Skin-to-skin contact after birth: Developing a research and practice guideline.

AIM: Skin-to-skin contact immediately after birth is recognised as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality. However, the implementation and definition of skin-to-skin contact is inconsistent in both practice and research studies. This project utilised the World Health Organization guideline process to clarify best practice and improve the consistency of application. METHODS: The rigorous guideline development process combines a systematic review with acumen and judgement of experts with a wide range of credentials and experience. RESULTS: The developed guideline received a strong recommendation from the Expert Panel. The result concluded that there was a high level of confidence in the evidence and that the practice is not resource intensive. Research gaps were identified and areas for continued work were delineated. CONCLUSION: The World Health Organization guideline development process reached the conclusion immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 g with experienced staff if assistance is needed), after all modes of birth. Delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.

The nine stages of skin-to-skin: practical guidelines and insights from four countries.

Incorporating systematic evidence with clinical expertise is a key element in the quest to improve quality of care and patient outcomes. The evidence supporting skin-to-skin contact in the first hour after birth is robust and includes significantly improved outcomes for both mother and infant. This paper compares available iterative data about newborn behaviour in the first hour after birth to further describe the observable behaviour pattern and to provide clinical insight for further research. Although the evidence for positive outcomes through skin-to-skin contact are robust, there is a dearth of research specifically focused on clinical practice. The methodology considers the four available data sets that used Widström's 9 stages, which consists of studies from Japan, Sweden, Italy and the United States, examining the parameters of each stage across settings from around the world. This research provides an expanded understanding of the timing of the newborn's progression through Widström's 9 observable stages. We found that newborns in all four data sets began with a birth cry and continued through the remaining stages of relaxation, awakening, activity, rest, crawling, familiarization, suckling and sleeping during the first hours after birth and consolidated the data into a Sign of the Stages chart to assist in further research. The evidence supports making a safe space and time for this important newborn behaviour. Clinical practices should encourage and protect this sensitive period.

Skin-to-skin contact the first hour after birth, underlying implications and clinical practice.

AIM: This paper integrates clinical expertise to earlier research about the behaviours of the healthy, alert, full-term infant placed skin-to-skin with the mother during the first hour after birth following a noninstrumental vaginal birth. METHOD: This state-of-the-art article forms a link within the knowledge-to-action cycle, integrating clinical observations and practice with evidence-based findings to guide clinicians in their work to implement safe uninterrupted skin-to-skin contact the first hours after birth. RESULTS: Strong scientific research exists about the importance of skin-to-skin in the first hour after birth. This unique time for both mother and infant, individually and in relation to each other, provides vital advantages to short- and long-term health, regulation and bonding. However, worldwide, clinical practice lags. A deeper understanding of the implications for clinical practice, through review of the scientific research, has been integrated with enhanced understanding of the infant's instinctive behaviour and maternal responses while in skin-to-skin contact. CONCLUSION: The first hour after birth is a sensitive period for both the infant and the mother. Through an enhanced understanding of the newborn infant's instinctive behaviour, practical, evidence-informed suggestions strive to overcome barriers and facilitate enablers of knowledge translation. This time must be protected by evidence-based routines of staff.

The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth.

BACKGROUND: Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin, have been previously studied in relation to neonatal outcomes, especially breastfeeding, with conflicting results. We examined the normal neonatal behavior of suckling within the first hour after a vaginal birth while in skin-to-skin contact with mother in relation to these commonly used drugs. Suckling in the first hour after birth has been shown in other studies to increase desirable breastfeeding outcomes. METHOD: Prospective comparative design. Sixty-three low-risk mothers self-selected to labor with intrapartum analgesia/anesthesia or not. Video recordings of infants during the first hour after birth while being held skin-to-skin with their mother were coded and analyzed to ascertain whether or not they achieved Stage 8 (suckling) of Widström's 9 Stages of newborn behavior during the first hour after birth. RESULTS: A strong inverse correlation was found between the amount and duration of exposure to epidural fentanyl and the amount of synthetic oxytocin against the likelihood of achieving suckling during the first hour after a vaginal birth. CONCLUSIONS: Results suggest that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decreased the likelihood of the baby suckling while skin-to-skin with its mother during the first hour after birth.

A plausible pathway of imprinted behaviors: Skin-to-skin actions of the newborn immediately after birth follow the order of fetal development and intrauterine training of movements.

