Skin-to-skin transfer from the delivery room to the neonatal unit for neonates of 1,500g or above: a feasibility and safety study

Objective

Immediate skin-to-skin contact (SSC) is already standard care for healthy term newborns, but its use for term or preterm newborns requiring admission to neonatal intensive care unit (NICU) with or without respiratory support is challenging. This study aimed to assess the safety and feasibility of SSC during the transfer of newborn infants, using a new purpose-built mobile shuttle care-station, called "Tandem".

Material and methods

A monocentric prospective observational study was conducted at the tertiary referral center of the Université libre de Bruxelles in Brussels, Belgium after ethical approval by Hopital Erasme's Ethics Committee (ClinicalTrials.gov ID: NCT06198478). Infants born with a birth weight above 1,500 g were included. Following initial stabilization, infants were placed in SSC with one of their parents and transferred to the NICU using the Tandem.

Results

Out of 65 infants initially included, 64 (98.5%) were successfully transported via SSC using the Tandem. One transfer was not successful due to last minute parental consent withdrawal. The median (range) duration of continuous skin-to-skin contact after birth was 120 min (10-360). SSC transfers were associated with gradually decreasing heart rate (HR) values, stable oxygen saturation levels (SpO2), and no increase in median fraction of inspired oxygen (FiO2). Heatloss was predominantly observed during initial setup of SSC. There was no significant difference in the occurrence of tachycardia, desaturation or hypothermia between preterm and term neonates. No equipment failures compromising the transfer were recorded.

Conclusion

Skin-to-skin transfer of infants with a birthweight of equal or above 1,500 g using the Tandem shuttle is feasible and associated with stable physiological parameters. This method facilitates early bonding and satisfies parents.

Clinical Trial Registration

ClinicalTrials.gov (NCT06198478).

Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study

BACKGROUND

In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk for severe COVID-19-related complications and maternal morbidity and mortality.

OBJECTIVE

This study aimed to analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes when Omicron was the variant of concern.

STUDY DESIGN

INTERCOVID-2022 was a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes and to assess vaccine effectiveness. Women diagnosed with laboratory-confirmed COVID-19 during pregnancy were compared with 2 nondiagnosed, unmatched women recruited concomitantly and consecutively during pregnancy or at delivery. Mother-newborn dyads were followed until hospital discharge. The primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index, severe perinatal morbidity and mortality index, preterm birth, neonatal death, referral to neonatal intensive care unit, and diseases during the neonatal period. Vaccine effectiveness was estimated with adjustment for maternal risk profile.

RESULTS

We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) nondiagnosed mothers. Among the diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (relative risk, 0.46; 95% confidence interval, 0.23-0.91) the risk of being diagnosed with COVID-19 when compared with those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically indicated preterm birth, respiratory distress syndrome, and number of days in the neonatal intensive care unit. Newborns of unvaccinated mothers had double the risk for neonatal death (relative risk, 2.06; 95% confidence interval, 1.06-4.00) when compared with those of nondiagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the highest vaccine effectiveness (64%; 95% confidence interval, 10%-86%). Vaccine effectiveness was not as high for messenger RNA vaccines only. Vaccine effectiveness against moderate or severe neonatal outcomes was much lower, namely 13% in the booster-vaccinated group (all vaccines) and 25% and 28% in the completely and booster-vaccinated groups, respectively (messenger RNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women ≤100 days (14 weeks) before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks). Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk for infecting newborns.

CONCLUSION

When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk for neonatal death. Neonates of vaccinated mothers had a decreased risk for preterm birth and adverse neonatal outcomes. Because the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19, mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.

Parental holding of infants improves haemodynamics in the cardiac ICU

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Pilot study shows skin-to-skin care with parents improves heart rate variability in preterm infants in the neonatal intensive care unit

Background

Skin-to-skin care in the newborn intensive care unit typically lasts for short periods of time and enhances breastfeeding, attachment, and parental self-esteem. Heart rate variability (HRV) increases with gestational age and is a measure of maturation of parasympathetic vs. sympathetic autonomic nervous system activity. HRV measurements may be useful in capturing changes in autonomic regulation in response to skin-to-skin care.

Objective

To analyze the effects of skin-to-skin care on HRV in preterm infants receiving respiratory support. We hypothesized that skin-to-skin care would result in a more mature pattern of parasympathetic activity.

Methods

In this prospective crossover study, infants <30 weeks' gestation and 1-6 weeks postnatal age had HRV recorded for 30 min before, during, and after skin-to-skin care sessions. HRV characteristics analyzed included the standard deviation of the normal-to-normal interval (SDNN), the root mean squared of successive differences of normal-to-normal intervals (RMSSD), and the standard deviation of decelerations (SDDec).

Results

10 infants between 25 5/7-29 6/7 weeks gestational age and 7-41 days postnatal age completed 22 sessions while receiving respiratory support (positive pressure ventilation or nasal cannula oxygen). Two measures of HRV (SDNN and RMSSD) were significantly decreased by the end of the skin-to-skin sessions, compared to pre-session values. SDNN decreased from a median of 10.44 ms before the session to 6.70 ms after being placed back in bed (p < 0.05), with RMSSD decreasing from a median of 6.80 ms before the session to 4.32 ms while being held at the end of 30 min (p < 0.05).

Discussion

Skin-to-skin care with a parent resulted in a more mature autonomic nervous system pattern in preterm infants receiving respiratory support, suggesting physiologic benefit for the infant. No adverse events were seen during any session.

[Getting involved with your baby: stories of fathers starting out in the maternity ward]

Gaining a better understanding of fathers' experiences in the maternity ward, and more specifically around childbirth, enables a better understanding of the process of becoming a father. The stakes are high, since these shared moments form part of the bonds that support the development of father-baby communication.

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

AIM

Skin-to-skin contact immediately after birth is recognized as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality. However, implementation and definition of skin-to-skin contact is inconsistent in both practice and research studies. This project utilized the World Health Organization guideline process to clarify best practice and improve the consistency of application.

METHODS

The rigorous guideline development process combines a systematic review with acumen and judgement of experts with a wide range of credentials and experience.

RESULTS

The developed guideline received "strong recommendation" from the Expert Panel. The result concluded that there was a high level of confidence in the evidence and that the practice is not resource intensive. Research gaps were identified and areas for continued work delineated.

