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Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is recommended as the mainstay of newborn thermoregulation and care. Routine suctioning of infants at birth was not been found to be beneficial. Neither amnioinfusion, suctioning of meconium-stained babies after the birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more often than not, less intervention is better. The recommendations support a gentle, physiologic birth and family-centered care of the newborn.
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Evidence-Based Practices for the Fetal to
Newborn Transition
Judith S. Mercer, CNM, DNSc, Debra A. Erickson-Owens, CNM, MS,
Barbara Graves, CNM, MN, MPH, and Mary Mumford Haley, CNM, MS
Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to
neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat
loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to
assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes
have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord
clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed
cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is
recommended as the mainstay of newborn thermoregulation and care. Routine suctioning of infants at birth
was not been found to be beneficial. Neither amnioinfusion, suctioning of meconium-stained babies after the
birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome.
The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not
appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more
often than not, less intervention is better. The recommendations support a gentle, physiologic birth and
family-centered care of the newborn. J Midwifery Womens Health 2007;52:262–272 © 2007 by the
American College of Nurse-Midwives.
keywords: cord blood harvesting, epidural, maternal analgesia, midwifery care, newborn management,
opioids, oxygen use, skin-to-skin care, suctioning, thermoregulation, umbilical cord clamping
INTRODUCTION
The transition from fetus to newborn is a normal physio-
logic and developmental process— one that has occurred
since the beginning of the human race. Many hospital
routines that are used to assess and manage newborns
immediately after birth developed because of convenience,
expediency, or habit, and have never been validated. Some
practices are so ingrained that older traditional practices,
such as providing skin-to-skin care or delaying cord clamp-
ing, must be considered “experimental” in current studies.
1
However, recent research is beginning to identify some
older practices that should not have been abandoned and
some current practices that should be stopped. In order to
achieve a gentle, physiologic birth and family-centered care
of the newborn, practices that might interfere with maternal
and newborn bonding need to be closely scrutinized. This
article examines the evidence about practices related to the
newborn transition, including the effects of various drugs
used labor, umbilical cord clamping, thermoregulation,
suctioning, and resuscitation of the newborn.
EFFECT OF MATERNAL ANALGESIA
ON NEWBORN TRANSITION
Most analgesic agents commonly used to alleviate labor
pain readily transfer to the fetus via the placenta. Usually,
the effects of the analgesic agents are subtle, as most full
term infants transition easily from fetus to newborn. How-
ever, some specific medications have the potential to disturb
normal neonatal transition.
2
Although there is a large body of literature on the various
effects of analgesic agents, the reports of neonatal outcomes
are often incomplete or inconclusive. The ethical and
practical implications of assigning women to various pain
management modalities make randomized control trials
(RCTs) on pharmacologic management of labor pain and its
effect on the neonatal transition difficult to conduct.
A comprehensive literature review (English only) using a
combination of search terms (maternal analgesia, effects on
newborn, newborn transition, labor drugs, newborn, epi-
dural, first 4 hours, and neonatal outcomes ) resulted in three
Cochrane Reviews,
3–5
nine systematic reviews (includes
RCTs and other types of studies),
6 –14
six RCTs,
15–20
a case
control study,
21
a retrospective cohort study,
22
and three
observational studies.
23–25
These studies compared types of
parenteral opioids (dosages, route of administration, and
co-drugs), epidural versus parenteral opioids, epidural ver-
sus combined spinal– epidural analgesia, epidural dosing
(traditional vs. light), and parenteral opioids versus epidural
analgesia versus no analgesia. Neonatal outcomes in these
studies include Apgar scores, umbilical cord pH, respiratory
depression, neonatal sepsis evaluation, breastfeeding suc-
cess, neurobehavioral effects, and admission to a neonatal
special care unit.
Apgar Scores and Umbilical Cord pH
Most studies report no effect of analgesic agents (paren-
teral opioids or epidurals with local anesthetics, with or
without opioids) on Apgar scores or umbilical cord pH
values.
6,11,13,14,17,20
One systematic review
9
of RCTs
Address correspondence to Judith S. Mercer, CNM, DNSc, FACNM,
Nurse-Midwifery Program, University of Rhode Island College of Nursing,
2 Heathman Road, Kingston, RI 02881-2021. E-mail: jmercer@uri.edu
262 Volume 52, No. 3, May/June 2007
© 2007 by the American College of Nurse-Midwives 1526-9523/07/$32.00 doi:10.1016/j.jmwh.2007.01.005
Issued by Elsevier Inc.
and well designed prospective cohort studies found that
newborns exposed to parenteral opioids (5 trials, N
2015 infants) had a higher incidence of 1-minute Apgar
score 7 compared to newborns exposed to epidural
analgesia. However, at 5 minutes, the Apgar scores did
not differ significantly (6 trials, N 2545).
In a Cochrane review by Anim-Somuah et al.,
4
new-
borns exposed to epidural analgesia had a decreased risk
of having an umbilical cord pH 7.2 compared to
newborns whose mothers had nonepidural analgesia.
However, there was no significant difference between
groups in 5-minute Apgar scores. Findings from the
PEOPLE study, a multicenter RCT (N 1862), which
examined delayed pushing and prolonged second stage
of labor in primigravidas with continuous epidural anal-
gesia, found lower umbilical cord pH (7.15 venous
or 7.10 arterial; RR, 2.45; 95% CI, 1.35– 4.43) in the
newborns whose mothers delayed the start of pushing as
compared to the control group who began pushing at the
start of second stage.
26
Yet, no newborns in the delayed
pushing group had any sign of perinatal asphyxia as
measured by the Neonatal Morbidity Index. These data
suggest that Apgar scores and umbilical cord pH are
common gross measures of newborn well-being that may
not adequately assess the subtle effects of maternal
analgesic agents on the newborn.
