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The Sacred Hour: Uninterrupted Skin-to-Skin Contact Immediately After Birth
Raylene Phillips MD, IBCLC, FAAP ⁎
Division of Neonatology, Loma Linda University Children’s Hospital, Loma Linda, CA
abstractarticle info
Keywords:
Birth
Newborn
Skin-to-skin
Breastfeeding
The manner in which a new baby is welcomed into the world during the first hours after birth may have short-
and long-term consequences. There is good evidence that normal, term newborns who are placed skin to skin
with their mothers immediately after birth make the transition from fetal to newborn life with greater
respiratory, temperature, and glucose stability and significantly less crying indicating decreased stress.
Mothers who hold their newborns skin to skin after birth have increased maternal behaviors, show more
confidence in caring for their babies and breastfeed for longer durations. Being skin to skin with mother
protects the newborn from the well-documented negative effects of separation, supports optimal brain
development and facilitates attachment, which promotes the infant’s self-regulation over time. Normal babies
are born with the instinctive skill and motivation to breastfeed and are able to find the breast and self-attach
without assistance when skin-to-skin. When the newborn is placed skin to skin with the mother, nine
observable behaviors can be seen that lead to the first breastfeeding, usually within the first hour after birth.
Hospital protocols can be modified to support uninterrupted skin-to-skin contact immediately after birth for
both vaginal and cesarean births. The first hour of life outside the womb is a special time when a baby meets
his or her parents for the first time and a family is formed. This is a once-in-a-lifetime experience and should
not be interrupted unless the baby or mother is unstable and requires medical resuscitation. It is a “sacred”
time that should be honored, cherished and protected whenever possible.
© 2013 Published by Elsevier Inc.
The power of first impressions is well known. None may be more
significant than the first experiences of a newborn baby exiting
mother’s womb. Our first impression of life outside the womb, the
welcome reception we receive immediately after birth, may color our
perceptions of life as difficult or easy, hostile or safe, painful or
comforting, frightening or reassuring, cold and lonely or warm and
welcoming. The events surrounding birth have the potential to set the
stage for patterns of subconscious thought processes and behaviors
that persist for a lifetime.
Second only to the experience of dying, the experience of being
born may be the most mysterious. Since most adults have no conscious
memory of what it was like to be a newly born infant, let alone what it
was like to be a fetus in the womb, most have not bothered to speculate
about the birth process from the baby’s perspective. Yet, when the
unconscious memory is open to recall during hypnosis, vivid and
detailed memories of prenatal life, the birth experience and early
events as a newborn infant readily emerge for many.
While the mechanism for how a fetus or a newborn can create such
fully formed memories with such immature brains remains unknown,
the reality of prenatal, birth and newborn memories cannot be denied.
There are many accounts of young children (usually up to about age
3–5 years) who remember events that occurred around the time of
their birth and feelings they experienced. The perceptions and
interpretations are sometimes skewed, but the vividness and accuracy
of specific details and events are often astounding.
In his groundbreaking book, “Babies Remember Birth,”David
Chamberlain, PhD, shares his research, which compared the birth
stories of 10 different mothers with the birth memories of their children.
During separate sessions under hypnosis, mothers and their children
were asked to describe the birth process. Although the children, some
now adults, had not been told about their birth history, their accounts of
the events surrounding their births contained many specificandunique
detailsincommonwiththeirmother’s accounts, validating the accuracy
of the children’s birth memories.
1
Dr. Chamberlain’snewestbook,
“Windows to the Womb”documents the large body of research
exploring the many and varied ways that unborn and newly born
babies are able to show us their capacities for learning and memory.
2
Why is this important? If babies and even fetuses are, indeed,
capable of forming memories that remain in their subconscious for
life, how they are treated at birth and their early experiences outside
the womb matter much more than we have been led to believe!
Because the first hour after birth is so momentous, we have named
it “The Sacred Hour”at our hospital. Every culture has occasions and
ceremonies it holds sacred that are honored, cherished and protected.
In most cultures, for example, a wedding ceremony is considered a
sacred occasion. This special event honors the symbolic union of two
individuals who have chosen to share their lives together. No one
Newborn & Infant Nursing Reviews 13 (2013) 67–72
⁎Addresscorrespondenceto Raylene Phillips,MD, IBCLC, FAAP,Division of Neonatology,
Loma Linda University Children’s Hospital,11175 Campus Street, Suite11121, Loma Linda,
CA 92354.
E-mail address: rphillips@llu.edu.