We hypothesize that the competence of a newborn in the first hours after birth is the direct result of behavior training that begins during the first 12 weeks of fetal life. Correlation of Widström's 9 Instinctive Stages (behaviors of the full-term newborn during the first hours after birth) with the developmental movements during fetal life demonstrate that the fetus is invested in learning specific tasks, in a specific order, that are evolutionarily necessary for survival during the first hour and beyond.

The effect of labor medications on normal newborn behavior in the first hour after birth: A prospective cohort study.

BACKGROUND: Skin-to-skin contact after birth between mother and baby has immediate and long-term advantages. Widström's 9 Stages of Newborn Behavior offer an opportunity to evaluate a baby in the natural, expected and optimal habitat. Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin (synOT), have been studied in relation to neonatal outcomes with conflicting results. AIMS: Determine the effects of common intrapartum medications on the instinctive behavior of healthy newborns during the first hour after birth through a prospective cohort study. STUDY DESIGN: Video record newly-born term infants during the first hour after birth while in skin-to-skin contact with mother. Code and analyze videos using Widström's 9 Stages; compare with the labor medications mothers received. SUBJECTS: Convenience sample of sixty-three low-income mothers self-selected to labor with or without intrapartum analgesia. OUTCOME MEASURES: Duration of time infants spend in each of Widström's 9 Stages for four cohorts: 1) exposed to no synOT or epidural fentanyl during labor, 2) exposed to fentanyl (but not synOT), 3) exposed synOT (but not fentanyl), 4) exposed to both fentanyl and synOT. RESULTS: A strong inverse correlation was found between intrapartum exposure to fentanyl and synOT and the normal behavior of an infant, as measured by time in each Stage. CONCLUSIONS: Intrapartum exposure to the drugs fentanyl and synOT is associated with altered newborn infant behavior, including suckling, while in skin-to-skin contact with mother during the first hour after birth. Widström's 9 Stages offer an opportunity to analyze newborn behavior whilst in the optimal habitat of the infant.

Experience of perceived barriers and enablers of safe uninterrupted skin-to-skin contact during the first hour after birth in Uganda.

OBJECTIVE: To identify barriers and enablers to conducting safe uninterrupted skin-to-skin contact (SSC) in the first hour after birth in a low-resource setting and to evaluate how health care professionals coped with the identified barriers after completion of an intervention package. DESIGN AND SETTING: A qualitative method using focus-group and individual interviews with health professionals at a governmental hospital in Uganda. PARTICIPANTS: 81 health professionals. INTERVENTIONS: A 6-step intervention package including, amongst other things, showing a DVD on safe uninterrupted SSC following birth and discussing with the professionals what barriers and possibilities there were to changing practice to allow SSC for one hour. MEASUREMENTS AND FINDINGS: The thematic analysis of the intervention interviews yielded the following themes: Perceived barriers including medical events, psychosocial issues and standard midwifery practice; Pragmatic barriers including economic constraints in the hospital and community; Anticipated barriers by staff and families; Enabling events including staff involvement. Most of the barriers involving expenses were not solved. When the mother and infant had to move to the postnatal ward within one hour after birth, there were difficulties in keeping SSC during the transportation, but this obstacle was partly solved. A few mothers (i.e. depressed and/or adolescent) were considered to be unwilling to keep the infant skin-to-skin; this difficulty was not solved. Practising SSC led the participants to find advantages such as reduced work load and positive effects on pain during suturing. CONCLUSIONS: SSC following birth was shown to be applicable and accepted by the health professionals. The involvement of professionals had clinical implications, such as initiatives to broadcast the message of SSC by radio to the community and introduce SSC to women having a Caesarean section.

High female mortality resulting in herd collapse in free-ranging domesticated reindeer (Rangifer tarandus tarandus) in Sweden.