Respiratory Depression
Morphine, meperidine (Demerol; Sanofi-Aventis,
Bridgewater, NJ), and fentanyl are the opioids that have
been studied the most in labor analgesia research. These
opioids, as well as newer alternatives, such as nalbuphine
(Nubain; Endo Pharmaceuticals, Chadds Ford, PA) and
butorphanol (Stadol; Bristol-Meyers Squibb, New York,
NY), have been associated with newborn respiratory
depression. However, there is insufficient evidence to
clarify the relationship between medication dosage and
respiratory depression at birth. Opioids are known for
their high lipid solubility, which allows rapid transfer of
the drug through the placenta and into the fetus. The risk
of respiratory depression is highest if birth occurs at the
time of peak fetal uptake— between 1 and 4 hours after
administration of drug to the mother.
27
Naloxone (Narcan; Endo Pharmaceuticals) is currently
used in clinical practice to reverse respiratory depression
following administration of opioids. One systematic
review reported that naloxone administration to the
newborn is more common when parenteral opioids and
patient-controlled opioid analgesia is used, compared to
epidural analgesia.
9,18,19
Another review found no dif-
ferences in naloxone use between types of analgesia.
6
Many of the studies included were too small to draw
conclusions for clinical practice recommendations. Nal-
oxone should not be given routinely at the time of birth.
8
Neonatal Sepsis Evaluation
Lieberman and O’Donoghue
11
found that epidural use
was associated with a higher incidence of maternal fever
and subsequent neonatal sepsis evaluation. However,
Capogna
7
suggested that, while the number of neonates
receiving sepsis evaluations varies between institutions,
there is no evidence that epidural exposure increases the
incidence of neonatal sepsis.
Breastfeeding
There has been a longstanding concern about the nega-
tive impact of labor analgesic agents on breastfeeding
success. Analgesic effects are known to include suckling
inhibition, delay in the establishment of breastfeeding,
decreased neonatal alertness, and diminished neurobe-
havioral function.
6,12
However, most of these effects
were noted in observational studies that were published
more than 30 years ago.
In a review
10
of two prospective cohort studies done
more recently (N 2364), there was no correlation
between breastfeeding success and use of either paren-
teral opioids or epidural/spinal analgesia during labor.
Capogna
7
reports that “theoretically,” the types and
amount of epidural analgesia may affect breastfeeding
success, but suggests early maternal infant bonding may
have a greater effect on breastfeeding than does the type
of maternal analgesic agent used during labor. The
results of a small observational study (N 28) revealed
that neonates not exposed to pain medication exhibited
an important prebreastfeeding behavior (spontaneously
moving towards the breast and massaging the mother’s
nipple), which is believed to contribute to suckling.
23
Newborns (n 12) in the first 120 minutes after birth,
exposed to either intravenous (IV) meperidine, epidural
with local anesthetic, or a combination of both had
increased amounts of crying and a delay in developing
breastfeeding behaviors.
23
In a study of 129 infants,
Riordan
24
found that fetal exposure to labor analgesia
agents (IV opioids or epidural or IV opioids plus epi-
dural) diminished early suckling but did not effect
duration of breastfeeding through 6 weeks.
Radzyminski
25
observed no difference in breastfeed-
ing behaviors when comparing neonates exposed to
ultra–low dose anesthetics via labor epidurals (n 28) to
neonates with no exposure to pain medication (n 28).
Judith S. Mercer, CNM, DNSc, FACNM, is a Professor at the University
of Rhode Island College of Nursing and Adjunct at Brown University.
Debra A. Erickson-Owens, CNM, MS, is a doctoral student at the
University of Rhode Island and former Director of the University of Rhode
Island Nurse-Midwifery Program.
Barbara Graves, CNM, MN, MPH, FACNM, is the Program Director at the
Baystate Midwifery Education Program.
Mary Mumford Haley, CNM, MS, is in clinical practice at East Bay Family
Health Center and Memorial Hospital of Rhode Island and is on faculty at
the University of Rhode Island.
Journal of Midwifery & Women’s Health www.jmwh.org 263
Beilin
16
reported that women (n 58) who received an
epidural with high dose fentanyl (150 mcg) had more
difficulty breastfeeding in the first 24 hours compared to
women (n 59) with either an intermediate dose (1–150
mcg) or no fentanyl (n 60), although the difference did
not reach statistical significance. Yet, at 6 weeks post-
partum, a greater number of the women in Beilin’s
high-dose fentanyl group were no longer breastfeeding.
In a retrospective cohort study (N 99), Volmanen
22
found that more women who had an epidural in labor
described not having enough milk when compared
to women without an epidural (15 vs. 6, P.006) in
the first 12 weeks postpartum. Lieberman and
O’Donoghue
11
caution in their systematic review that
further study is needed to evaluate breastfeeding success
rates with the use of epidural analgesia.
Early Neurobehavioral Effects
Studies of the effect of maternal analgesic agents on early
neonatal neurobehavior showed minimal differences in
the neurobehavioral scores of newborns exposed to
epidural opioids versus newborns exposed to parenteral
opioids.
11
Even results comparing epidural-exposed
newborns to newborns with little or no medication
exposure did not show a clear difference between groups.
Beilin found lower neurobehavioral scores in newborns
exposed to high versus low (or none) dose fentanyl
(150 mcg) epidurals.
16
Intravenous fentanyl just before
spinal anesthesia for elective cesarean birth had no
impact on neurobehavioral scores.
15
Admission to a Neonatal Intensive Care Unit
No differences were found in neonatal intensive care unit
(NICU) admissions of infants exposed to epidural versus
nonepidural or no analgesia in labor
4
or in comparing
epidural and combined spinal– epidural analgesia.
3
Ex-
posure to maternal analgesia does not appear to increase
an infant’s risk for admission to the NICU.
