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Abstract
Objective To explore fathers' experiences of the resuscitation of their baby at delivery.
Design A descriptive, retrospective design using tape-recorded semistructured interviews with fathers present during the resuscitation of their baby at delivery. Fathers described what happened, their interactions with healthcare professionals, their feelings at the time and afterwards.
Setting Participants were recruited from a large teaching hospital in the UK.
Participants A purposive sample of 20 fathers whose baby required resuscitation at delivery.
Results Participant responses were analysed using thematic analysis. Four broad themes were identified: ‘preparation’, ‘knowing what happened’, ‘his response’ and ‘impact on him’. Fathers had no difficulty recalling their emotions during the resuscitation. These feelings remained vivid and were mostly negative. Most fathers wanted to go to their baby during the resuscitation but did not do so. They felt they should stay with their partner, did not want to impede the resuscitation or felt they were not ‘allowed’ to go to their baby. The fathers' position in the room and the extent to which they were focusing on their partner had an impact on their recollection of what happened. Fathers had no opportunity to discuss the resuscitation with healthcare professionals afterwards. Several fathers felt they had not yet recovered from the experience and a few had symptoms synonymous with post-traumatic stress disorder.
Conclusion This is the first study to specifically explore fathers' experiences of newborn resuscitation. The findings should inform healthcare education, policy development and the provision of support to fathers.
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Introduction
Most fathers in the UK attend the birth of their baby.1 ,2 In situations where the baby requires resuscitation, the father will also be present because delivery and resuscitation usually take place in the same room. Although fathers' experience of childbirth is increasingly being explored, these studies have usually only involved fathers of healthy babies.3,–,6 While fathers' experiences of newborn resuscitation have not been specifically investigated, ‘witnessed resuscitation’ (WR); the presence of a relative during the resuscitation of a family member has been extensively explored in other care settings over the past 25 years.7,–,9 This WR research has identified a number of benefits and more negative effects for relatives which have informed the development of evidence-based guidelines and recommendations. These emphasise the importance of briefing relatives before they go into the resuscitation area, provision of support by a chaperone throughout the resuscitation and debriefing the relatives afterwards.9,–,11
What is already known on this topic
▶ Most fathers in the UK attend the birth of their baby and as a consequence some will also attend the resuscitation of their child.
▶ Evidence-based guidelines and protocols inform practice during witnessed resuscitation in settings such as adult and paediatric intensive care and accident and emergency departments.
▶ Fathers' experiences of newborn resuscitation have not previously been explored.
What this study adds
▶ This is the first known study to provide insight to the experiences of fathers who attend the resuscitation of their baby at delivery.
▶ Being present during the resuscitation of their baby had a profound and on-going impact on the fathers.
▶ Fathers in this study did not receive the support recommended during witnessed resuscitation despite their being concerned about their partner and their baby.
More specific guidance about supporting parents in the delivery room is given in the recently updated newborn life support training programmes, mainly in relation to communicating with them before, during and after the event.12 ,13 It is also identified that the parents should be encouraged to touch or hold the baby after the resuscitation if appropriate.12 However, no specific guidance is given about ways to support the father. It is not known the extent to which these or the more general WR recommendations are addressed when fathers attend newborn resuscitation at delivery. This was explored as part of a wider study of father's experiences of complicated and preterm childbirth and neonatal unit (NNU) admission. The purpose of this part of the study was to explore the experiences and perceptions of fathers of who were present during their baby's resuscitation at delivery and to identify their support needs.
