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Healthy Birth Practice #6, Keeping Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding

Mother and Child Reunion

The goal of Lamaze “Healthy Birth Practice #6, Keeping Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding” is to encourage and support mothers so they may confidently insist that they not be separated from their newborns, and be allowed to have ample opportunity for skin-to-skin contact without delay or interruption, as recommended by a multitude of sources concerned with infant and maternal health.

Dr. Lennart Righard’s seminal study1, published in the Lancet in 1990, gave rise to his famous video, “Delivery Self Attachment”2, which illustrated parts of that research.  It shows babies who, when left undisturbed on their mothers’ bodies immediately after birth, find the breast by themselves, crawl to it and suckle with competence. It observes also those babies whose abilities are either impaired or negated because of exposure to intrapartum meds, separation from their mothers after birth, or both.

“Newborns have a great need for love which makes a separation between mother and child most unfortunate”3, Lennart is quoted as saying, poignantly, in a blurb on the packaging of his video. A banner below that quote, set in 16-point type and caps, proclaims “THIS SIX MINUTE VIDEO WILL CHANGE PROTOCOLS!”

It is ”unfortunate” indeed that  many mothers still experience resistance to this best-evidence protocol; hospital staff and caregivers still whisk newborns away for routine procedures, processing and observation after just a few minutes of time with their mothers.   As with so many maternity-care practices, the protocols that Righard thought with certainty would change, are still in place, even as the evidence for keeping mother and baby together mounts.  Some state Departments of Health, as that in Ohio, have got it right, and officially recommend skin-to-skin. That state prints and distributes cards for its WIC program that read, in part:  “Hold me, Mom. Babies who are held skin-to-skin on their mother‘s chest right after birth are happier and less likely to cry, are more likely to latch on and [sic] breastfeeding well, have better heart rates, have better temperatures than under a warmer, have better blood sugars, burn less [sic]  calories than under a warmer. So, be sure to tell your doctor and the hospital nurses that you want to hold your baby for at least the first hour after the birth, skin-to-skin (baby naked, not wrapped in a blanket). That‘s the best way to introduce your baby to the world”4. (Emphasis mine.) How can we account for the fact that a mother is advised by a government agency to “be sure” to tell her doc and staff to give her best-evidence care? Even for this well-documented and uncomplicated course of action, we cannot count on our caregivers to act reliably in the interests of mother and baby.  Again, a Healthy Birth Practice can be read as a subtle warning: Do not let them take your baby from you for the first hour!

Mothers have always needed to keep their babies with them, and supporting evidence for that urgent desire has been around for quite a while.  In 1979, Michel Odent proposed, in a theory and review article on human ecology, and under the aegis of his Primal Research Center, that the natural ecology  for an infant is to be skin-to-skin (S2S) with the mother. The Human Ecolog deals with “primal” health, a branch of epidemiology that brings together studies exploring correlations between what happens during the primal period (fetal life, perinatal period and the year following birth) and what occurs later in life in terms of health and personality traits. The treatment of mother and newborn as an inseparable dyad is the basis for those studies and can be found compiled in the Primal Health Research Data base 5.

With the understanding of what is best for the “primal” health of the newborn, and in light of the wisdom of Healthy Birth Practice #6, the Baby Friendly Hospital Initiative of the WHO and UNICEF very specifically and unequivocally advises that mothers and infants remain together 24 hours a day.  As of May 2011, out of 3,000 or so hospital maternity centers and free standing birth centers in this country, only 110 have achieved the status of Baby Friendly.  No wonder women must be advised and exhorted to ask or demand treatment that should be just pro forma in every LDR. Why must women spend precious energy and focus during labor to advocate for best-evidence care for themselves when that kind of care should just be expectations met?  Period.