1527-3369/1302-0508$36.00/0 –see front matter © 2013 Published by Elsevier Inc.
http://dx.doi.org/10.1053/j.nainr.2013.04.001
Contents lists available at SciVerse ScienceDirect
Newborn & Infant Nursing Reviews
journal homepage: www.nainr.com
would think of interrupting a wedding ceremony to give the bride and
groom details about the flight arrangements for their honeymoon.
Everyone recognizes that this information can wait until after the
ceremony is completed. Birth is another sacred event. It is a time
when a new member of the family arrives, is greeted for the first time
and welcomed by his or her parents. Yet, in many hospital settings,
this once-in-a-lifetime process is routinely interrupted for details that
can easily wait until after the new baby has had time to adjust to life
outside the womb in the loving arms of the mother, and after the baby
and parents have had time to meet each other as a new family.
What might the first moments after birth be like for the newborn
infant? If a fetus has been fortunate enough to spend his fully allotted
266 days in the womb since conception, he has had the luxury of
having all his emerging developmental needs met. The uterus and the
placenta have provided warmth, protection, nutrition and oxygen, as
well as close and continual proximity to the mother’s heart and voice.
Being in the womb is the “natural habitat”for the unborn fetus. After
birth, the mother’s body and breasts take over the function of the
uterus and placenta in providing warmth, protection, nutrition, and
support for optimal oxygenation, as well as close and continual
proximity to the mother’s heart and voice. Being skin to skin with the
mother is the newborn infant’s“natural habitat”—the one place
where all his needs are met.
This is true for all mammals and can readily be seen in the animal
world. Everywhere one looks in nature, mother and newborn
mammals are as close as they can get to each other skin to skin or
fur to fur. Nature is wise and provides instincts that drive behaviors
designed to assure survival of the species.
There are many well-documented benefits of skin-to-skin contact
between a newborn infant and its mother. Skin-to-skin contact
improves physiologic stability for both mother and baby in the
vulnerable period immediately after birth, increases maternal
attachment behaviors, protects against the negative effects of
maternal–infant separation, supports optimal infant brain develop-
ment, and promotes initiation of the first breastfeeding, resulting in
increased breastfeeding initiation and duration rates. Although a
complete review of all the benefits of early postpartum skin-to-skin
contact between mother and newborn is beyond the scope of this
article, we will briefly explore several of them.
Skin-to-Skin Contact Provides Physiologic Stability
Being skin to skin with mother stabilizes the newborn’s respiration
and oxygenation, increases glucose levels (reducing hypoglycemia),
warms the infant (maintaining optimal temperature), reduces stress
hormones, regulates blood pressure, decreases crying and increases
the quiet alert state.
3
Thermal synchrony is a phenomenon whereby the temperature of
mother’s chest increases to warm a cool baby and decreases to cool an
overly warm baby. While often seen with premature infants who are
skin to skin in kangaroo care, this phenomenon is equally important
for the newborn infant who has just exited the warmth of mother’s
womb into the cooler extra-uterine environment, wet and easily
chilled. In a study done with babies after cesarean delivery, babies
held skin to skin by their fathers had higher temperature and glucose
levels compared to those of babies left alone under warmers.
4
Skin-to-Skin Contact Promotes Maternal Attachment Behaviors
Attachment is so necessary for survival of the newborn mammal,
that nature has not left it to chance, and has provided biochemical
activators that prime the brain’s reward circuitry to increase maternal
care-giving behaviors. Hormones known to influence attachment
behaviors are increased by skin-to-skin contact. This is true in adults
as well, but is especially important in the vulnerable newborn period.
Oxytocin is one such hormone that has been particularly well studied in
relationship to attachment and is often referred to as the “love
hormone.”It has been shown to increase relaxation, attraction, facial
recognition, and maternal care-giving behaviors, all necessary to ensure
infant survival. Oxytocin is increased during skin-to-skin contact and
levels spike whenever the newborn’s hand massages mother’s breasts.
5
Multiple studies in the 1970–1980s compared behaviors of
mothers who had short periods (as little as 15 minutes) of skin-to-
skin contact with their newborns to those who briefly viewed their
infants and then were reunited every 4 hours for feeding while the
babies were otherwise kept in a nursery separate from their mothers.
At the end of the postpartum hospital stay, mothers who had even
brief early skin-to-skin contact with their infants were more confident
and comfortable handling and caring for their babies than mothers
who had been separated from their babies.
6
Results lasted well beyond the neonatal period. At 3 months,
mothers with early skin-to-skin contact kissed their babies more and
spent more time looking into their infant’s faces. At 1 year they
demonstrated more touching, holding, and positive speaking behav-
iors, kept more follow-up appointments with their primary care
providers and breastfed their babies longer. One study showed double
the breastfeeding duration associated with only 15 minutes of skin-
to-skin holding immediately after birth.