Reindeer herding in Sweden is a form of pastoralism practised by the indigenous Sámi population. The economy is mainly based on meat production. Herd size is generally regulated by harvest in order not to overuse grazing ranges and keep a productive herd. Nonetheless, herd growth and room for harvest is currently small in many areas. Negative herd growth and low harvest rate were observed in one of two herds in a reindeer herding community in Central Sweden. The herds (A and B) used the same ranges from April until the autumn gathering in October-December, but were separated on different ranges over winter. Analyses of capture-recapture for 723 adult female reindeer over five years (2007-2012) revealed high annual losses (7.1% and 18.4%, for herd A and B respectively). A continuing decline in the total reindeer number in herd B demonstrated an inability to maintain the herd size in spite of a very small harvest. An estimated breakpoint for when herd size cannot be kept stable confirmed that the observed female mortality rate in herd B represented a state of herd collapse. Lower calving success in herd B compared to A indicated differences in winter foraging conditions. However, we found only minor differences in animal body condition between the herds in autumn. We found no evidence that a lower autumn body mass generally increased the risk for a female of dying from one autumn to the next. We conclude that the prime driver of the on-going collapse of herd B is not high animal density or poor body condition. Accidents or disease seem unlikely as major causes of mortality. Predation, primarily by lynx and wolverine, appears to be the most plausible reason for the high female mortality and state of collapse in the studied reindeer herding community.

Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial.

BACKGROUND: Infants with latch-on problems cause stress for parents and staff, often resulting in early termination of breastfeeding. Healthy newborns experiencing skin-to-skin contact at birth are pre-programmed to find the mother's breast. This study investigates if skin-to-skin contact between mothers with older infants having severe latching on problems would resolve the problem. METHODS: Mother-infant pairs with severe latch-on problems, that were not resolved during screening procedures at two maternity hospitals in Stockholm 1998-2004, were randomly assigned to skin-to-skin contact (experimental group) or not (control group) during breastfeeding. Breastfeeding counseling was given to both groups according to a standard model. Participants were unaware of their treatment group. Objectives were to compare treatment groups concerning the proportion of infants regularly latching on, the time from intervention to regular latching on and maternal emotions and pain before and during breastfeeding. RESULTS: On hundred and three mother-infant pairs with severe latch-on problems 1-16 weeks postpartum were randomly assigned and analyzed. There was no significant difference between the groups in the proportion of infants starting regular latching-on (75% experimental group, vs. 86% control group). Experimental group infants, who latched on, had a significantly shorter median time from start of intervention to regular latching on than control infants, 2.0 weeks (Q1 = 1.0, Q3 = 3.7) vs. 4.7 weeks (Q1 = 2.0, Q3 = 8.0), (p-value = 0.020). However, more infants in the experimental group (94%), with a history of "strong reaction" during "hands-on latch intervention", latched-on within 3 weeks compared to 33% in the control infants (Fisher Exact test p-value = 0.0001). Mothers in the experimental group (n = 53) had a more positive breastfeeding experience according to the Breastfeeding Emotional Scale during the intervention than mothers in the control group (n = 50) (p-value = 0.022). CONCLUSIONS: Skin-to-skin contact during breastfeeding seems to immediately enhance maternal positive feelings and shorten the time it takes to resolve severe latch-on problems in the infants who started to latch. An underlying mechanism may be that skin-to-skin contact with the mother during breastfeeding may calm infants with earlier strong reaction to "hands on latch intervention" and relieve the stress which may have blocked the infant's inborn biological program to find the breast and latch on. TRIAL REGISTRATION: Karolinska Clinical Trial Registration number CT20100055.

A Realistic Evaluation of Two Training Programs on Implementing Skin-to-Skin as a Standard of Care.

The authors used realistic evaluation to examine the real-world effectiveness of two 5-day training techniques on sustained optimal skin-to-skin practices that support Step 4 of the revised Baby-Friendly Hospital Initiative (BFHI). The authors found that education alone was insufficient to effect sustainable practice change. Exposure to the 5-day immersion model (Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success, or PRECESS) alone or combined with education was an effective strategy to change and sustain the standard of care for skin-to-skin practice (p < 0.00001). The intended outcome of sustained practice change toward implementation of skin-to-skin care through immersion or a combined approach shows promise and should be repeated in other localities.

Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates.