In summary, the current evidence on the safety of
maternal analgesia (parenteral opioids or epidural or com-
bined epidural/spinal) and the effects on the neonate are
limited, and at times confusing, making it difficult to draw
conclusions for clinical practice. Newborns not exposed to
any labor analgesic agents appear to exhibit important
prebreastfeeding behaviors necessary for successful suck-
ling sooner than analgesia-exposed newborns, but the ef-
fects of labor analgesic agents on early suckling and
breastfeeding duration is unclear. The long-term impact of
neurobehavioral effects from maternal analgesia is uncer-
tain. Future studies must look beyond gross measures, such
as Apgar scores and umbilical cord pH, and focus on
long-term neonatal outcomes, such as attachment, breast-
feeding duration, and neurobehavioral effects.
THE TIMING OF UMBILICAL CORD CLAMPING
Currently, no formal guidelines about the best timing for
umbilical cord clamping exist. Clamping the cord immedi-
ately after birth results in a 20% reduction in blood volume
for the neonate and up to a 50% reduction in red cell
volume.
28
Several RCTs have indicated that more infants
who experience immediate clamping have anemia of in-
fancy compared to infants who had delayed clamping
(Table 1). A number of studies have related anemia of
infancy, even when treated with iron, with less favorable
neurodevelopmental and behavioral outcomes up to age
10.
29
There are no studies of immediate or delayed cord
clamping that follow children beyond 6 months of age.
Immediate Cord Clamping and Anemia
Since the publication of the last review of the literature on
umbilical cord clamping,
30
one systematic review
31
and
four additional RCTs involving term infants
32–35
have been
published. The four studies, whose subjects included 827
mother–infant pairs, were all conducted in resource-poor
countries over the last 4 years. All included women at term
with no medical or obstetric complications. Although the
findings of each study are slightly different, they all found
higher newborn hematocrit and hemoglobin levels within
the first 24 hours after birth without adverse outcomes in the
infants who experienced delayed cord clamping. Two of the
studies found significantly fewer signs of anemia at 3 and 6
months in infants with delayed cord clamping. Synopses of
the four studies can be found in Table 1. The systematic
review is discussed below.
Van Rheenen and Brabin
31
conducted a systematic re-
view of two randomized controlled trials
34,36
that compared
immediate versus delayed cord clamping in term infants to
determine the effect on anemia status after 2 months of age.
Their secondary objective was to assess the incidence of
polycythemia and/or jaundice during the first week of life in
infants who experienced delayed cord clamping. The au-
thors found that delayed cord clamping, especially in
anemic mothers, increased hemoglobin status and reduced
the risk of anemia at 2 to 3 months of age (RR, 0.32; 95%
CI, 0.02– 0.52). Although infants with delayed clamping
had higher hematocrit levels, no reports of symptomatic
polycythemia or jaundice were found. The authors stated
that delaying clamping may be especially beneficial in
developing countries where anemia rates are high.
The current literature refutes the idea that delayed cord
clamping causes symptomatic polycythemia and indicates
that immediate clamping of the cord may often lead to
anemia of infancy.
Clamping the Nuchal Cord Before Delivery of the Shoulders
In addition to anemia, possible neurologic harm from
clamping a nuchal cord before birth has been identified.
37
A recent integrated review of the literature on nuchal
264 Volume 52, No. 3, May/June 2007
cord management found reports showing increased risks
to the newborn when the cord was clamped before the
shoulders are delivered.
38
Leaving the cord intact and
using the somersault maneuver is recommended espe-
cially if shoulder dystocia is suspected. During the
somersault maneuver, the infant’s head is kept near the
perineum as the body delivers so that little traction is
exerted on the cord (Figure 1).
38
Resuscitation at the
perineum allows the infant to regain the blood trapped in
the placenta and can be accomplished using all the proper
tenets of neonatal resuscitation.
Cord Blood Harvesting
Increasing blood volume by delayed clamping should
result in the infant receiving a greater allotment of
hematopoietic stem cells and red blood cells. Hemato-
poietic stem cells are pluripotent, meaning that they can
develop into many different cell types.
39
Evidence sug-
gests that hematopoietic stem cells may migrate to and
help repair damaged tissue during inflammation and can
differentiate into such cells as glia, oligodendrocytes, and
cardiomyocytes as needed.
40
In a rat model of cerebral
palsy, half the damaged rats were given human umbilical
stem cells within 24 hours of the injury. The infusion of
cord blood appeared to prevent development of the
rodent version of cerebral palsy, which was clearly
evident in the damaged rats who did not get human cord
blood.
41
Yet cord blood harvesting companies advertise
cord blood as “medical waste” and encourage parents to
collect it at birth. Although cord clamping time is not
prescribed in the instructions for cord blood harvesting,
the suggestion is that the earlier the cord is clamped, the
larger the harvest will be. This practice of cord blood
harvesting is not supported by the American Academy of
Pediatrics unless there is a clear medical need within the
family.
42
Parents need to be fully informed by providers
Table 1. Randomized, Controlled Trials on Cord Clamping in Full-Term Infants
Authors, Year,
Location Study Population
Cord Management
Placement of Infant Significant Results Comments
Chaparro et al.
(2006)
32
; Mexico
Women 37–42 wks; singleton
pregnancy, vaginal birth,
normal pregnancies, plan
to breastfeed for 6 mo, no
smokers; no IUGR or major
anomalies (excluded after
birth); 358 infants
randomized
EC: CC at 10 s (mean
16.5 s); DC: CC at 2
minutes (mean 94 s);
Level: held at the level
of the uterus
POV: At 6 mo, DC infants had
higher MCV (81 vs. 79.5 fL;
P.001), ferritin (51 vs.