Method
Participants
A purposive sample of 20 first-time fathers was recruited from the NNU within a large National Health Service (NHS) trust. To ensure maximum variability within the sample, any father fulfilling the inclusion criteria was invited to take part.14 Participants were first-time fathers present during the resuscitation of their singleton baby at delivery, were aged 18 years or more, were able to give informed consent and take part in interviews in English. As this was the first study to specifically explore fathers' experiences of newborn resuscitation, fathers of babies requiring all forms of respiratory support were recruited. However, fathers whose baby did not survive the resuscitation were not recruited. All participants gave informed consent. One father decided not to participate. The fathers were between 19 and 44 years (median 29 years). Eighteen were employed and had a range of occupations. One father was unemployed and one was a fulltime student. Nineteen fathers were living with their partner (10 married, 9 cohabiting) and one was living with his parents. The sample included fathers from a range of ethnic and social groups that correspond with those represented in the study site's local population. Fourteen fathers described themselves as White British/English, four said they were of Asian origin and two said they were Black African. The babies were born between 24+1 and 41 weeks gestation (median 32+6 weeks), their birth weights ranged between 604 g and 3.9 kg (median 1.49 kg). Diversity within the sample enabled fathers to describe a range of experiences (table 1).15
Types of delivery, characteristics of the babies and nature of resuscitation
Interviews
Semistructured, qualitative interviews were undertaken using key questions and follow-up questions; this flexible approach enabled fathers to describe what happened, their feelings and responses in their own words.14 ,16 The interviews ranged between 22 and 78 min (mean 48 min). Fathers were interviewed on their own, in a quiet private room within the NNU. With participant consent, the interviews were tape-recorded to facilitate verbatim transcription and analysis. At the end of the interview, all fathers were given a debriefing sheet identifying possible sources of support. In accordance with qualitative methods, data collection, interview transcription and data analysis were carried out concurrently (MH).16 ,17
Analysis
Thematic analysis was undertaken using the software package ‘NVivo 7’. The first transcript was coded into broad themes which incorporated a number of subthemes. A separate theme or subtheme was generated when the data captured something new. Subsequent transcripts were coded using the same framework with new themes and subthemes added as appropriate. ‘NVivo’ software facilitates coding and development of themes. It also enables the researcher to identify relationships between the themes.18 Data collection continued until nothing new was identified (data saturation).14 ,15 The coded data, themes and subthemes were reviewed and amended until the final framework was agreed (MH/HP).
Ethics approval
The study was approved by the Solihull Local Research Ethics Committee (05/Q2706/104). University and trust approvals were also obtained.
Results
The analysis generated four broad themes: ‘preparation’, ‘knowing what happened’, ‘his response’ and ‘impact on him’.
Preparation
Just over half the fathers (12) knew during the antenatal period that their baby may require NNU admission and sought information about pre-eclampsia, congenital abnormalities or prematurity. However, none accessed information about newborn resuscitation (table 2 (2.1)). In most cases, they did not realise their baby might require this level of support at delivery. Most fathers were told by health care professionals (HCP) immediately before the birth that their baby would need additional care. However, this information was usually limited, and HCPs often made vague comments suggesting the baby might need some help. It was only in retrospect that fathers realised they meant resuscitation. There were some cases where fathers accepted that during an unexpected emergency, HCPs have been unable to give them detailed information. However, in others cases when fathers asked for more information, this was often not forthcoming (table 2 (2.2)).
Preparation
Knowing what happened
Most fathers did not know what specific resuscitation their baby had received; they were unaware at the time and most had not been told subsequently. A father's lack of awareness was influenced by his position in the room, his not asking questions either at the time or afterwards and a lack of direct information from HCPs. Although most fathers did not attempt to watch the resuscitation because they were focusing on their partner, others said their view was obstructed. This often occurred when the resuscitation took place in the operating theatre and when a father stood up to see what was happening, he was told to sit down. In some instances, fathers asked questions that remained unanswered. On other occasions, fathers ascertained what was happening by overhearing conversations between HCPs or observing their non-verbal communication. Sometimes, other HCPs advocated on their behalf and most commonly, this was the anaesthetist (table 3 (3.1)). Some fathers discovered some time after the resuscitation what had happened, usually by chance (table 3 (3.2)).