CONCLUSION

The World Health Organization guideline development process reached the conclusion immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth. Delaying non-essential routine care in favor of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for progression of newborns through their instinctive behaviors.

Implementing the Role of Neonatal Assessment Nurse to Improve Skin-to-Skin Care and Breastfeeding Exclusivity

OBJECTIVE

To improve rates of exclusive breastfeeding during the postpartum hospital stay by implementing a new role of dedicated neonatal assessment nurse (NAN), whose primary function was neonatal care beginning immediately after birth.

DESIGN

Quality improvement project with plan-do-study-act using evidence-based guidelines for implementing the NAN role.

SETTING/LOCAL PROBLEM

Labor and delivery department of a tertiary care teaching hospital in the southeastern United States; breastfeeding exclusivity rates at this hospital were in the range of 50%.

PARTICIPANTS

Registered nurses employed in the labor-delivery-recovery unit, mother-baby unit, and NICU.

INTERVENTION/MEASUREMENTS

The NAN role was implemented to promote immediate skin-to-skin care (SSC) for stable newborns after vaginal and cesarean birth. Each NAN's competency was evaluated at the beginning and end of the education session through a pretest/posttest, and a skills validation was used to affirm their readiness for the new role. The outcome measure was breastfeeding exclusivity at the time of discharge from the hospital. SSC initiation and duration immediately after birth were the process measures.

RESULTS

Twenty-five bedside registered nurses participated in this quality improvement project. There was a statistically significant difference between the pretest and posttest scores (p < .001), indicating a knowledge increase. All nurses met the skills validation criteria. The rate of SSC immediately after vaginal birth increased from 49% to 82% and after cesarean birth from 33% to 63%. Breastfeeding exclusivity rate at the time of discharge from the hospital increased from 50% to 86%.

CONCLUSION

The NAN role provided transitional care at the bedside without the separation of mothers and newborns. This was an innovative role, without the need to hire new staff, that provided evidence-based care, resulting in improved SSC and exclusivity of breastfeeding before discharge.

The Effect of Breastfeeding in the First Hour and Rooming-In of Low-Income, Multi-Ethnic Mothers on In-Hospital, One and Three Month High Breastfeeding Intensity

Despite the known benefits of exclusive breastfeeding, the value of Baby-Friendly Hospital Interventions in increasing breastfeeding rates has been challenged, particularly the interventions of breastfeeding in the first hour of life and rooming-in. This study aimed to measure the association of breastfeeding in the first hour of life and rooming-in with high breastfeeding intensity of low-income, multi-ethnic mothers intending to breastfeed. A prospective, longitudinal cohort study was performed on 149 postpartum mothers who intended to breastfeed their infants. Structured interviews were performed at birth and one and three months. Breastfeeding intensity was defined as the percentage of all feedings that were breast milk, and high breastfeeding intensity was defined as a breastfeeding intensity >80%. The data were analyzed by chi-square, t-test, binary logistic regression analysis, and multivariate logistic regression analysis. Breastfeeding in the first hour was associated with increased high breastfeeding intensity in the hospital (AOR = 11.6, 95% CI = 4.7-28.6) and at one month (AOR = 3.6, 95% CI = 1.6-7.7), but not at three months. Rooming-in was associated with increased high breastfeeding intensity in the hospital (AOR 9.3, 95% CI = 3.6-23.7) and at one month (AOR = 2.4 (1.1-5.3) and three months (AOR 2.7, 95% CI 1.2-6.3). Breastfeeding in the first hour and rooming-in are associated with increasing breastfeeding and should be incorporated into practice.

The content, experiences and outcomes of interventions designed to increase early skin-to-skin contact in high-income settings: A mixed-methods systematic review

AIM

To explore the content, experiences and outcomes of interventions designed to increase early skin-to-skin contact (SSC) in high-income settings.

METHODS

A mixed-methods systematic review was undertaken across six bibliographic databases. References of all included studies were hand-searched. All papers were quality appraised using a mixed-method appraisal tool. A narrative synthesis was used to synthesise both quantitative and qualitative findings.

RESULTS

Database searches generated 1221 hits, and two studies were identified via hand-searching. Ten studies were included; most (n = 7) were designed to improve SSC following a caesarean section, and half were of low/poor quality. Outcomes related to SSC prevalence and/or duration (n = 7), breastfeeding prevalence, (n = 4) and six explored mothers' and/or health professionals' experiences of the intervention. While the interventions had 'some' impact on the prevalence of SSC, the duration was often limited and not in line with WHO recommendations. Breastfeeding rates (exclusive/any) were found to improve but generally not to a significant extent. Mother and healthcare professionals were positive about the interventions, with barriers to implementation noted. Most interventions targeted healthcare professionals, rather than mothers.

CONCLUSION

High-quality interventions that increase SSC in line with WHO recommendations, and that target both health professionals and parents are needed.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

Effects of prenatal exposure to maternal COVID-19 and perinatal care on neonatal outcome: results from the INTERCOVID Multinational Cohort Study

BACKGROUND

The effect of COVID-19 in pregnancy on maternal outcomes and its association with preeclampsia and gestational diabetes mellitus have been reported; however, a detailed understanding of the effects of maternal positivity, delivery mode, and perinatal practices on fetal and neonatal outcomes is urgently needed.

OBJECTIVE

To evaluate the impact of COVID-19 on fetal and neonatal outcomes and the role of mode of delivery, breastfeeding, and early neonatal care practices on the risk of mother-to-child transmission.

STUDY DESIGN

In this cohort study that took place from March 2020 to March 2021, involving 43 institutions in 18 countries, 2 unmatched, consecutive, unexposed women were concomitantly enrolled immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed up until hospital discharge. COVID-19 in pregnancy was determined by laboratory confirmation and/or radiological pulmonary findings or ≥2 predefined COVID-19 symptoms. The outcome measures were indices of neonatal and perinatal morbidity and mortality, neonatal positivity and its correlation with mode of delivery, breastfeeding, and hospital neonatal care practices.