Skin-to-Skin Contact Protects From the Negative Effects of Separation
Babies are born ready to interact with mother. If a newborn has not
been exposed to excessive medication, its alert awareness and intense
focus on its mother’s face is obvious to all who are present. Until the
moment the cord is cut, a mother and her baby are literally a single
biological organism. Until several months after birth, mother and baby
remain a single “psychobiological organism.”The experience of an
infant who is separated from the mother is graphically described by
Gallager. “Mother and offspring live in a biological state that has much
in common with addiction. When they are parted, the infant does not
just miss its mother. It experiences a physical and psychological
withdrawal from a host of her sensory stimuli not unlike the plight of
a heroin addict who goes ‘cold turkey.”’ (p 13)
7
From a baby’s perspective, separation is life threatening! The
universal response of baby mammals to separation from the mother is
biphasic; first protest, then despair. The initial response to separation
from the mother is to protest with loud cries and intense activity. This is
an instinctive response to beingoutside the newborn’s“natural habitat,”
the place of warmth, nutrition and safety. Loud cries and intense activity
are protests designed to bring the newborn’s plight to the mother’s
attention so she can bring the newborn back into contact with her body,
providing rescue from cold, starvation, potential harm, or even death.
While this is readily seen in the animal world, the same instinctive
response is also clearly seen in newborn human infants. When the
crying behavior of human infants who are separated from their mothers
is compared to those who are skin to skin with their mothers, it has
been found that separated infants have 10 times the number of cries
and 40 times the duration of crying.
8
Because separation is the cultural
norm in the developed world and newborn cryingis so common, many
see it as normal behavior, yet frantic crying is not good for newborns. It
impairs lung functioning, increases intra-cranial pressure, jeopardizes
the closure of the foramen ovale, and increases stress hormones.
If separation continues for a prolonged period, the newborn
mammal’s response is “despair”. The baby’s cries eventually stop,
intense activity ceases and the infant becomes still —the baby gives
up. This is also an instinctive behavior to avoid attracting attention
from potential predators. All systems slow down for prolonged
survival. Temperature drops, heart rate decreases and metabolism
slows down. Hypothermia, bradycardia, and hypoglycemia are all
common complications of newborns that are separated from their
mothers even in Special Care Nurseries. Short periods of separation
resulting in protest is not thought to be harmful to the developing
68 R. Phillips / Newborn & Infant Nursing Reviews 13 (2013) 67–72
brain, but repetitive and prolonged separation resulting in “despair”
has been well documented as harmful with lifelong consequences.
This was such a concern in primate research that a document was
published in 2002 entitled, “The Welfare of Non-human Primates used
in Research: Report of the Scientific Committee on Animal Health and
Animal Welfare”in which the biphasic response of “protest”and
“despair”to maternal–infant separation was described, including the
physiological disturbance in the regulation of heart rate, body
temperature, sleep patterns, cortisol secretion and the immune
system. This document recommended that research primates not be
separated from mothers for 6–18 months, depending on the species of
monkey. Monkeys raised in isolation from their mothers invariably
became deeply depressed within a few days and remained socially
withdrawn. They often became pathologically violent in adolescence
and thus unfit for research.
9
Hundreds of experiments in animal research have documented the
negative effects of maternal–infant separation. In many studies designed
to explore the effects of stress on various organ systems, separation of
newborns from their mothers produces enough stress to see profound
and often permanent changes in the organ system being studied that
persist to adulthood. One such study examined the separation of piglets
from their mothers on days 3–11 for only 2 hours per day. On days 12
and 56 the piglets’weight,behaviors,immunesystem,hormonal,and
brain parameters were measured. Results showed decreased weight
gain and activity levels, increased corticotrophin releasing hormone
activation in the hypothalamus, higher plasma levels of cortisol,
increased glucocorticoid receptors, suppression of the immune function
and higher interleukin concentration in the limbic area.
10
A more recent study examined mare–foal attachment and the
bonding and social development of foals during the first year of life,
corresponding to the developmental period from birth to adolescence
in humans.
11
Foals that had experienced human handling for 1 hour
after birth while being gently restrained from contact with their
mothers (who remained in close proximity) showed the same
biphasic response to separation as seen in primates. They first
struggled valiantly, trembled and had increased respirations (pro-
test), then became motionless but maintained high tone (freeze/
despair). After 1 hour when they were released, there was a delay in
the first standing and first suckling. Many had inappropriate suckling
patterns, making sucking motions in the air or toward their human
handler and chewing on the teat. All foals eventually learned to suckle
and were raised with their mothers in the same pasture as were the
foals that had not been handled for the first hour after birth.