Knowing what happened
His response
This theme includes the fathers' focus of concern, whether they stayed with their partner or went to the baby and the coping strategies they used. All fathers talked about the conflict they felt over their focus of concern; their partner or their baby. Several thought either or both would not survive. Reflecting on this conflict caused some fathers to become upset. One interview was stopped briefly but resumed when the father wanted to continue. Most fathers felt they were more concerned about their partner and said this was influenced by the length of their relationship, worrying about how she would cope if the baby died and feeling they did not have a bond with their baby (table 4 (4.1)). In contrast, a few fathers felt they were more concerned about their child. To some extent, this occurred if his partner was otherwise well (table 4 (4.2)).
His response
Conflict continued for fathers over staying with their partner or going to the resuscitaire. Although most wanted to go to their baby, they felt they ought to stay with their partner. This was because they thought they could do more for her by reassuring and supporting her than they could for their baby. They were also concerned about impeding their baby's care. None recalled being encouraged to go to their baby and assumed HCPs wanted him to stay where he was. Some felt this more strongly by saying they were not ‘allowed’ to go to the baby, and this was generally the case when the baby was delivered in the operating theatre (table 4 (4.3)). One father spontaneously went to the resuscitaire but quickly returned to his partner. He did not have physical contact with his baby during the resuscitation.
Fathers alluded to their coping style when they described their response to the resuscitation. Several talked about how they coped with other stressful situations and felt they used the same strategies. Although a range of approaches were described, fathers most commonly adopted emotion-focused coping strategies.19 They tried not to think about what was happening, avoided watching the resuscitation and focused on reassuring themselves of a positive outcome (table 4 (4.4)). One father left the room during the resuscitation.
Impact on him
The fathers reflected on the impact of the resuscitation at the time and subsequently. They had no difficulty recounting their feelings during their baby's resuscitation (table 5 (5.1)). Although they did not know specifically what was happening to their child, fathers described experiencing mostly negative emotions. Fathers said they were worried, distressed, petrified, panic-stricken or scared. However, none regretted being present. This was largely because their anxiety and fear surrounding the resuscitation was mixed with joy and pride at the birth. These more positive feelings were experienced at a time when their baby's prognosis remained uncertain.
Impact on him
None of the fathers felt they received emotional support from HCPs during the resuscitation and none were chaperoned. Several wanted to talk to someone about their feelings and experiences afterwards, but most had not done so. They felt it was inappropriate to talk to their partner, family, friends, work colleagues and other NNU fathers about their experiences (table 5 (5.2)). They had no opportunity to discuss what had happened with HCPs; one father joked that this was because HCPs thought fathers were unimportant. Consequently, most fathers felt they had not dealt with their feelings about the resuscitation. While some said they wanted to ‘move on’ and not dwell on events, others felt they were still affected by what had happened. A few fathers described symptoms synonymous with post-traumatic stress disorder such as nightmares and flashbacks (table 5 (5.3)).
Discussion
The fathers in this study gave detailed and emotional descriptions of their experiences and recalled their feelings without difficulty. Their recollections of events were detailed and vivid. Although few knew exactly what resuscitation their baby required, their description of mostly negative emotions indicates that they felt their baby's survival was in jeopardy. Given that almost half the babies required what may be regarded as being ‘minimal’ resuscitation, the responses of these fathers are all the more striking. In order to cope with their feelings during the resuscitation, most fathers adopted emotion-focused strategies.19 There is therefore the potential for HCPs to misinterpret these behaviours as disinterest. Uncertainty regarding the survival of their partner and baby is demonstrated by the conflict fathers described over the focus of their concern. The fathers' greater concern for their partner may have been influenced by their lack of understanding of their baby's condition particularly as they were given limited information before or during the resuscitation. They were also not encouraged to go to their baby or to touch or speak to their child during the resuscitation. They were not chaperoned during the event or debriefed afterwards.
