-72. Velaphi, S, and D Vidyasagar. 2008. "The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium." Semin Fetal Neonot Med 13 (6): 375-82. Wattman, PA, JM Brewer, BP Rogers et al. 2004. "Building evidence for practice: A pilot study of newborn bulb suctioning at birth." J Midwifery Wom Heal 49 (1): 32-38. I Melissa Marks is a passionate advocate for gentle, unhindered birth. As a senior student at the Florida School of Traditional Midwifery, Melissa, along with her husband, their soon-to-be-born baby and their dog and cat, are looking forward to the day that they will start a homebirth practice, build a geodesic dome and rescue a few chickens.

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