Experimental foals showed clear signs of insecure attachment by
staying closer to their mothers, playing less with their peers, and
showing less curiosity in exploring novel objects in the pasture. More
disturbingly, they were also more aggressive towards the other foals.
All foals were weaned at 7 months with a temporary separation from
their mothers. The experimental foals were less adaptable to the
change, producing stress vocalizations for 4 compared to 2 days. All
foals were reunited with their mothers after weaning and then
permanently separated at 1 year. The experimental foals continued to
keep more distance from their peers and showed more aggressive
behaviors during adolescence and adulthood.
11
Stanley Graven, MD, a developmental neonatologist cautions, “It is
a serious mistake for professionals who provide care for neonates to
assume that the principles derived from careful animal studies do not
apply to human infants. The risk of suppression or disruption of
needed neural process…is very significant and potentially lasts a
lifetime.”(p 210).
12
Skin-to-Skin Contact Supports Optimal Brain Development
The brains of newborn infants are not fully mature. The human
brain of a newborn is only 25% the size it will be in adulthood. While
all cells are present, myelination and synaptic development are not
yet complete. Allan Schore, PhD, a neurobiologist from UCLA, and
others have been exploring the roll of attachment and brain
development for many years and explain that the amygdala is in a
critical period of maturation in the first 2 months after birth. The
amygdala is located deep in the center of the brain and is part of the
limbic system involved in emotional learning, memory modulation,
and activation of the sympathetic nervous system. Skin-to-skin
contact activates the amygdala via the prefronto-orbital pathway
and thus contributes to the maturation of this vital brain structure.
13
Harry Harlow, PhD, in his famous research with Rhesus monkeys
found that monkeys raised without their mothers preferred the touch
of a fur-covered wire surrogate mother to one without fur but with
milk in a bottle. Touch was more important than food to motherless
monkeys!
14
Drs. William Mason and Gerson Berkson demonstrated
that touch and movement were both required for normal brain and
social development by a novel experiment where baby monkeys were
raised with a motionless fur-covered surrogate mother or an identical
fur-covered surrogate that moved in a random back and forth and up
and down motion. Only monkeys who were raised with both touch
and motion had normal brain development, demonstrating the
importance of maternal holding and carrying throughout infancy for
ongoing brain development.
15
Based on the work of Harlow, Mason and Berkson, James Prescott,
PhD, a neuropsychologist and health scientist administrator at the
National Institute of Child Health and Human Development (NICHD),
one of the institutes of the United States National Institutes of Health
(NIH) from 1966 to 1980, asserted that touch and motion were the
most important senses for normal brain development. He was the first
to identify that touch and motion were critical for normal neurointe-
gration of the cerebellum–limbic–prefrontal cortex.
16
In addition to his own research, Dr. Prescott examined the research
of anthropologists who had provided detailed descriptions of
primitive cultures. After evaluating the data about 49 primitive
cultures, Dr. Prescott was able to predict which cultures were peaceful
versus violent cultures with a simple observation. Cultures in which
babies were carried on mothers’bodies throughout the first year after
birth were more peaceful cultures and those that did not were more
violent cultures. Interestingly, he also identified an association
between longer duration of breastfeeding (greater than 2 1/2 years)
and low or absent suicide rates in 26 primitive cultures. Dr. Prescott
speculated that there is a sensitive period during infant brain
development when pleasurable touch and movement are necessary
and protective against depression and violence.
17
John Bowlby, the
famous attachment psychologist, also claims that infant carrying and
direct body contact are essential for normal infant development. Being
skin-to-skin during the first hour after birth sets a pattern of behaviors
between mothers and infants that supports continued body contact
and carrying, and thus normal brain development of the infant.
18
Mother–infant attachment is important in the development of the
newborn’s ability to self-regulate and maintain homeostasis. At first,
the mother is the baby’s regulator. The dyadic interaction between the
mother and the newborn controls and modulates the newborn’s
exposure to environmental stimuli and by doing so serves as a
regulator of the developing individual’s internal homeostasis.
19,20
Face-to-face and voice-to-ear communication, eye-to-eye contact,
and hand-to-body touch are not just pleasant interactions between
mother and baby, but involve active brain development as synaptic
connections are formed. The mother rouses the sleepy infant and
encourages interaction by her voice, touch, and eye contact and if the
infant becomes over-stimulated, the attuned mother will hold her
baby close, make soothing sounds and shield her baby from loud
noises or bright lights to allow the baby to become calm and relaxed
again. This regulatory function of the newborn–mother interaction
may be an essential promoter of synaptic connections and functional
brain circuits in the newborn brain.