RESULTS

A total of 586 neonates born to women with COVID-19 diagnosis and 1535 neonates born to women without COVID-19 diagnosis were enrolled. Women with COVID-19 diagnosis had a higher rate of cesarean delivery (52.8% vs 38.5% for those without COVID-19 diagnosis, P<.01) and pregnancy-related complications, such as hypertensive disorders of pregnancy and fetal distress (all with P<.001), than women without COVID-19 diagnosis. Maternal diagnosis of COVID-19 carried an increased rate of preterm birth (P≤.001) and lower neonatal weight (P≤.001), length, and head circumference at birth. In mothers with COVID-19 diagnosis, the length of in utero exposure was significantly correlated to the risk of the neonate testing positive (odds ratio, 4.5; 95% confidence interval, 2.2-9.4 for length of in utero exposure >14 days). Among neonates born to mothers with COVID-19 diagnosis, birth via cesarean delivery was a risk factor for testing positive for COVID-19 (odds ratio, 2.4; 95% confidence interval, 1.2-4.7), even when severity of maternal conditions was considered and after multivariable logistic analysis. In the subgroup of neonates born to women with COVID-19 diagnosis, the outcomes worsened when the neonate also tested positive, with higher rates of neonatal intensive care unit admission, fever, gastrointestinal and respiratory symptoms, and death, even after adjusting for prematurity. Breastfeeding by mothers with COVID-19 diagnosis and hospital neonatal care practices, including immediate skin-to-skin contact and rooming-in, were not associated with an increased risk of newborn positivity.

CONCLUSION

In this multinational cohort study, COVID-19 in pregnancy was associated with increased maternal and neonatal complications. Cesarean delivery was significantly associated with newborn COVID-19 diagnosis. Vaginal delivery should be considered the safest mode of delivery if obstetrical and health conditions allow it. Mother-to-child skin-to-skin contact, rooming-in, and direct breastfeeding were not risk factors for newborn COVID-19 diagnosis, thus well-established best practices can be continued among women with COVID-19 diagnosis.

Exploratory study of fathers providing Kangaroo Care in a Neonatal Intensive Care Unit

AIM AND OBJECTIVES

To explore fathers' views and experiences of providing Kangaroo Care (KC) to their baby cared for in a Neonatal Intensive Care Unit (NICU).

BACKGROUND

Kangaroo Care has been known to improve the health outcome for preterm, low birth weight and medically vulnerable term infants and achieve the optimal perinatal health wellbeing for parents and infants. Historically, mothers are considered as the dominant KC providers, whereas fathers are spectators and have been overlooked. Little is known about the fathers' perspectives in providing KC in NICUs.

METHODS

Individual semi-structured interviews were conducted with 10 fathers who delivered KC to their baby when in the NICU. Data were analysed using Braun and Clarke's six-phase thematical framework. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed to report this qualitative study.

FINDINGS

Fathers in this study identified they were passing a silent language of love and connecting with their baby by the act of KC in a challenging environment. Three themes emerged: 'Positive psychological connection', 'Embracing father-infant Kangaroo Care' and 'Challenges to father-infant Kangaroo Care'.

CONCLUSION

The findings of this study show KC enhances the bonding and attachment between fathers and infants. The conceptualisation of the paternal role in caregiving to a newborn is evolving as a contemporary practice. Further research is warranted to confirm or refute the study findings. Policies and facilities should be modified to include father-infant KC within the fields of neonatal care.

RELEVANCE TO CLINICAL PRACTICE

It is important for nurses and other health professionals to support and enable fathers to give KC. Father-infant KC is recommended in neonatal care settings.

Women's Perceptions of Hospital-Based Breastfeeding Care and the Association With Exclusive Breastfeeding

OBJECTIVE

To examine the differences in women's perceptions of hospital-based breastfeeding care and the association of these perceptions with exclusive breastfeeding.

DESIGN

Observational, mixed-methods study.

SETTING/LOCAL PROBLEM

A 932-bed, Baby-Friendly Hospital Initiative-designated, university hospital with approximately 2,000 births per year, where 50% of women who wanted to breastfeed were supplementing with formula before hospital discharge.

PARTICIPANTS

Thirty-four women who gave birth to a term, singleton newborn and had a desire to breastfeed exclusively.

MEASUREMENTS

Women's perceptions were assessed using a modified version of the Questionnaire for the Breastfeeding Mother.

RESULTS

Women's perceptions of breastfeeding care were positively associated with exclusive breastfeeding (p = .049). In addition, the influence of how a woman's own mother fed her as an infant was shown, because women who themselves were breastfed as infants were more likely to exclusively breastfeed their own newborns. Content analysis showed that women appreciated the care received in the hospital from lactation consultants and access to a hospital-administered breastfeeding clinic after discharge.

CONCLUSION

Creating a hospital environment supportive of breastfeeding could yield positive breastfeeding outcomes for women and newborns.

Increasing Skin-to-Skin in a Level IV NICU: A Quality Improvement Project

PURPOSE

To evaluate the effect of a bundled intervention on the number of skin-to-skin ("kangaroo care") events occurring in a level IV NICU.

DESIGN

A quality improvement effort centering around the introduction of an intervention bundle intended to safely increase the rate of skin-to-skin holding. Rates of unplanned extubations were recorded as a balancing measure to estimate safety.

SAMPLE

All infants admitted to the NICU from December 2017 through September 2019 were included. The "preintervention" period was the 6 months prior to the initiation of the intervention bundle (December 2017-May 2018).

RESULTS

The absolute number of skin-to-skin holds increased from the preintervention phase (range 7-28 holds/month, median 11 holds/month) to the postintervention phase (range 16-100 holds/month, median 55 holds/month). The total unplanned extubations showed no significant change between the preintervention and postintervention periods.

"We All Join Hands": Perceptions of the Kangaroo Method Among Female Relatives of Newborns in The Gambia

Family support is essential for kangaroo mother care (KMC), but there is limited research regarding perceptions of female relatives, and none published from West African contexts. In-depth interviews were conducted from July to August 2017 with a purposive sample of 11 female relatives of preterm neonates admitted to The Gambia's referral hospital. Data were coded in NVivo 11, and thematic analysis was conducted applying an inductive framework. Female relatives were willing to support mothers by providing KMC and assisting with domestic chores and agricultural labor. Three themes were identified: (a) collective family responsibility for newborn care, with elder relatives being key decision makers, (b) balance between maintaining traditional practices and acceptance of KMC as a medical innovation, and (c) gendered expectations of women's responsibilities postnatally. Female relatives are influential stakeholders and could play important roles in KMC programs, encourage community ownership, and contribute to improved outcomes for vulnerable newborns.