There are a number of possible reasons why fathers could not recall HCPs giving them information about the resuscitation. Fathers may have been correct in their recollection. HCPs may not have felt it was their responsibility to inform the father or that they had other more important priorities at the time. Alternatively, HCPs may have given information but fathers ‘tuned it out’ as a coping strategy, or HCPs may have deliberately underplayed what was happening to minimise the potential impact of more detailed information.9 ,20 Giving information during emergency procedures can be complex, time-consuming and challenging; outcomes are often uncertain; the situation can change rapidly and the information needs of individuals who maybe highly stressed can be difficult to assess.13 ,21 Nevertheless, the apparent lack of information reported by fathers before, during and after their baby's resuscitation highlights issues regarding information giving, professional responsibility and non-compliance with practice guidelines.12 ,13 It also does not embrace the concept of family-centred care.22
Strengths and limitations
This is the first known study to specifically explore fathers' experiences of newborn resuscitation. Face-to-face interviews enabled fathers to tell their story in their own words. While these accounts were given retrospectively, none of the fathers had difficulty recalling their feelings. Fathers may have felt obliged to make positive comments about their experiences because their baby and in some cases their partner continued to receive care within the hospital.16 However, they were reassured that their comments would be anonymised and all fathers felt able to make negative comments at some point during their interview. While fathers could have found recounting their baby's resuscitation distressing,16 most seemed to find the interview a positive experience23 and said they hoped the study would help other fathers. Although undertaken in one setting, with 20 fathers, the findings from this independent study provide insight to the experiences of fathers and the context in which they occurred.17 The extent to which the findings apply to other fathers who encounter similar experiences can therefore be considered.
To gain a broader view of fathers' experiences, this study could be replicated with fathers under 18 years of age, non-English speakers, experienced fathers or fathers of multiple births or both. The longer term impact on fathers could also be investigated. It would also be valuable to explore the experiences of fathers where the baby did not survive the resuscitation. Although such a study would present ethical challenges, it would provide insight to an event that it might be anticipated has profound impact on a father. This in turn could influence the provision of support to such fathers in a positive way.
Implications for practice
A number of factors can be identified for HCPs to consider; several relate to the provision of information. In cases where problems were identified during the antenatal period, most fathers did not realise that the need for resuscitation was likely. This lack of awareness impacted on their preparation for the birth. This highlights the need for HCPs to ensure families fully understand the implications of what they are being told and includes all types of resuscitation that a baby may require. Some fathers would have liked a more detailed explanation of what was likely to happen immediately before the resuscitation and the opportunity to discuss what happened after the event. While this may not be the case for every father, HCPs should endeavour to determine the preferences of individual fathers.
Fathers encountering the resuscitation of their baby at delivery often do so with little warning at a time when their partner also requires emergency interventions. In these situations, fathers often experience more complex scenarios than relatives who witness the resuscitation of a family member in other settings. However, the findings suggest that these fathers did not receive the level of support recommended during WR8,–,10 ,24 ,25 and identifies issues for HCPs and the service more generally to consider in the provision of care and support for fathers. Possible strategies include enabling fathers who want to observe the resuscitation to do so, including in complex settings such as the operating theatre and helping fathers to go to their baby or to touch or speak to their child during the resuscitation if they wish. The provision of a chaperone during the resuscitation while desirable may be more problematic and may require commitment from service providers.
There is a growing awareness that meeting the needs of fathers facilitates their involvement in the lives of their children. Ways in which this can be promoted include ensuring birth environments are welcoming and supportive when problems arise.26 Supporting fathers before, during and after newborn resuscitation could be a step towards achieving this.
Acknowledgments
The authors would like to thank the fathers who participated in this study and were willing to share their experiences so readily. The authors would also like to thank the staff at the NHS Trust and in particular the neonatal nurse who helped MH to identify eligible participants.
References
Footnotes
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Collaborator Helen Pattison.
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Funding Development and approval of the study, participant recruitment, data collection and initial data analysis were undertaken when the first author held the Bliss Neonatal Nurse Research Fellow post at the National Perinatal Epidemiology Unit, University of Oxford. The first author's PhD fees were met by Birmingham City University and the first author. All other expenses were met by the first author. Aston University was the sponsor; this included the provision of university approval for the study. All aspects of the study were supervised by the second author.
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Competing interests None.
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Ethics approval Solihull Local Research Ethics Committee.
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Provenance and peer review Not commissioned; externally peer reviewed.