19
One-year old infants, who had
spent the first 1–2 hours skin-to-skin with their mother, were found
69R. Phillips / Newborn & Infant Nursing Reviews 13 (2013) 67–72
to have better self-regulation when evaluated in a research setting
during a structured play session. They were less easily frustrated and
better able to calm themselves.
21
Dr. Schore asserts that the brain is designed to be sculpted into its
final configuration by the effects of early experiences and that these
experiences are embedded in the attachment relationship.
22
He and
others who study attachment and brain development emphasize that
early interpersonal events can positively and negatively impact the
structural organization of the brain. Early experiences may shape
brain structure and function in a manner that is designed to provide
the individual with the type of brain best suited to the environment he
or she is born into. A traumatic or hostile environment would require
a brain designed for caution and defense, whereas a supportive
environment would allow for a brain designed to grow and thrive. If
the attachment relationship is, indeed, a major organizer of brain
development, then attachment is far more important than simply
providing a fundamental sense of safety or security.
23
If the birth process did not go as planned and the baby’sfirst
impressions of life outside the womb are less than ideal, all is not lost.
Bonding and attachment are so critical for survival that nature has
made it possible for both to occur at any time during a lifetime.
However, the longer after birth the process is begun, the more difficult
it is and greater is the risk of incomplete bonding or insecure
attachment. Fortunately, human beings are capable of recovering
from most types of trauma with appropriate insight, support, and
healing techniques. The bottom line is —whatever supports early
mother–infant attachment, supports infant brain development!
Skin-to-Skin Contact Increases Breastfeeding Rates and Duration
All mammals have a set sequence of behaviors at birth –all with a
single purpose –to breastfeed. Baby mammals are born to
breastfeed! Surprisingly, it is the newborn that initiates breastfeed-
ing, not the mother. However, being warm, being fed and being
protected are intricately and inseparably linked to being in the right
place, and the “right place”is bodily contact with mother. When skin
to skin, the newborn displays an impressive and purposeful motor
activity, which, without maternal assistance, brings the baby to the
mother’s breast. All newborn mammals are born knowing how to
breastfeed, but this is a place-dependent competence that requires
skin-to-skin contact.
As early as the 1970s, Ann-Marie Widstrom, PhD, RN, MTD, a
Swedish nurse-midwife, began to notice a pattern in the behaviors of
babies that were placed skin to skin with their mothers immediately
after birth and allowed to peacefully adjust to extra-uterine life with
no interruptions. Being a researcher, she began to document what she
saw and published her observations in 1990.
24
In 2011, a beautiful
teaching film was created by Healthy Children Project documenting
nine instinctive stages Dr. Widstrom had observed in the behaviors of
healthy newborn infants when they are placed skin to skin with the
mother immediately after birth and left uninterrupted until after the
first breastfeeding. The DVD, entitled “Skin to Skin in the First Hour
After Birth: Practical Advise for Staff after Vaginal and Cesarean Birth”
is a very useful tool for anyone involved in caring for newborns to
learn about normal infant behaviors when babies are placed skin to
skin after birth.
25
The nine instinctive stages include 1) the birth cry, 2) relaxation, 3)
awakening, 4) activity, 5) resting, 6) crawling, 7) familiarization, 8)
suckling, and 9) sleeping. The birth cry (1st stage) occurs immediately
after birth as the baby’s lungs expand but usually ends abruptly when
the baby is placed onto the mother’s chest. Relaxation (2nd stage)
begins when the birth cry stops and usually lasts 2–3 minutes during
which the baby is very quiet and still. Awakening (3rd stage) begins
with small head movements, as the infant opens his eyes and shows
some mouth activity. During activity (4th stage) the baby has more
stable eye opening, increased mouthing, and suckling movements and
often some rooting. Resting (5th stage) can occur at any time between
the other stages. Many assume, when babies were resting, that they
have given up trying to find the breast and seem to clearly need
assistance to breastfeed successfully. With knowledge of the nine
instinctive stages, we know this is simply a normal stage and babies
will move on when they are ready.
25
Indeed, rushing a newborn to the
breast during a resting stage is usually counterproductive. During
crawling (6th stage) the baby makes short pushing exertions with his
feet or slides his body towards one of the mother's breasts. The baby
may lift the upper torso and bob his head in a clear effort to get near the
breast. After reaching the breast, familiarization (7th stage) begins and
may last up to 20 minutes while the baby becomes acquainted with the
nipple by licking, touching and massaging. During all of these stages,
the baby moves in a purposeful manner but without frustration or
hurry. The challenge for those observing is to relax, leave the baby and
the mother alone and marvel at the amazing drama unfolding as the
baby finds the breast, latches and suckles without assistance or
interference. After adequate familiarization with the new environ-
ment and mother’s nipple, the newborn opens his mouth wide,
cupping the tongue which is now low in the bottom of the mouth,
grasps the nipple in a correct latch and begins to suckle (8th stage).