34 mL; P.0002), and
total body iron (48 vs. 44
g/dL, P.0003) than
EC infants. Diff HCT in NB
period: 62% vs. 60%; P
.003. After birth, HCT
70%: DC 13% vs. EC 8%;
P.15. Jaundice: DC
17% vs. EC 14%; P.36
Largest study to date to look at
any long-term outcomes.
Conservative in that they
used only a 2-min delay. No
significant differences in
HGB or HCT at 6 mo, but
iron stores increased by
27–47 mg in infants with
DC. No harmful effects
noted.
Cernadas et al.
(2006)
33
; Argentina
276 term infants; vaginal
and cesarean birth, no
complications, normal
pregnancies
EC: CC at 15 s (n 93);
IC: CC at 1 min (n
91); DC: CC 3 min (n
92)
POV: Venous HCT at 6 hrs: EC
54% vs. IC 57% vs. DC
59%. HCT 45% highest
with EC at 6 and 24 hrs.
HCT 65% was highest
in DC at 6 and 24 hrs
without clinical symptoms
No harmful effects were seen.
At 24–48 hrs, 16.9% of
infants with EC had HCT
45%. No increase in
maternal postpartum
hemorrhage. Authors
recommend DC.
Emhamed, van
Rheenen, and Brabin
(2004)
35
; Libya
Women 37–42 wks;
singletons; excluded for
major congenital
anomalies, maternal
complications; tight
nuchal cord, need for
resuscitation; 102 infants
2500 gms
EC: immediate (n 45);
DC: after cord stopped
pulsating (n 57);
oxytocic after CC
DC infants had significantly
higher HCT (53% vs. 49%;
P.004) and Hgb 17.1
vs. 18.5 g/dL (P.0005)
at 24 hrs. Three DC infants
had polycythemia with no
symptoms; two EC infants
needed phototherapy
No perinatal complications from
DC in this study. Authors
recommend DC as a safe,
simple intervention to
increase red cell mass.
Gupta and Ramji
(2002)
34
; India
Term infants (n 102) born
to anemic mothers (HGB
10 g/dL); vaginal birth,
no resuscitation needed at
birth; no major congenital
anomalies
EC: immediate (n 53);
LC: when placenta in
vagina (n 49); Infant
held 0–10 cm below
introitus
At 3 mos of age (n 58),
infants with LC had higher
serum ferritin levels (118
vs. 73; P.001). Odds
risk for anemia at 3 mos
was 7.7 times higher for
the EC group (95% CI,
1.84–34.9)
EC Infants weighed 2707 gms,
LC infants 2743 g. Iron
stores in neonates born to
anemic mothers can be
improved by LC (jaundice
and polycythemia not
addressed)
CC cord clamping; DC delayed cord clamping; EC early cord clamping; HCT hematocrit; HGB hemoglobin; IC intermediate cord clamping; IUGR intrauterine
growth restriction; MCV mean corpuscular volume; NB newborn; LC late cord clamping; POV primary outcome variable.
Journal of Midwifery & Women’s Health www.jmwh.org 265
during pregnancy in order to make sound decisions about
storing cord blood.
In summary, the current literature supports a lack of
harm for full term infants when cord clamping is delayed
up to 10 minutes with the newborn placed on the
maternal abdomen or held below the level of the peri-
neum. In addition, the evidence is strong that delayed
cord clamping offers full-term infants protection from
anemia. Based on the current evidence, the recommen-
dation is to delay cord clamping to prevent anemia of
infancy. Also, we recommend that clinicians not cut a
nuchal cord before delivery of the shoulders, but instead,
use the somersault maneuver to deliver the child and
resuscitate at the perineum as necessary.
Thermoregulation and Infant Placement
Keeping infants warm at birth is an essential part of
immediate newborn management. Newborns are at risk
for heat loss at birth because of their large surface area to
mass ratio, minimal subcutaneous tissue, and skin per-
meability to water. The procedure of skin-to-skin care
requires that the bare newborn is placed in direct contact
with the mother’s bare skin (usually prone). Skin-to-skin
care can occur immediately after birth and during the first
hour of life. When a newborn is placed skin-to-skin, the
woman provides heat directly to her newborn via con-
duction. Frequently, the newborn is dried completely and
a blanket is placed over infant and mother to prevent heat
loss through convection and evaporation.
A literature search on the topic of newborn thermo-
regulation revealed one 2004 Cochrane review, two
RCTs, and one observational physiologic study. Only
those studies published since the Cochrane review are
included in Table 2.
1,43– 46
In the term newborn, skin-to-skin care is associated
with both short- and long-term benefits. In the short term,
the newborn experiences an increase in body temperature
when compared to infants cared for in a warmer or
dressed and placed in a crib.
43,47,48
Even when a dressed
newborn is with the mother after the initial hour of
skin-to-skin contact, Fransson
45
found less difference
between the newborn’s core (rectal) temperature and the
temperature of the skin when compared to the tempera-
ture differential in newborns cared for in a crib. In
addition to aiding in maintaining temperature, infants
who had skin-to-skin care in the first hour were found to
sleep longer, spend more time in a quiet state, and were
better organized at 4 hours of age
46
(Table 2).
Long-term benefits of immediate skin-to-skin contact
and suckling during the first hour of life include a longer
duration of breastfeeding,
44
more maternal positive feel-
ings towards child rearing,
49
and improved scores for
maternal affection and maternal attachment.
1
Carfoot
43
found that 90% of the mothers who had skin-to-skin care
were very satisfied and 87% would prefer skin-to-skin
care again, compared to only a 59% satisfaction rating by
the mothers in routine care group.