Innovation in Practice: Preparing Doulas to Support Cesarean Births

Despite growing initiatives to support patient-centered labor and birth care, implementation of this care in the operating room is still limited. Doulas can be utilized in the operating room to facilitate evidence-based practices such as skin-to-skin contact for patients and newborns during cesarean birth. This article evaluates a curriculum and training method that was developed to educate doulas to provide safe and effective care during the cesarean birth experience. This intervention was found to be effective at improving doulas' self-perceived confidence in skills essential to support cesarean births and may serve as a model for other institutions to address barriers to the implementation of patient-centered evidence-based care in the operating room.

Umbilical cord clamping and skin-to-skin contact in deliveries from women positive for SARS-CoV-2: a prospective observational study

Objective

To demonstrate that delayed cord clamping (DCC) is safe in mothers with confirmed SARS‐CoV‐2 infection.

Design, setting and participants

Prospective observational study involving epidemiological information from 403 pregnant women with SARS‐CoV‐2 between 1 March and 31 May 2020. Data were collected from 70 centres that participate in the Spanish Registry of COVID‐19.

Methods

Patients' information was collected from their medical chart.

Main outcomes and measures

The rate of perinatal transmission of SARS‐CoV‐2 and development of the infection in neonates within 14 days postpartum.

Results

The early cord clamping (ECC) group consisted of 231 infants (57.3%) and the DCC group consisted of 172 infants (42.7%). Five positive newborns (1.7% of total tests performed) were identified with the nasopharyngeal PCR tests performed in the first 12 hours postpartum, two from the ECC group (1.7%) and three from the DCC group (3.6%). No significant differences between groups were found regarding neonatal tests for SARS‐CoV‐2. No confirmed cases of vertical transmission were detected. The percentage of mothers who made skin‐to‐skin contact within the first 24 hours after delivery was significantly higher in the DCC group (84.3% versus 45.9%). Breastfeeding in the immediate postpartum period was also significantly higher in the DCC group (77.3% versus 50.2%).

Conclusions

The results of our study show no differences in perinatal outcomes when performing ECC or DCC, and skin‐to‐skin contact, or breastfeeding.

Tweetable abstract

This study demonstrates that delayed cord clamping is safe in mothers with confirmed SARS‐CoV‐2 infection.

This study demonstrates that delayed cord clamping is safe in mothers with confirmed SARS‐CoV‐2 infection.

Prevalence and Components of Newborn Assessment Policies Related to Sudden Unexpected Postnatal Collapse

OBJECTIVE

To describe, in a convenience sample, different hospitals' nursing care policies related to normal newborn assessment, to summarize common components of those policies related to sudden unexpected postnatal collapse (SUPC) of the newborn, and to correlate characteristics of the hospitals with the presence or absence of a normal newborn assessment policy.

DESIGN

Descriptive evaluative design.

SETTING

Hospital representatives were contacted to complete a questionnaire and provide a copy of their policies regarding normal newborn assessment.

PARTICIPANTS

Representatives from 39 hospitals that provide maternal/newborn services within the United States completed the questionnaire and/or provided the investigator with a written nursing care policy for normal newborn assessment.

INTERVENTION/MEASUREMENTS

Components of the hospitals' normal newborn assessment policies were evaluated according to the framework of recommended components outlined by the American Academy of Pediatrics in Feldman-Winter et al. (2016).

RESULTS

The four components most often included in the policies submitted by 26 hospitals were maternal/newborn dyad assessments (n = 25, 96%), sequence of events postpartum (n = 15, 58%), monitoring (n = 9, 35%), and skin-to-skin contact procedures (n = 8, 30%). Differences were noted based on the size of the hospital as defined by the number of births and number of beds and also by the type of unit.

CONCLUSION

Few policies in this study aligned with the recommended suggestions from the American Academy of Pediatrics outlined in Feldman-Winter et al. (2016). It is also important to note that these recommended suggestions relate to safe skin-to-skin contact and rooming-in practices, which may in turn affect the incidence of SUPC. There is much work to be done in terms of disseminating evidence and developing and implementing newborn assessment policies related to SUPC.

[Not Available]

Body care and development of the premature infant. The observation of newborns' reactions to different stimulations enables their behaviour to be interpreted and the support provided to be adjusted. Developmental care such as swaddling, tucked posture and skin-to-skin contact favours the harmonious development of premature infants and encourages the parents to become involved in their care as early as possible.

Celebrate Birth!-Ava's Arrival

As a Certified Lamaze Childbirth Educator and poet, I wrote this poem to help a new mother come to terms with the fact she was unable to have a vaginal delivery. Her first born was in a transverse lie the entire third trimester. Despite numerous interventions, the baby would not turn and had to be delivered by cesarean surgery. This was the safest possible birth for mother and baby. The couple desperately wanted to hold true to the Lamaze Philosophy and Healthy Birth Practices. They insisted labor begin spontaneously, and so it did. The poem and photographs reveal the parents' fortitude, demonstrating the core premise of their birth plan was not negated. The outcome: healthy mother and healthy baby.

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.

What Is the Experience of Babywearing a NICU Graduate?

OBJECTIVE

To understand the experiences of caregivers using baby carriers to hold their infant after discharge from the NICU.

DESIGN

The qualitative research design was transcendental phenomenology.

SETTING/LOCAL PROBLEM

Caregiving of NICU graduates is associated with greater incidence of depression, anxiety, and posttraumatic stress disorder, which can impair caregivers' abilities to form secure attachments with their infants. In addition, lack of paid parental leave, especially among those of low socioeconomic status, can result in prolonged separations between infants and caregivers in the NICU, producing toxic stressors.

PARTICIPANTS

Eight caregivers ages 21 to 41 years whose infants were discharged from the NICU of a regional referral academic medical center in Oklahoma City, Oklahoma. Homogenous convenience sampling was used by posting recruitment flyers in common areas of the NICU frequented by family members.