This usually occurs about an hour after birth. Sleeping (9th stage)
follows usually between 1.5 and 2 hours after birth.
25
If all staff personnel are educated about this normal and instinctive
process, they will be equipped to be supportive of baby’s progress
towards the first breastfeeding. Knowledge of the nine instinctive
stages of newborn behaviors provides a roadmap to reassure staff that
assistance is not necessary and often interferes rather than helps.
Newborns should not be rushed to suckle when they have not had
time to go through the previous seven stages, as they will not be
ready. It has been noted, for example, that early in the familiarization
stage, the newborn’s tongue is flat and high in the roof of the mouth,
whereas just prior to self-attaching, the baby cups the tongue and
drops it while opening the mouth wide for a deep and effective latch.
When babies are rushed to the breast before all their senses are
awakened and before their tongues are familiar enough with the
nipple, latching is often unsuccessful and everyone is frustrated.
A DVD entitled “The Magical Hour: Holding Your Baby Skin to Skin
During the First Hour after Birth”is a wonderful resource for families
that includes interviews with parents whose babies had been placed
skin to skin immediately after birth. The DVD includes an explanation
of the nine instinctive stages of newborn behaviors and beautifully
filmed video recordings of babies experiencing each stage. A double-
sided, one-page handout describing the nine instinctive stages of
newborn behaviors is also available to be given to parents prenatally
and/or just prior to delivery.
26
If parents and family members are educated about what to expect
after their baby is born, they will be less inclined to interrupt the
process by wanting to hold the baby and be willing to leave the baby
skin to skin with the mother until after the first breastfeeding. Fathers
and other family members love knowing what to expect and watch in
amazement as babies progress through the stages as described by
staff, in the DVD and on the handout.
Protocols That Promote Uninterruped Skin-to-Skin Contact
Immediately After Birth
Many postpartum hospital care protocols are not designed to
support uninterrupted skin-to-skin contact between mother and baby
immediately after birth. Instead, they consist of a list of care activities
and tasks that nurses often feel they must accomplish as soon as
possible to get through their work assignments. Anything that is not
necessary for the immediate well-being of the newborn and mother
can, and should, be delayed until after the first breastfeeding. This
includes vitamin K injection, eye prophylaxis antibiotic ointment, foot
and hand printing, weighing, measurements and bathing.
70 R. Phillips / Newborn & Infant Nursing Reviews 13 (2013) 67–72
Occasionally an infant may need to be weighed to determine if he
qualifies for hypoglycemia protocols. Glucose testing can be done
while the asymptomatic infant is skin to skin with mother, as this will
support maximum glucose stability. If the results indicate that
intravenous glucose is required, at least the mother and infant have
received the benefits of early bonding with increased oxytocin levels,
as well as respiratory and temperature stability before separation is
necessary for further stabilization of glucose. Any symptomatic infant
should, of course, be immediately evaluated and stabilized. While
skin-to-skin care is usually not practical for the unstable baby or
mother, it should be the default plan of care for all normal newborns
and mothers, and postpartum care protocols should be created to
support this natural process.
Skin-to-Skin Contact After Cesarean Births
While more hospitals have implemented skin-to-skin care after
vaginal births, very few have extended this practice to the operating
room (OR) after cesarean births. Yet, stable mothers and babies deserve
to experience the same short- and long-term benefits of early skin-to-
skin contact after cesarean births, as do those who have vaginal births.
Indeed, mothers who have had a cesarean delivery often mourn the loss
of a normal vaginal birth they had hoped for and are especially
disappointed by not having their baby with them immediately after birth.
One mother whose baby was brought to her in the OR immediately
after birth recently stated, “Having my baby skin to skin in the OR after
my cesarean birth was the most meaningful experience ever. I couldn’t
have the vaginal birth I wanted, but at least I got to hold my baby skin
to skin right after birth, which is what I had hoped for.”
Another mother and father, whose twins were delivered by
cesarean birth at 37 weeks gestation, watched in amazement as
each boy went through the nine instinctive stages of behaviors at their
own individual pace, when they were placed skin to skin on mother’s
chest in the OR. They were both breastfeeding within the first hour
after birth, having each self-attached without assistance. These
parents were delighted with how different this experience was from
what occurred when their first son was born by cesarean delivery 3
years prior. Breastfeeding had been such a struggle after the
customary 2–3 hour separation when their son had been taken to
the nursery until after mother’s recovery period.