In conclusion, skin-to-skin contact is a safe, inexpen-
sive, and acceptable method of regulating the thermal
environment for healthy term newborns. This method can
Figure 1. Somersault maneuver. The somersault maneuver involves holding the infant’s head flexed and guiding it upward or sideways toward the pubic bone
or thigh, so the baby does a “somersault,” ending with the infant’s feet toward the mother’s knees and the head still at the perineum. 1, Once
the nuchal cord is discovered, the anterior and posterior shoulders are slowly delivered under control without manipulating the cord. 2,Asthe
shoulders are delivered, the head is flexed so that the face of the baby is pushed toward the maternal thigh. 3, The baby’s head is kept next to
the perineum while the body is delivered and “somersaults” out. 4, The umbilical cord is then unwrapped, and the usual management ensues.
Figure adapted with permission from Mercer et al.
38
266 Volume 52, No. 3, May/June 2007
be applied immediately after birth for most newborns.
There are short- and long-term benefits for both mother
and baby. The most consistent additional effects are
increased success and duration of breastfeeding and
scores of bonding and attachment. Skin-to-skin should be
considered a primary intervention for prevention of
neonatal hypothermia. Birthing units that separate moth-
ers and babies with the intention of preventing cold stress
unwittingly increase the risk of cold stress, and at the
same time deprive the pair of intimacy and bonding
while delaying breastfeeding initiation. The evidence
suggests that skin-to-skin contact should be the mainstay
of newborn thermoregulation.
Suctioning of the Newborn at Birth
Most obstetric texts describe clearing the newborn’s
nose and mouth at birth with a bulb syringe. Table 3
summarizes the findings of several small research
studies that have examined the impact of suctioning on
newborn respiratory status.
50 –53
All studies were con-
ducted on vigorous term infants and none found any
significant differences in health outcomes between
infants suctioned and not suctioned. These studies
demonstrate no benefits from routine suctioning after
birth and support abandoning suctioning as a routine
procedure.
Management of Infants With Meconium-Stained
Amniotic Fluid
Treatments to prevent meconium aspiration syndrome
have included amnioinfusion during labor, intrapartum
suctioning, and endotracheal intubation and suctioning of
infants with meconium-stained fluid. The most recent
evidence suggests that these practices are not helpful and
do not prevent meconium aspiration syndrome. Table 4
offers the current evidence about these practices.
54 –56
A
2006 review
57
shows no benefit to infants from these
practices.
Two classic nonrandomized studies done in the
1970s
58,59
suggested that suctioning the airway before
the birth would decrease the incidence of morbidity and
mortality associated with meconium aspiration syn-
drome. Subsequent studies comparing DeLee suctioning
with bulb suctioning found no differences in the inci-
dence and severity of meconium aspiration syndrome,
respiratory rates, or Apgar scores between the infants
who had suctioning either before delivery of the head or
after birth.
60–62
In 2004, the Meconium Study Network
55
conducted a large multicenter RCT comparing outcomes
of vigorous infants with meconium staining, with or
without suctioning on the perineum (Table 4). No differ-
ence was found between the two groups for any out-
comes, even when analyzing the subgroup with thick
Table 2. Literature Overview on Infant Placement at Birth and Skin-to-Skin Care
Authors, Year, Study
Type Study Population
Style of
Thermoregulation Results Comments
Carfoot, Williamson,
and Dickson
(2005)
43
; RCT
204 term mother–baby
pairs randomized to
either group
Early SSC compared with
RNC
Higher temps 1 hr after birth (P.02);
no difference in # breastfeeding at 4
mos, mothers more satisfied with SSC
(90% vs. 50%)
Largest trial to date; supports no
harm with SSC; found warmer
infants and high maternal
satisfaction with SSC
Vaidya, Sharma, and
Dhungel (2005)
44
;
RCT
92 lactating
mother–baby pairs
followed up to 6
mos
Randomized to 15 min of
SSC in the first hrs vs.
RNC (babies dressed
and given to mother)
Significantly more mothers in the SCC
group were breastfeeding at 6 mos of
age (77% vs. 38%)
Large study from a resource-poor
country; well done; cultural
differences may play a role
Fransson, Karlsson,
and Nilsson
(2005)
45
;
physiologic study
27 healthy term
babies during first
2 days of life
Determine normal
temperature patterns
and variations and the
influence of external
factors
Skin temperature of baby was higher
when with the mother, even if not
skin-to-skin
Highest temperatures were
recorded when baby was in
close contact with mother,
lowest when baby was in the
cot
Anderson et al.
(2003)
1
; Cochrane
review
Cochrane review of
806 participants in
17 studies
Early skin-to-skin
contact, baby naked
and prone on mother’s
bare chest versus
routine hospital care
Increased scores for maternal
love/touch/affection, increased
maternal attachment behavior
Safety and breastfeeding
success; editors recommended
improving methodological and
statistical integrity
Ferber and Makhoul
(2004)
46
; RCT
47 healthy
mother–baby pairs
All infants had SSC for
first 5–10 min. The
SSC group had SSC
from 15 min to 1 hr of
life; control group had
routine care in the
nursery
At 4 hrs, infants in the SSC group slept
longer (P.02) with more quiet
sleep time (P.01) and had better
flexion (P.03) and less extension
of limbs (P.05)
SSC appears to influence state
organization and motor
coordination
RCT randomized, controlled trial; RNC routine newborn care; SSC skin-to-skin.
Journal of Midwifery & Women’s Health www.jmwh.org 267
meconium. This suggests that intrapartum suctioning
does not prevent meconium aspiration syndrome. Simi-
larly, no benefit for the prevention of meconium aspira-
tion syndrome has been found following amnioinfusion
54
or from endotracheal intubation and suctioning of vigor-
ous term infants.
56
These practices should not be used to
prevent meconium aspiration syndrome.
57
Gastric Suctioning
It has been suggested that gastric suctioning of the
newborn might prevent regurgitation and aspiration of
meconium or other stomach contents. A MEDLINE
search on gastric suctioning of the newborn revealed
only one study relevant to this review.