INTERVENTION/MEASUREMENTS

Participants were educated before discharge on using baby carriers that held their infants in kangaroo position. They were asked to carry their infant in the carrier for 3 hours a day for the 2-month study period.

RESULTS

Six total themes were identified; four were previously identified in kangaroo care and skin-to-skin care research: Decreased Stress and Anxiety, Calmness and Sleep, Attachment, and Parental Empowerment; two were independent to this study: Ease of Work and Self-Care.

CONCLUSION

The themes identified indicate that babywearing has the potential to address harms-such as stress, fear, depression, anxiety, and posttraumatic stress disorder-that may be experienced by caregivers of infants discharged from the NICU. Babywearing can be used as an intervention to support caregivers and promote positive health outcomes after a NICU discharge.

Assessing Barriers to Implement Birth Kangaroo Care in Kentucky Birthing Hospitals

Introduction

Kentucky continues to have one of the lowest state breastfeeding rates in the country. In 2014, the majority of the birthing hospitals in Kentucky implemented a practice change to the healthcare model known as Birth Kangaroo Care (BKC) as an effort to increase breastfeeding initiation. The goal of this study was to identify current practices and barriers to implementing BKC.

Methods

An evaluation/surveillance study that incorporated an Internet survey to collect information about the practices and policies of BKC in birthing hospitals in Kentucky was completed.

Findings

The response rate was 54% (n = 25). The birthing hospitals responders to the survey (84%) reported that a BKC policy was established after the educational intervention. Data identified two perceived barriers regarding uninterrupted BKC. One barrier was the interruption by family members to hold the newborn, and the second was a delay in BKC for medical evaluations of the baby by staff members.

Conclusion

Breastfeeding rates after implementation of the BKC policy in Kentucky birthing hospitals showed a statistically significant (p = .02) improvement of "ever breastfed" infants.

Determinants of Exclusive Breastfeeding Cessation in the Early Postnatal Period among Culturally and Linguistically Diverse (CALD) Australian Mothers

There are limited epidemiological data on exclusive breastfeeding (EBF) among culturally and linguistically diverse (CALD) Australian mothers to advocate for targeted and/or culturally-appropriate interventions. This study investigated the determinants of EBF cessation in the early postnatal period among CALD Australian mothers in Sydney, Australia. The study used linked maternal and child health data from two local health districts in Australia (N = 25,407). Prevalence of maternal breastfeeding intention, skin-to-skin contact, EBF at birth, discharge, and the early postnatal period (1-4 weeks postnatal), were estimated. Multivariate logistic regression models were used to investigate determinants of EBF cessation in the early postnatal period. Most CALD Australian mothers had the intention to breastfeed (94.7%). Skin-to-skin contact (81.0%), EBF at delivery (91.0%), and at discharge (93.0%) were high. EBF remained high in the early postnatal period (91.4%). A lack of prenatal breastfeeding intention was the strongest determinant of EBF cessation (adjusted odds ratio [aOR] = 23.76, 95% CI: 18.63-30.30, for mothers with no prenatal breastfeeding intention and aOR = 6.15, 95% CI: 4.74-7.98, for those undecided). Other significant determinants of EBF cessation included a lack of partner support, antenatal and postnatal depression, intimate partner violence, low socioeconomic status, caesarean birth, and young maternal age (<20 years). Efforts to improve breastfeeding among women of CALD backgrounds in Australia should focus on women with vulnerabilities to maximise the benefits of EBF.

Effect of Kangaroo Mother Care on hospital management indicators: A systematic review and meta-analysis of randomized controlled trials

Results of previous studies about the effect of Kangaroo Mother Care (KMC) on hospital management indicators (HMIs) (length of stay [LOS], readmission to hospital, parent satisfaction, and parent's preference for same postdelivery care) had high confusions. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials on the effect of KMC on HMI in comparison with the conventional neonatal care (CNC). In this systematic review and meta-analysis study, required data were collected by searching the following keywords: "length of stay," "readmission to hospital," satisfaction," same post-delivery," "hospital management," indicators, "skin-to-skin," "Kangaroo Mother Care," randomized trial. The following databases were searched: Google Scholar, PubMed, EMBASE, Scopus, and Cochrane. To estimate the hospital management indicators, computer software Comprehensive Meta-Analysis 2 was used. Finally, 18 articles were included to analysis. The overall LOS standard different between groups (KMC vs. CNC) was - 0.91 days (95% confidence interval [CI], -2.14-0.32, Q = 25.6, df = 10, P = 0.004, I ² = 60.98). The overall readmission to hospital standard different between groups was - 1.78% (95% CI, -1.21%-0.86%, Q = 0.024, df = 1, P = 0.87, I ² = 0.00). The overall parent satisfaction standard different between groups was 5.3% (95% CI, -32.4%-43%, Q = 0.052, df = 2, P = 0.97, I ² = 0.00). The overall standard different between groups was 16.2% (95% CI, -24.7%-57.1%, Q = 0.040, df = 1, P = 0.84, I ² = 0.00). KMC improves HMI but not significantly. According to the current study result and other studies that report positive effect of KMC on health status of the newborns and parents, implemented of KMC in low- and middle-income countries recommended.

Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice

Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant's traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant's traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.

Nurses Leading Safe Infant Sleep Initiatives in the Hospital Setting

Every day, 10 otherwise healthy infants die from sleep-related deaths in the United States. These deaths, termed sudden unexpected infant death, remain the leading cause of post-neonatal death in the United States despite known modifiable risk factors and prevention recommendations. In birthing hospitals, many parents report being given incorrect and sometimes no information about infant sleep safety, which creates immediate and long-term safety concerns. In this article, we provide an overview of sudden unexpected infant death, including sudden unexpected postnatal collapse, and the latest safe sleep recommendations from the American Academy of Pediatrics. We also offer practical guidelines for nurses-those working at the bedside and those in leadership positions-who may be seeking to improve the quality of infant sleep practices in their organizations.

Determinants of in-hospital feeding practices in Shiraz, Iran: Results of a prospective cohort study

BACKGROUND

In-hospital feeding practices have been shown negatively to affect breastfeeding exclusivity and duration. The purpose of this study was to report the prevalence and determinants of delayed breastfeeding, provision of traditional prelacteal foods, and use of infant formula in hospital.