Many other mothers have enthused at how easy breastfeeding was
when their baby had an opportunity to go skin to skin immediately
after cesarean birth in the OR compared to their struggles with
breastfeeding after separation with their previous cesarean delivery.
Breastfeeding is not impossible after early separation, but it is very
often much harder. Many mothers are not prepared or are unwilling
to persist in attempts to breastfeed after cesarean births with
separation. This is reflected in lower breastfeeding rates after most
cesarean deliveries.
27
Because skin to skin in the OR is such a new practice, in order for
staff to be comfortable with the process, much preparation must be
done prior to the first occurrence. Obstetricians, anesthesiologists and
those responsible for newborn care must be educated about the
evidence-based rationale for introducing skin-to-skin contact in the
OR, including the many benefits for stable mothers and babies. They
must also be assured that the safety and well-being of mothers and
babies will always be the first priority. Knowing that they will have
immediate veto power if any concerns arise goes a long way toward
reducing anxiety about beginning the practice of placing babies skin
to skin in the OR.
After the practice has begun, anesthesiologists are often amazed by
how stable mothers are immediately after cesarean delivery when
their babies are skin to skin. Because mothers are so focused on their
new baby, their perception of pain is often diminished and their
anxiety levels are significantly decreased, resulting in increased
stability of heart rates and blood pressures. In addition, mothers and
babies keep each other warm, resulting in increased temperature
stability for both.
A few practical matters will make thepracticego smoothly. First, the
nurse who will receive the baby and do the initial drying and placing of
baby on mother’s chest should check with the obstetrician and
anesthesiologist prior to the delivery to verify that there are no
concerns for the baby or the mother’s stability. Secondly, she should
introduce herself to the mother and confirm that she would like to hold
her baby skin to skin immediately after birth (if this has not already
been done). It is helpful to ask the anesthesiologist if the mother’sarm
can be released from the arm board (if it has been secured) in order for
her to touch her baby, and let the mother know she will need to
straighten her arm every few minutes when a blood pressure must be
taken. Be sure the mother’s gown is unsnapped so it can be easily
lowered to uncover her chest when placing the baby and be sure she is
not wearing a bra. Take note of intravenous lines and poles so as to
avoid them when placing the baby. Lastly, a diaper should be ready as
well as warmed towels or blankets to dry and cover baby.
After the baby is delivered and the cord is clamped and cut, the
receiving nurse will dry the baby, noting if he is vigorous and crying
(assuring a 1-minute Apgar score of 8 or 9). After quickly drying the
baby, if all is well, the nurse can diaper the baby and place the baby on
the mother’s chest in transverse position with the baby’s head on one
breast and the abdomen on the other breast, and then cover the baby
with a warmed towel.
A diaper is not absolutely necessary but will avoid the possibility of
meconium getting on the mother in the OR. It is much more difficult to
clean up meconium in the OR than in the delivery room after a vaginal
birth. An accepted practice is to diaper babies who go skin to skin in
the OR, but forego the diaper after a vaginal delivery. A hat is not
required to keep the baby warm when skin to skin and appears to be
annoying to many babies, interfering with normal rooting. A hat can
be placed when the baby is taken from the mother’s chest for cares
after breastfeeding. Many babies try to lift away from the hard plastic
umbilical clamp if the cord is clamped short in the traditional fashion.
This apparent discomfort can be easily avoided if the cord is cut and
clamped 8–10 inches long, so that the clamp is not directly between
baby and mother. The cord can be re-clamped and trimmed shorter at
anytime after breastfeeding or at the time of the first bath.
Routine bulb suctioning should be avoided, as it is often a very
negative oral experience for the baby. By far, the majority of babies are
able to clear their own secretions with no trouble. If the baby is having
difficulty clearing oral secretions, further evaluation is probably
needed. Updated 2011 Newborn Resuscitation Program guidelines
advise against routine bulb suctioning.
28
A nursing caregiver should visually monitor the baby while on the
mother’s chest until the surgery is complete, being sure the baby’s
head is positioned so the nares are always visible, the baby’s color,
perfusion and respirations remain stable, and baby doesn’t slide off
the mother’s chest towards her neck. If this happens, the baby can be
gently repositioned without being lifted off the mother’s skin. If the
baby advances to the crawling stage while in the OR and goes
searching (or lurching) for the breast to suckle, the dad can gently grip
the baby’s leg or thigh to assure the baby stays on the mother’s chest.