Widstrom
63
studied the effect of gastric suction on
newborn circulation and subsequent feeding behavior.
Healthy, term newborns were randomly assigned to
have gastric suction (n 11) or no gastric suction
(n 10). At birth, the newborns were dried and placed
on the mother’s chest. No suctioning of the airway was
done, and all infants began to breathe spontaneously.
The umbilical cord was clamped and cut between 60
and 90 seconds after birth. Pulse and blood pressure
were recorded every minute from 5 to 10 minutes of
age. Between the first two blood pressure recordings,
infants in the suction group had a #8 suction catheter
inserted through the mouth into the stomach, and the
contents were aspirated. The procedure lasted approx-
imately 20 seconds. The infants were maintained in a
prone position on their mother’s chests and were
Table 3. Oropharyngeal Suctioning at Birth*
Author, Year, Study Type* Intervention and Sample Size Significant Results Comments
Cordero and Hon (1971)
53
;
non-randomized
Bulb suction (n 41) vs.
catheter suction (n 46)
The catheter group developed severe arrhythmia
(n 7) and became apneic (n 5)
First study to show that suctioning
disrupted infant transition
Estol et al. (1992)
51
;
prospective,
non-random trial
(assigned by hour of
birth)
Bulb suction (n 20) vs. no
suction (n 20)
Respiratory resistance and lung compliance
were not different at 10, 30, or 120 min
No significant differences between
infants with and without
suctioning; no advantage to
infants from suctioning
Carrasco, Martell, and
Estol (1997)
50
; RCT
Immediate suction with
catheter (n 15) vs. no
suctioning (n 15)
Suctioned group had lower SaO
2
between 1–6
min of life (P.05); time to reach 86%–
92% SaO
2
shorter in nonsuctioned group
No respiratory distress in either
group; no advantage to infants
from suctioning
Waltman et al. (2004)
52
;
RCT
Bulb suction on perineum and
just after birth (n 10)
vs. no suction (n 10)
No difference in Apgar scores at 1, 5, or 10
min; higher heart rate [166–173 (n 10)
bpm] in no suction group compared to
suction group (150–166 bpm); lower SaO
2
from 10–20 min in non-suctioned group
(although 90%)
No benefits to the infants from
suctioning demonstrated
Bpm beats per minute.
*Study populations: All infants were vigorous term infants.
Table 4. Current Evidence for Practices Related to Management of Infants Born With Meconium-Stained Amniotic Fluid
Treatment Recommendation Reference Study Details
Amnioinfusion No benefit to infants found for the
prevention of MAS
Fraser et al. (2005)
54
Multicenter RCT, women (n 1998) in labor at term with
MSAF stratified by presence of variable decelerations
and randomly assigned to amnioinfusion or standard
care. Amnioinfusion did not reduce risk of MAS, or
perinatal death.
Intrapartum suctioning
before delivery of
shoulders
No benefit to any infants including
high risk infants; suctioning of
infant before delivery is not
indicated
Vain et al. (2004)
55
RCT, blinded, infants (n 1176) suctioned on perineum
compared with infants (n 1225) not suctioned. No
difference in Apgar scores, respiratory distress, use of
oxygen, need for ventilation, MAS (4% in each group),
or death.
Endotracheal intubation
and suctioning after
birth of vigorous
infants
No benefits to any infants; not
recommended for vigorous
infants
Wiswell et al. (2000)
56
RCT, vigorous term infants (n 2094) with MSAF
randomly assigned to intubation and suctioning or to
expectant management. Intubation and suctioning did
not result in lower incidence of MAS or other respiratory
disorders.
MAS meconium aspiration syndrome; MSAFmeconium-stained amniotic fluid; RCT randomized, controlled trial.
268 Volume 52, No. 3, May/June 2007
observed for 3 hours. While the two groups did not
differ in average heart rate, one infant in the suction
group had an episode of bradycardia, and infants in the
suction group experienced an increased blood pressure
when the catheter was withdrawn. Defensive motions
were observed in nine of the suctioned infants. Suck-
ling was delayed until 62 minutes in the suction group
versus 55 minutes in the no suction group. There was
also a greater lag in hand-to-mouth movements in
the suction group (P.005). This small study found
harm and no benefit from gastric suctioning, indicating
that it should not be used in the routine care of the
neonate.
ROOM AIR VERSUS OXYGEN FOR NEONATAL RESUSCITATION
Current research addressing the potential benefits and
risks of use of oxygen versus room air for neonatal
resuscitation included six intervention studies
64–69
and a
Cochrane Library review.
70
The outcomes of these stud-
ies demonstrate no differences between the oxygen and
room air groups in mortality, Apgar scores, time to first
cry, time to onset of regular respirations, hypoxic isch-
emic encephalopathy, or neurologic follow-up examina-
tion results (Table 5).
71
One study evaluated markers of
oxidative stress.
68
History of Oxygen Use and Studies
By the 1950s, it was recognized that the administration of
high levels of oxygen to premature infants led to vaso-
constriction of the retinal arteries followed by disordered
vessel growth causing retrolental fibroplasias, now
known as retinopathy of prematurity.
72
Research in the
late 1970s demonstrated that administration of 100%
oxygen also reduced cerebral blood flow in the newborn
infant.
73,74
Saugstad
75
conducted animal studies, which suggested
that the use of 100% oxygen during neonatal resuscita-
tion might result in excess oxygen radicals and slower
response to resuscitation. A pilot study with human
infants supported the safety of using room air during
newborn resuscitation.
65
A follow-up multicenter, inter-
national quasiexperimental study of 599 infants weighing
more than 1000 gm who required positive pressure
ventilation for resuscitation (ResAir 2), found no differ-
ences in outcomes when infants were resuscitated with
room air versus 100% oxygen (Table 5).