METHODS

Between June 2014 and March 2015, 700 women were recruited from three public and two private maternity hospitals in Shiraz, Iran. Data were collected at recruitment via face-to-face interviews and extracted from medical records. Multivariable logistic regression was used to explore the association of feeding practices with a variety of maternal characteristics and hospital practices.

RESULTS

Only 32.2% of infants were breastfed within 1 hour of birth, with 40.8% receiving a traditional prelacteal food, and 34.9% given formula during their hospital stay. Compared with infants delivered vaginally, those delivered by cesarean were more likely to have experienced delayed breastfeeding and received formula, but less likely to have received traditional prelacteal foods. Infants who did not experience skin-to-skin contact were more likely to have experienced delayed breastfeeding and received traditional prelacteal foods and formula in hospital.

CONCLUSIONS

Although four out of the five hospitals were designated as Baby-Friendly, several of the 10 Steps to Successful Breastfeeding were not adhered to. The high rate of cesarean delivery was a barrier to the early initiation of breastfeeding and the majority of infants did not experience early skin-to-skin contact. Maternity care practices should be reviewed and include a clear breastfeeding care plan for women who undergo a cesarean delivery.

Physiology of Stress and Use of Skin-to-Skin Care as a Stress-Reducing Intervention in the NICU

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

Effect of Kangaroo Mother Care on Successful Breastfeeding: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND & AIMS

Evaluating the effect of Kangaroo Mother Care (KMC) on breastfeeding success shows conflicting results. Regarding the importance of breastfeeding and uncertainties about its effect, this study intended to conduct a systematic review and meta-analysis of randomised controlled trials on the effect of KMC on success of breastfeeding.

METHODS

In this systematic review and meta-analysis study, required data were collected by searching the following keywords: breastfeeding, Breast-Feeding, "skin-to-skin", "Kangaroo Mother Care", randomized clinical trial. The following databases were searched: Google Scholar, PubMed, EMBASE, Scopus, and Cochrane Central Register of Controlled Trials. Two authors independently extracted the data. To estimate the Breast-Feeding outcome variables, CMA2 software was used. The risk of bias of studies was assessed with the criteria developed in the Cochrane Handbook.

RESULTS

Twenty articles were included. In the KMC and CNC groups, 1,432 and 1,410 neonates were examined. Breastfeeding success rate was higher in the KMC group within different time slots, however this difference was not statistically significant (RR=1.11(95CI, 0.93-1.34) and RR=1.13(95%CI, 0.92-1.34) based on the time slot and birth weight, respectively). The inter-groups differences in the mean scores of Infant Breast-Feeding Assessment Tool (IBFAT) were statistically significant (P<0.05). Breastfeeding was initiated very sooner in the KMC group, suggesting a statistically significant inter-groups difference -0.72(95%CI, from -0.92 to -0.53) (P<0.05). Majority of the studies had a high risk of bias.

CONCLUSION

Findings indicated a superiority of KMC over CNC in terms of breastfeeding success. Assessment of the complications and costs of KMC implementation is recommended.

Mapping, Measuring, and Analyzing the Process of Skin-to-Skin Contact and Early Breastfeeding in the First Hour After Birth

BACKGROUND

Although the benefits of immediate, continuous, uninterrupted skin-to-skin contact (SSC) and early breastfeeding have been widely researched and confirmed, the challenge remains to improve the consistency of this practice. Fewer than half of newborns worldwide are breastfed in the first hour.

DESIGN

Cross-sectional descriptive study utilizing iterative review and analysis of video ethnography as well as data extracted from patient records.

SAMPLE AND SETTING

Eighty-four medically uncomplicated mothers and full-term newborns were observed during the first hour after birth at a Baby-Friendly designated hospital in the United States.

FINDINGS

Process mapping using an algorithm which included Robson criteria indicated that although included mothers were expected to give birth vaginally and had no medical concerns that would preclude eligibility for SSC in the first hour after birth, 31 of 84 newborns (37%) did not receive immediate SSC after vaginal birth as planned and only 23 (27.4%) self-attached and suckled.

CONCLUSION

Process mapping of optimal skin-to-skin practice in the first hour after birth using the algorithm, HCP-S2S-IA, produced an accurate and useful measurement, illuminating how work is conducted and providing patterns for analysis and opportunities for improvement with targeted interventions.

[Newborn care in the delivery room]

The arrival of a newborn in the delivery room is a precious and unique moment which caregivers support by seeing to the comfort and wellbeing of the baby and his or her parents. Developmental care is introduced early, skin-to-skin contact is favoured and invasive treatment is only performed if strictly necessary. At the same time, the teams are ready to intervene in the event of a complication.

Cerebral oxygenation during skin-to-skin care in preterm infants not receiving respiratory support

OBJECTIVE

Skin-to-skin care (SSC) has proven benefits in preterm infants, but increased hypoxic and bradycardic events have been reported. This may make clinicians hesitant to recommend SSC as standard care. We hypothesised that regional cerebral oxygenation (rStO₂) measured with near infrared spectroscopy is not worse during SSC compared with standard incubator care.

DESIGN

Prospective, observational, non-inferiority study.

SETTING

Single tertiary perinatal centre in Australia.

PATIENTS

Forty preterm infants (median (IQR) 30.6 (29.1-31.7) weeks' gestation) not receiving respiratory support were studied on day 14 (8-38).

INTERVENTIONS

Recordings during 90 min of incubator care, followed by 90 min of SSC. Each infant acted as their own control and caregivers were blinded to the rStO₂ measurements.

MAIN OUTCOME MEASURES

The primary outcome was the mean difference in rStO₂ between SSC and incubator care. The prespecified margin of non-inferiority was -1.5%. Secondary outcomes included heart rate (HR), peripheral oxygen saturation (SpO₂), time in quiet sleep, temperature and hypoxic (SpO₂ <80% for >5 s) or bradycardic events (HR <80 bpm for >5 s) and time spent in cerebral hypoxia (rStO₂<55%) and hyperoxia (rStO₂>85%).

RESULTS

Mean (SD) rStO₂ was lower during SSC compared with incubator care: 73.6 (6.0)% vs 74.8 (4.6)%, mean difference (95% CI) 1.3 (2.2 to 0.4)%. HR was 5 bpm higher, SpO₂ 1% lower and time in quiet sleep 24% longer during SSC. Little evidence of a difference was observed in temperature. The number of hypoxic or bradycardic events as well as the proportion of time spent in cerebral hypoxia and hyperoxia was very low in both periods.