Kangaroo Care, “a universally and biologically sound method of care for all newborns,” 6 incorporating S2S, breastfeeding and support of mother and baby, has become a standard of care in many NICUs.  While there is no citation to back up that statistic, Wikipedia represents that fully 82% of NICUs in the US practice KC.  That is not surprising, given the wealth of studies going all the way back to 1979 that show how effectively KC helps at-risk babies i.e., improving and normalizing vital signs, stabilizing breathing and heart rate and normalizing glucose and stress levels. Many studies can be accessed at the kangaroo care website: http://www.kangaroomothercare.com.   Kangaroo Care babies have been shown to have significantly higher scores in visual and auditory  orientation, alertness, cuddliness, self-quieting, attention and state regulation, and higher scores at 6 months on the Infant Temperament Questionnaire than standard-care infants.  Kangaroo care has been shown to promote neonatal behavioral organization and enhanced developmental outcomes through the first year of life. 7Is it such a stretch to extrapolate that practice to all term healthy newborns whose need for their mothers is just as acute as that of those in NICUs?

There are some fascinating studies about interactions between mother and baby immediately after birth that investigate “the  ‘smellscape’ of mother’s breast: the effects of odor on neonatal arousal, oral and visual responses”.8 Here are just a couple of  observations from a multitude of studies available: “volatile compounds originating in areolar secretions or milk, release mouthing, stimulate eye-opening and delay and reduce crying in newborns”.9 “The odor of human milk is more attractive to human newborns than formula milk…independent of postnatal feeding experience.”10

The skin-to-skin interactions between mother and babe are maturational for newborn; the contact stimulates the vagal nerve, causing increased growth in size of the villi in the newborn gut, which provides a larger surface area for the absorption of nutrition. Nancy Mohrbacher, author and breastfeeding expert, in her article “Rethinking Swaddling” 11 has pointed out the differences between the infant held skin-to-skin and those who were wrapped and held by their mothers.  She cites studies showing that swaddling delays the first breastfeed and leads to less effective suckling, greater weight loss, and more jaundice. Routine swaddling has negative effects on the infant whether in the hospital or at home.

In the main, Healthy Birth Practice #6 addresses a mother’s time in the hospital, to promote behavior that is really just a prelude to how mother and baby should proceed together when they go home. But along with that vital and valuable information, another aspect of a new mother’s experience needs to be examined and promoted… we must begin to examine with mothers something that is rarely mentioned, rarely talked about by OBs, and rarely discussed as part of the normal and natural part of a new life coming into the world…the remarkable abilities and competence of the newborn.  Birthing of the placenta gets more coverage in birth literature than do the stellar capacities of a new baby.

The Righard video of newborn behavior amazes because we see the antithesis of what first-time mothers imagine that their infants will be like.  Popular images show a greasy-eyed newborn, wrapped up and be-blanketed as tight as a little taco, handed over to mom to hold. The Righard video, familiar to many of us, causes gasps at the first images of that lively newborn pushing its little legs against its mother’s abdomen, bobbing its little head with power and purpose, and performing the initial latch with brio.  Mothers need to be told that, even if they have had intrapartum medications, they must continually give their newborns the opportunity to perform as they are hard-wired to do, and we must emphasize that newborns are capable and competent. Dr. Christina Smillie’s approach to breastfeeding…and her video “Baby-Led Breastfeeding12 rely on the baby’s instinctive responses to seek and find the breast when they are allowed to stay on their mother’s bodies.  It demonstrates without equivocation how well babies can navigate about to find the breast. Every mother-to-be should be told about the amazing capabilities of her newborn, and encouraged to spend time every day with her newborn skin-to-skin.  That information should be part of every childbirth education syllabus.