67
Table 5. Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type
of Study Study Population
Intervention and
Application Significant Results Comments
Ramji et al.
(2003)
66
;
quasi-randomized
by date of birth
Term newborns needing
resuscitation
RA (n 210) vs.
100% 0
2
(n 221)
No differences in mortality, heart rate, Apgar
scores, time to first breath, HIE. Time to
first cry: RA 2 min vs. 3 min in 0
2
group
(P.008). Duration resuscitation: RA 2
min vs. 0
2
3 min (P.000076)
No indication that 100% 0
2
offers benefits over RA.
Resuscitation appears
faster with RA
Saugstad et al.
(2003)
71
;
follow-up
Infants in prior trials
who had reached
18–24 mos
Follow-up of
ResAir study
(591 infants,
of whom 410
available for
follow-up)
No differences in: weight, length,
developmental milestones, language
development, hearing, or cerebral palsy
between infants resuscitated with RA
vs. 0
2
No long-term advantage to
use of 100% 0
2
. Study
weakened by low (70%)
follow-up rate
Vento et al.
(2003)
69
; blinded,
randomized
Term infants needing
resuscitation
RA (n 51) vs.
100% 0
2
(n 55)
No statistical difference in Apgar scores.
Time to first cry: RA 1.4 min vs. 0
2
1.97
min (P.05). Time to regular
respirations: RA 5.3 min vs. O
2
6.8 min
(P.05)
No advantage to 100% 0
2
use
Vento et al.
(2001)
68
; blinded,
randomized
Asphyxiated term
infants and normal
controls
RA (n 19) vs.
100% 0
2
(n 21) vs.
controls
(n 26)
No statistical difference in Apgar scores.
Time to first cry: RA 1.2 min vs. 0
2
1.7
min (P.05). Time to regular
respirations: RA 4.6 min vs. 7.5 min (P
.05). Higher levels of markers of oxygen
free radicals at 28 days in 0
2
vs. RA
groups
Even a brief exposure to
100% 0
2
may cause
prolonged oxidative
stress
Saugstad et al.
(1998)
75
;
quasi-randomized
by date of birth,
not blinded
BW 1000 gm, no
major anomalies
RA (n 388) vs.
100% 0
2
(n 311)
No significant difference in mortality, HIE,
ABG. Apgar 1 min: RA 5; 0
2
4 min (P
.004); no difference in Apgar 5 min; more
infants w/5 min Apgar 7in0
2
group
(P.03); Time to first breath: RA 1.1
min, 0
2
1.5 min (P.004); first cry: RA
1.6 min, 0
2
2.0 min (P.006)
25.7% “treatment failures”
in RA switched to 0
2
at
90 sec; comparable to
numbers in 0
2
group
(29.8%) who had
bradycardia and/or
central cyanosis at 90 s
ABG arterial blood gas; BW birth weight; HIE hypoxic ischemic encephalopathy; 0
2
oxygen; RA room air.
Journal of Midwifery & Women’s Health www.jmwh.org 269
Cerebral Blood Flow
To investigate the effect of supplemental oxygen on
cerebral blood flow, Lundstom
64
randomized 70 preterm
infants to receive either room air (group I) or 80%
oxygen (group II) during initial stabilization in the
delivery room. The primary outcome of cerebral blood
flow was significantly higher in group I randomized to
room air (median 15.9; interquartile range 13.6 –21.9
mL/100 g/min) compared to group II with 80% oxygen
(median 12.3; interquartile range 10.7–13.8 mL/100
g/min; P.0001) at 2 hours of age.
Markers of Oxidative Stress
Vento et al.
68,69
measured the effect of resuscitation with
room air or 100% oxygen on levels of markers of
oxidative stress in term infants delivered vaginally (Ta-
ble 5). Nineteen asphyxiated infants were randomized to
resuscitation with room air, 21 were randomized to 100%
oxygen, and 26 infants without asphyxia served as
controls. The markers of oxidative stress were initially
higher in the umbilical arteries of both the asphyxiated
groups compared to the controls. At 72 hours of age, the
oxygen group had levels of oxygen-free radicals that
were statistically higher than the newborns in the room
air group. By 28 days of age, the infants in the room air
group had values similar to the values of the newborns in
the control group, whereas the infants in the oxygen
group continued to have statistically higher oxygen-free
radical values than either the room air subjects or
controls. Even a short exposure to 100% oxygen may
result in prolonged oxidative stress.
Neonatal Resuscitation Guidelines
The American Academy of Pediatrics/American Heart
Association Neonatal Resuscitation Program provides an
authoritative set of recommendations. The fifth edition of
Textbook of Neonatal Resuscitation
76
contains a signifi-
cant change in the use of 100% oxygen from earlier
editions. Although the authors continue to recommend
the use of 100% oxygen, they acknowledge that research
suggests that “less than 100% may be just as useful.”
77
The new guideline recommends use of room air at time
of resuscitation, but if there is not an appropriate re-
sponse within 90 seconds, oxygen is indicated.
CONCLUSION
An important tenet of practice for all health care person-
nel is to first do no harm. This idea takes on additional
importance when dealing with newborns, as there is
almost no long-term data on the safety of many proce-
dures. No clear conclusions can be drawn from studies on
maternal analgesia effects on the newborn; thus, judi-
cious use of medications in labor is recommended with
further study of better biobehavioral assessment tools to
differentiate outcomes. Delaying clamping of the umbil-
ical cord appears to offer protection from anemia without
harmful effects. The practice of immediate clamping,
especially with a nuchal cord, should be discontinued.