CONCLUSIONS

Mean rStO₂ was marginally lower during SSC without observed differences in hypoxic or bardycardic events but an increase in time spent in quiet sleep.

TRIAL REGISTRATION NUMBER

This trial is linked to Australian New Zealand Clinical Trials Registry: identifier 12616000240448. It was registered pre-results.

Providing Evidence-Based Care During the Golden Hour

The Golden Hour encompasses a set of evidence-based practices that contribute to the physiologic stabilization of the mother-newborn dyad after birth. Important elements of the Golden Hour include delayed cord clamping, skin-to-skin contact for at least an hour, the performance of newborn assessments on the maternal abdomen, delaying non-urgent tasks (e.g., bathing the newborn) for 60 minutes, and the early initiation of breastfeeding. The Golden Hour contributes to neonatal thermoregulation, decreased stress levels in a woman and her newborn, and improved mother-newborn bonding. Implementation of these actions is further associated with increased rates and duration of breastfeeding. This article explores the evidence supporting the Golden Hour and provides strategies for successfully implementing a Golden Hour protocol on a hospital-based labor and delivery unit.

An implementation algorithm to improve skin-to-skin practice in the first hour after birth

Evidence supporting the practice of skin‐to‐skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin‐to‐skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin‐to‐skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self‐attachment and suckling. However, the most recent Cochrane review of early skin‐to‐skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin‐to‐skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin‐to‐skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.

[An innovative position during skin-to-skin contact in neonatology]

Skin-to-skin is, by its very nature, the only relational care entirely devoted to the parent-baby relationship, from the infant's time in neonatal intensive care. However, current practice is unsuited to visual and tactile exchange. A simple change to the baby's positioning helps to improve the quality of the immediate interaction between the infant and the mother, benefiting the development of the baby and parenthood.

Systematic Review of Skin-to-Skin Care for Full-Term, Healthy Newborns

OBJECTIVE

To determine the effect of skin-to-skin mother-infant holding, touch, and/or massage on full-term, healthy newborns and their primary caregivers.

DATA SOURCES

A seven-member scientific advisory panel searched the databases PubMed, CINAHL, and Scopus using the search terms massage, skin-to-skin contact, kangaroo care, touch, therapeutic touch, and full-term newborns for research with human participants published in English with no date parameters.

STUDY SELECTION

The initial search yielded 416 articles. After reviewing titles and retaining only articles that met the review criteria, 280 articles remained. The panel co-chairs reviewed and discussed the abstracts of these articles and retained 90 for review.

DATA EXTRACTION

Each article was assigned to one panel member and one co-chair for review. Members of the panel met via teleconference to present articles and to determine whether they had scientific merit and addressed the research question. Articles that did not meet these standards were eliminated. Forty articles included relevant evidence: 33 articles on skin-to-skin holding and 7 on infant massage.

DATA SYNTHESIS

We created a table that included the purpose, design, and findings of each study. This information was synthesized into a feasibility report by the co-chairs.

CONCLUSION

Evidence supports recommendations for skin-to-skin care for all full-term, healthy newborns. Although there is inadequate evidence to recommend massage as standard care for all newborns, massage has been shown to help consolidate sleep patterns and reduce jaundice.

["Valentin was born prematurely"]

Anne-Charlotte B. is the proud mother of Valentin, born prematurely seven years ago. Despite the complications of the birth, the initial separation and the difficult start to breastfeeding, Valentin gradually gained weight and has never suffered any sequelae. The family has since grown.

Role of Baby-Friendly Hospital Care in Maternal Role Competence

The objective of this pilot study was to determine women's perceptions of their levels of maternal role competence at discharge from a Baby-Friendly hospital. A convenience sample of 30 women completed two self-report questionnaires: a demographic questionnaire and the Perceived Maternal Parenting Self-Efficacy scale. Women report that they perceived high levels of maternal role competence with a mean total score of 69.80 (standard deviation = 6.86) out of 80. As women experience breastfeeding in Baby-Friendly hospitals, maternal role competence may develop with appropriate support.

Design, Implementation, and Early Outcome Indicators of a New Family-Integrated Neonatal Unit

Neonatal units are becoming more family-centered based on evidence of improved health outcomes when parents provide care to newborns. Physical environment constraints, as well as nursing care traditions and practices, have been barriers to providing care that includes close parental involvement. Our hospital's experience in implementing a unique model of family-centered care in a Level II nursery suggests that this model of care is beneficial to families, satisfying to health care providers, and a viable model for practice. Some basic outcome data are discussed along with suggestions for future research.

Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: A systematic review

Rates of breastfeeding uptake are lower after a caesarean birth than vaginal birth, despite caesarean rates increasing globally over the past 30 years, and many high-income countries reporting overall caesarean rates of above 25%. A number of factors are likely to be associated with women's infant feeding decisions following a caesarean birth such as limited postoperative mobility, postoperative pain, and ongoing management of medical complications that may have triggered the need for a caesarean birth. The aim of this systematic review was to evaluate evidence of interventions on the initiation and duration of any and exclusive breastfeeding among women who had a planned or unplanned caesarean birth. Seven studies, presenting quantitative and qualitative evidence, published in the English language from January 1994 to February 2016 were included. A limited number of interventions were identified relevant to women who had had a caesarean birth. These included immediate or early skin-to-skin contact, parent education, the provision of sidecar bassinets when rooming-in, and use of breast pumps. Only one study, an intervention that included parent education and targeted breastfeeding support, increased initiation and continuation of breastfeeding, but due to methodological limitations, findings should be considered with caution. There is a need to better understand the impact of caesarean birth on maternal physiological, psychological, and physical recovery, the physiology of lactation and breastfeeding and infant feeding behaviors if effective interventions are to be implemented.