PURPOSES: Skin-to-skin care after birth often is absent, interrupted, or delayed for routine procedures. The purposes of this project were to improve skin-to-skin care and exclusive breastfeeding at hospital discharge. METHODS: For Part 1, we used a descriptive observational design, with video-ethnography and interaction analysis (PRECESS-Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success), during a 5-day quality improvement pilot study in a U.S. hospital (August 13-17, 2010). For Part 2, we used electronic health record review to test for differences in monthly rates of skin-to-skin care and exclusive breastmilk feeding (baseline, July 2010; post-intervention, August-December 2010). RESULTS: In Part 1, 11 mothers and babies participated: 10 (91%) received immediate skin-to-skin care, eight (73%) received uninterrupted skin-to-skin care, nine (82%) planned to breastfeed, six (67%) of these babies were exclusively breastfeeding at hospital discharge, and five (83%) of the six babies who completed all nine instinctive stages during skin-to-skin care were exclusively breastfeeding at hospital discharge. In our subsequent review (Part 2), we found a significant improvement (25% above baseline) in the overall rate of skin-to-skin care across post-intervention months (Pearson χ(2)=23.798, df=5, p<0.000), predominantly from improvements in the cesarean section population. The rates of exclusive breastfeeding showed no significant change. CONCLUSIONS: The PRECESS immersion method may help to rapidly improve skin-to-skin care. Babies who undergo all nine stages during skin-to-skin care may be more likely to exclusively breastfeed. Mothers need support during skin-to-skin care to recognize their baby's readiness to breastfeed. Skin-to-skin care during cesarean surgery may reduce maternal stress and improve satisfaction with the surgical experience.

Hands-on approach during breastfeeding support in a neonatal intensive care unit: a qualitative study of Swedish mothers' experiences.

BACKGROUND: Assisting mothers to breastfeed is not easy when babies experience difficulties. In a neonatal intensive care unit (NICU), nurses often help mothers by using hands-on-breast without their permission. Little is known about how mothers feel about this unusual body touching. To gain more knowledge from mothers who lived through this experience, this hands-on practice was studied in a NICU in Sweden. METHODS: Between January and June 2001, in-depth interviews were conducted with ten mothers of preterm or sick term infants and all of them experienced the hands-on approach. In this research, Radnitzky's seven principles of hermeneutic interpretation were applied in order to interpret the meaning of mothers' responses. This article presents results related to the period of initiation of breastfeeding. This qualitative study was based on a combination of the models of Gustafsson, Orem, and Aarts' Marte Meo. RESULTS: Five main themes were identified: Insult to integrity, Manipulating the baby, Understanding and adjustment, Breasts as objects, Alternatives to this practice. Hands-on help in the breastfeeding situation was experienced as unpleasant and the women experienced their breasts as objectified. The mothers accepted the hands-on help given by nursing staff, even though they considered it unpleasant. Most mothers expressed a need for assistance when starting breastfeeding, but could not suggest any alternative to hands-on help such as demonstrating with an artificial breast and a doll. CONCLUSION: The study provides information about how mothers experience unexpected hands-on help with breastfeeding in a NICU, which has not been described previously. Since most mothers in this study regarded this behavior as unpleasant and not helpful mostly because it was unexpected and unexplained, it would be important to either explain beforehand to mothers what type of physical approach could be attempted on their body or better, to avoid this type of approach completely.

Night rooming-in: who decides? An example of staff influence on mother's attitude.

BACKGROUND: In 1989 the World Health Organization and UNICEF introduced the "Ten Steps" for successful breastfeeding. One step suggests that a mother and her newborn baby should remain together day and night during the hospital stay. The purpose of this study was to investigate, first, whether or not mothers in our hospital roomed-in with their babies at night, second, the attitudes of mothers toward night rooming-in and their feelings of closeness to their babies, and third, how mothers perceived hospital staff attitudes toward night rooming-in. METHODS: All mothers ( n = 132) of Nordic ancestry and with good knowledge of the Swedish language, who were admitted to the maternity wards during a 2-week period at Karolinska University Hospital, Stockholm, Sweden, answered a questionnaire on demographic background data and their current night rooming-in practices, including an attitude scale. RESULTS: Most study mothers were positive toward night rooming-in, regardless of whether they had roomed in with their babies at night (93% positive) or not (73% positive). Mothers who had not roomed-in with their babies were more likely to perceive that the staff believed their babies should stay in the nursery compared with those mothers who practiced night rooming-in (z = -2.733, p = 0.006). Mothers not rooming-in with their babies scored closeness to their babies as less important than those mothers who roomed-in with their babies (z = -3.780, p = 0.0002); they also were more worried about their own and their babies' sleep (z = -2.321, p = 0.02) and disturbing noises (z = -3.487, p = 0.0005). CONCLUSIONS: Mothers who left their babies in the nursery at night more often perceived that the staff believed their babies should stay in the nursery, rating closeness between mother and infant lower. Hence, negative staff attitudes toward night rooming-in may implicitly suggest to mothers that closeness between mothers and babies is not important.