The evidence suggests that skin-to-skin care of the
newborn after birth and during the first hour of life
should be the mainstay of newborn thermoregulation and
care. Routine suctioning of the infant at birth should be
abandoned. Meconium-stained babies should not be suc-
tioned on the perineum and vigorous infants should not
be intubated and suctioned. There is no evidence that
amnioinfusion prevents meconium aspiration syndrome.
The mounting evidence suggests that use of 100%
oxygen at birth to resuscitate newborns may cause
harmful effects. Room air is permissible for the first 90
seconds with oxygen available if there is not an appro-
priate response in that time.
Routine interventions, such as suctioning the airway or
stomach or using 100% oxygen for resuscitation, or
immediate clamping of the umbilical cord, have never
based on any clear evidence that they improve newborn
care or outcomes. Yet some of these practices are so
firmly entrenched that it will take a large body of
research to change the standard. We must continue to
build a body of knowledge that supports the evidence:
more often than not, less intervention is better.
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... Inadequate (0-8) Satisfactory (9)(10)(11)(12)(13)(14)(15) Adequate (16)(17)(18)(19)(20) ...
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In India, most of the deliveries happen in homes under the watchful eyes of elders or Trained Birth Attendants' (TBA). The care the new born receives depends a lot on the knowledge, skills and attitude of the mothers during that covid-19 pandemic mothers are supposed to be lacking in knowledge, practices and attitude of new born care which is very essential. Ac to need of present scenario we conduct the study with objectives to assess the knowledge, practices and attitude, on new born care, among mothers during covid-19& tried to find the relationship between knowledge on newborn care and selected socio-demographic variables among p mothers. The next objective is to find the association between attitudes on newborn care and selected socio-demographic variables among mothers & to find the association between newborn care practices of mothers with selected socio-demographic variables. For the present study A descriptive survey was adopted to collect data through structured interview schedule, structured items and an attitude scale from 100 mothers at M P. The data was tallied and analyzed using mean, percentage, Chi-Square test and F test for averages and associations. The findings revealed the average knowledge, practices and attitude scores to be 70.90%, 79.45% and 81.72%. The sociodemographic variables of age, education, occupation and income were found to be significantly influencing knowledge, practices and attitude level there was a significant correlation between practice and attitudes levels. The findings of the study showed that majority of the mothers were between 20 to 40 years old had a family income more than 5000Rs, an educational status PUC and lived in joint and extended families. The knowledge levels of mothers were to be good at 70.90% this proves H0. The practices level and attitude levels were also high though there was a significant correlation between practices and attitude. The mother is usual person for the immediate care provider of the newborn. Hence, her knowledge, attitude and practices regarding newborn care is influenced by various factors. Even when knowledge is adequate, they may not practice it correctly nor have favorable attitude towards the care of new born. Therefore, educational programs specially directed at mother are a need for time and the satisfactory performance could be owed to factors such as antenatal clinics, antenatal counseling, mass media companies and presence of seniors and relatives at home.
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... Aun así, hay que señalar que la maternidad en la que se estudia esta prevalencia tan elevada tenía implementado el contacto piel con piel de la madre con el recién nacido como práctica habitual. Existe una fuerte evidencia de que el contacto piel con piel de la madre con el recién nacido inmediato e ininterrumpido tras el parto tiene beneficios con respecto a la lactancia (19,20). En nuestra maternidad de estudio se fomenta igualmente el contacto piel con piel, lo que podría contribuir de forma importante en el porcentaje de IPLM detectado. ...
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Of the approximately 13 percent of live-born infants born through meconium-stained amniotic fluid (MSAF), an estimated 5 to 12 percent develop meconium aspiration syndrome (MAS). Proper treatment of meconium-stained infants who remain vigorous is controversial. This prospective, randomized trial attempted to determine whether MAS can be prevented by intubation and suctioning. The 2094 infants enrolled in the trial, from 12 centers, had a gestational age of at least 37 weeks, were born through MSAF, and seemed to be vigorous immediately after birth. A total of 1051 infants were assigned to the intubation and suction (INT) group, whereas 1043 were managed expectantly (EXP group). Infants in the INT group were intubated immediately after birth and were suctioned using a Neotech aspirator for 1 to 5 seconds as the endotracheal tube was withdrawn. The two treatment groups were similar in prenatal care, the consistency of stained amniotic fluid, fetal heart rate monitoring, and amnioinfusion therapy. Gender, race, and 5-minute Apgar scores also were comparable. Sixty-two infants (3 percent of the total) developed MAS, and another 4.2 percent had different respiratory disorders, most often transient tachypnea. MAS developed in 3.2 percent of the INT group and 2.7 percent of the EXP group, and the rates of other respiratory conditions also were similar. The risk of either MAS or other respiratory problems increased with the thickness of the stained amniotic fluid, but, even with the thickest fluid, intubation conferred no obvious benefit. MAS was more frequent after cesarean delivery and when the mother had made five or more prenatal visits. On logistic regression analysis, other respiratory disorders were related to the same factors as well as to relatively thick amniotic fluid, a lack of oropharyngeal suctioning, no fetal heart rate monitoring or abnormal monitoring findings, and meconium in the trachea (Fig. 1). Low Apgar scores and oligohydramnios also correlated with these disorders. Nearly half of the infants with MAS required mechanical ventilation or continuous positive airway pressure, as did 15 percent of those with other respiratory disorders. Fig. 1 Tracheal suctioning does not limit the risk of respiratory distress in meconium-stained infants who remain vigorous after birth compared with expectant management. The procedure is quite innocuous, however, and still is recommended for infants who are not vigorous if they develop symptoms of respiratory distress or require positive-pressure ventilation. Pediatrics 2000;105:1–7
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An accumulating body of data indicates that optimal newborn resuscitation is not performed with 100% oxygen. On the contrary, ambient air seems to have several advantages compared with supplemental oxygen. Present guidelines on newborn resuscitation should be critically reviewed and revised according to scientific evidence.