Sudden Unexpected Postnatal Collapse of the Newborn

Sudden unexpected postnatal collapse is a rare but devastating neonatal event. A well-appearing, full-term newborn with Agpar scores of eight or more suddenly crashes, often with full respiratory and cardiac arrest. Up to half of newborns with sudden unexpected postnatal collapse die, with many survivors suffering serious neurological damage. The first 2 hours of life are the hours of greatest risk, coinciding with the time frame when nurses encourage breastfeeding and uninterrupted skin-to-skin contact between women and newborns. Nursing assessments and measures to promote neonates' optimal transition to extrauterine life through skin-to-skin contact and early breastfeeding while decreasing the risk of this catastrophic event are described. Nursing surveillance to promote optimal transition in a safe environment is essential, and birth facilities should allocate staffing resources accordingly.

Implementing a Protocol Using Glucose Gel to Treat Neonatal Hypoglycemia

Neonatal hypoglycemia is a leading cause of admission of neonates to the NICU. Typical treatment for neonatal hypoglycemia includes supplementation with formula or, in some cases, intravenous glucose administration. These treatments, though effective at treating hypoglycemia, interrupt exclusive breastfeeding and interfere with mother-infant bonding. Our institution developed a treatment algorithm for newborns at risk for neonatal hypoglycemia. The new algorithm called for the oral administration of 40% glucose gel. This intervention resulted in a 73% decreasein admission rates to the NICU for hypoglycemia, and it supported exclusive breastfeeding, skin-to-skin contact, and mother-infant bonding.

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

BACKGROUND

Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin, have been previously studied in relation to neonatal outcomes, especially breastfeeding, with conflicting results. We examined the normal neonatal behavior of suckling within the first hour after a vaginal birth while in skin-to-skin contact with mother in relation to these commonly used drugs. Suckling in the first hour after birth has been shown in other studies to increase desirable breastfeeding outcomes.

METHOD

Prospective comparative design. Sixty-three low-risk mothers self-selected to labor with intrapartum analgesia/anesthesia or not. Video recordings of infants during the first hour after birth while being held skin-to-skin with their mother were coded and analyzed to ascertain whether or not they achieved Stage 8 (suckling) of Widström's 9 Stages of newborn behavior during the first hour after birth.

RESULTS

A strong inverse correlation was found between the amount and duration of exposure to epidural fentanyl and the amount of synthetic oxytocin against the likelihood of achieving suckling during the first hour after a vaginal birth.

CONCLUSIONS

Results suggest that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decreased the likelihood of the baby suckling while skin-to-skin with its mother during the first hour after birth.

Behavior of the Newborn during Skin-to-Skin

BACKGROUND

Early skin-to-skin contact (SSC) significantly increases the breastfeeding rate in healthy term infants.

OBJECTIVE

This study aimed to confirm previously described behavioral sequences during SSC.

METHODS

We recorded live and videotaped infant behavioral sequences during SSC in a cohort of healthy term infants, whose outcome was then evaluated.

RESULTS

We studied 17 mother-infants dyads. While the majority of infants (59%) had behavioral phases that have been previously reported, some of them had alternative sequences. We observed the infant's massage of the mother's breast with its hand during SSC, which had not been previously reported. We found no correlations between behavioral sequence during SSC, breastfeeding, and neonatal outcome. Moreover, maternal pain stimuli did not affect the neonatal SSC behavioral sequence.

CONCLUSION

Our study confirms that immediate and undisturbed postpartum SSC is characterized by specific behavioral phases whose sequence may vary without affecting the suckling rate at the end of SSC, breastfeeding success, or the short-term neonatal outcome.

Healthy Birth Practice #6: Keep Mother and Baby Together- It's Best for Mother, Baby, and Breastfeeding

Mothers and babies have a physiologic need to be together at the moment of birth and during the hours and days that follow. Keeping mothers and babies together is a safe and healthy birth practice. Evidence supports immediate, uninterrupted skin-to-skin care after vaginal birth and during and after cesarean surgery for all stable mothers and babies, regardless of feeding preference. Unlimited opportunities for skin-to-skin care and breastfeeding promote optimal maternal and child outcomes. This article is an updated evidence-based review of the "Lamaze International Care Practices That Promote Normal Birth, Care Practice #6: No Separation of Mother and Baby, With Unlimited Opportunities for Breastfeeding," published in The Journal of Perinatal Education, 16(3), 2007.

Postcesarean Section Skin-to-Skin Contact of Mother and Child

The first hour postpartum is critical for long-term, healthy development. At 12 de Octubre Hospital, Madrid, Spain, we developed and implemented a multidisciplinary strategy based on a consensual, participatory protocol for all health care professionals involved in cesarean deliveries. Our aims were 2-fold: the initiation of skin-to-skin (StS) contact with the newborn immediately after birth, regardless of the feeding method chosen, and the recognition of the importance of a companion present for support during the cesarean section (father or other designated by the mother). The objective of this article is to describe a policy developed to ensure timely postcesarean StS contact. Our protocol for neonatal StS contact with the mother is based on reported benefits found in literature, the World Health Organization's international recommendations, and deep respect for a process that is both natural and instinctive. We call it "humanizing the cesarean."

Parental presence and holding in the neonatal intensive care unit and associations with early neurobehavior

OBJECTIVE

To investigate the effects of parental presence and infant holding in the neonatal intensive care unit (NICU) on neurobehavior at term equivalent.

STUDY DESIGN

Prospective cohort enrolled 81 infants born 30 weeks gestation. Nurses tracked parent visitation, holding and skin-to-skin care throughout the NICU hospitalization. At term, the NICU Network Neurobehavioral Scale was administered. Associations between visitation, holding and early neurobehavior were determined using linear and logistic regression.

RESULT

The mean hours per week of parent visitation was 21.33±20.88 (median=13.90; interquartile range 10.10 to 23.60). Infants were held an average of 2.29±1.47 days per week (median=2.00; interquartile range 1.20 to 3.10). Over the hospital stay, visitation hours decreased (P=0.01), while holding frequencies increased (P<0.001). More visitation was associated with better quality of movement (P=0.02), less arousal (P=0.01), less excitability (P=0.03), more lethargy (P=0.01) and more hypotonia (P<0.01). More holding was associated with improved quality of movement (P<0.01), less stress (P<0.01), less arousal (P=0.04) and less excitability (P<0.01).

CONCLUSION

Infants of caregivers who were visited and held more often in the NICU had differences in early neurobehavior by term equivalent, which supports the need for and importance of early parenting in the NICU.

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

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