When the surgery is completed, the sterile drape has been
removed and the mother is ready for transfer to the gurney for
transport to the recovery room, the baby’s legs can be slowly and
gently moved to a vertical position so the baby’s head is between the
mother’s breasts. The mother can cross her arms over her baby and
the nurse who has been observing can place her hands on top of the
mother’s hands to be sure the baby is secure as the mother is turned
from side to side to remove soiled linen and as she slides over to the
gurney. This is a simple process and the baby need never leave the
mother’s chest during the transfer and en route to the recovery room,
but will simply continue going through the nine instinctive stages
towards the first breastfeeding.
71R. Phillips / Newborn & Infant Nursing Reviews 13 (2013) 67–72
If the baby is lifted from the mother’s chest, he will become distressed
anddisorientedandwhenreplacedskintoskinmuststartalloverand
advance through the stages again. The second time through will be
somewhat quicker, but breastfeeding will be delayed. About 1.5–2hours
after birth, newborns fall into a deep sleep and if the nine instinctive
behaviors have been interrupted several times, the baby may not be able
to complete them to experience suckling until several hours later.
The good news is that when the baby awakens, if he is placed skin to
skin, he will go through the stages again to find the breast and self-
attach. This instinctive behavior will be present for about the first four
months after birth and should be encouraged, especially in the first few
days as the mother and the baby grow accustomed to breastfeeding.
Babies quickly learn how to latch correctly and then will be able to
consistently achieve an effective latch while clothed or wrapped in a
blanket, but in the early postpartum period, being fully skin to skin
(both the mother and the baby) will activate their instinctive feeding
behaviors and help assure successful breastfeeding.
Early Postpartum Skin-to-Skin Contact Is Endorsed by
Many Organizations
The benefits of skin-to-skin contact immediately after birth for
stable mothers and babies is so well documented, it is recommended
by all major organizations responsible for the well-being of newly
born infants, including The World Health Organization (WHO), the
American Academy of Pediatrics (AAP), the Academy of Breastfeeding
Medicine (ABM), and the Neonatal Resuscitation Program (NRP).
The WHO advises that, given the importance of thermoregulation,
skin-to-skin contact should be promoted and “kangaroo care”
encouraged in the first 24 hours after birth. The AAP recommends
that healthy infants be placed and remain in direct skin-to-skin
contact with their mothers immediately after delivery until the first
feeding is accomplished.
29
The ABM Protocol #5, Revision 2008 states, “The healthy newborn
can be given directly to the mother for skin-to-skin contact until the
first feeding is accomplished. The infant may be dried and assigned
Apgar scores and the initial physical assessment performed as the
infant is with the mother. Such contact provides the infant optimal
physiologic stability, warmth, and opportunities for the first feeding.
Delaying procedures such as weighing, measuring and administering
vitamin K and eye prophylaxis (up to an hour) enhances early parent–
infant interaction.”
30
(p 2).
The NRP says that skin-to-skin care can be used to provide routine
resuscitation for all normal newborns. The changes included in the
updated 2011 NRP indicate that even the vigorous meconium-stained
newborn need not receive initial steps at the radiant warmer, but may
receive routine care (with appropriate monitoring) with the mother.
It clarifies that routine care includes staying with the mother in skin-
to-skin contact to ensure warmth. It also specifies that suctioning
following birth (including bulb suctioning with a bulb syringe) should
be reserved for babies who have obvious obstruction to spontaneous
breathing or who require positive pressure ventilation.
28
Conclusions
Being skin to skin with th e mother is the best way for a stable baby to
adjust to life outside the womb. It is endorsed by multiple organizations
responsible for the care and well-being of infants. It is, not only safer for
both babies and mothers, but provides multiple short- and long-term
beneficial effects. Early postpartum skin-to-skin contact increases
physiologic stability, promotes optimal psycho-emotional well-being,
and supports structural and functional infant brain development.
However, being skin to skin with the mother immediately after
birth is much more than simply a nice way to be welcomed into the
world. The first hour after birth is a once-in-a-lifetime occasion for
both the baby and the parents. It is a “sacred hour,”during which a
family is formed. This unique experience, once lost, can never be
relived. Although not the only time when bonding occurs, something
special happens during the first hour after birth. We must not
cavalierly deprive parents and babies of this experience unless there is
a very good reason. Instead, we must do everything in our power to
honor, cherish and protect this special time for new families.
Acknowledgment
The author would like to acknowledge the work of Dr. Nils Bergman,
MD, MPH, PhD, a global advocate for mothers and babies. Thank you for
all you have taught me and countless others about the critical
importance of keeping both term and preterm newborns together in
as much skin-to-skin contact with their mothers as possible.
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