A couple of videos that came out this year also address that important hour or so after birth, and illustrate the nine stages through which the newborn progresses.  Sponsored by the Healthy Children Project, the video called The Magical Hour13 and based on the research of Anne-Marie Widstrom and colleagues, is aimed at parents-to-be, and shows newborns in all the stages of adaptation to life outside from Stage One, the Birth Cry, to Stage Nine, Sleep. The other video, Skin to Skin in the First Hour after Birth: Practical Advice for Staff after Vaginal and Cesarean Birth 14, also from the Healthy Children Project, is aimed at hospital staff, delineating the same nine stages as The Magical Hour. It lays out guidelines for the treatment of mother and baby immediately after birth, whether vaginal or cesarean, with the view that the implementation of direct and uninterrupted contact between mother and newborn is the perfect beginning for a new family.

http://youtu.be/xzQWv5ZWtIM

 

 

References

1-      Lancet, Vol. 336,1105-07

2-      Delivery Self Attachment, 1995 Lennart Righard & Kittie Franz, Geddes Productions, Los Angeles, CA

3-      Ibid

4-       Ohio Department of Health. (2008). Hold me, Mom. Columbus, Oh: Ohio Dept.  of Health Printing, Warehouse # 3977.23.

5- www.primalhealthresearch.com Odent, M. (2006).  Homo Super-predator to Homo Ecologicus. http://www.wombecology.com/homo.html#top.

6-www.kangaroomothercare.com/whatis01/htm

7-Fukida M, Moriuchi, Akiyama T, Nugent JK, Brazelton, TB, Arisawa K, Takahashi T, & Saito H (2002) The effects of kangaroo care on neonatal neurobehavioral organization, infant development and temperament in healthy infants through one year. J Perinatology, 22(5).384-379

8-Doucet S, Soussignan R, Sagot P, Schaal B, Dev Psychobiol 49(2); 129-38, 2007 Equipe d’Ethologie et de Psycholbiologie Sensorielle Centre des Sciences du Gout Umr 5170 CNRS Dijon, France. doucet@cesg.cnrs.fr

9-Ibid

10-Mizuno K, Mizuno N, Shinohara T, et al; Mother-infant Skin-to-skin contact after delivery results in early recognition of own mother’s milk odour. Acta Paediatrica 93(12):1640-1645, 2004 katsuorobi@aol.com

11-Rethinking Swaddling, International Journal of Childbirth Education, 2010

12-Baby-Led Breastfeeding, Geddes Productions, Los Angeles, CA, 2007, Christina M Smillie, Ivy Makelin, Kittie    Franz

13-The Magical Hour; Holding Your Baby for the First Hour After Birth. DVD Produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc

14-Skin to skin in the First Hour After Birth: Practical Advice for Staff after Vaginal         and Cesarean Birth,  DVD Produced by  Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc


Posted by:  Jackie Levine, LCCE, FACCE, CD(DONA), CLC

Baby Friendly Initiative, Breastfeeding, Evidence Based Medicine, Films about Pregnancy, Healthy Birth Practices, Healthy Care Practices, Patient Advocacy, Practice Guidelines, Uncategorized , , , , , , , , , , , , , ,

  1. June 28th, 2011 at 13:21 | #1

    As a childbirth educator and/or doula, how do you advise expectant moms to request and ensure uninterrupted S2S immediately after birth? What’s the best way to deal with “efficient” nurses who want to perform the standard newborn tests, weighing, etc. immediately after the cord has been cut?

  2. avatar
    Jacqueline Levine
    June 28th, 2011 at 21:04 | #2

    Cara, the answer to your fine question is one that has implications for every category of best-evidence maternity-and-newborn care, because each intervention, each action to which mother and/or baby are subjected must always be guided by the principle of informed consent/refusal. Before I teach the little strategies that help achieve uninterrupted S2S, indeed before I teach the little tricks I’ve accumulated to help avoid any routine intervention, I teach what may be the best thing I can give all mothers…a strong foundation from which to ask for or demand what is theirs by right. Knowledge of their legal rights, their human rights as mothers, is a powerful tool. It confers a solid place to stand for mothers when they are confronted by “hospital policies”.

    Childbirth Connection has enumerated the rights of childbearing women, and my favorite words embody the foundation on which mothers are able to demand evidence-based care: “Every woman and infant has the right to receive care that is consistent with current scientific evidence. Practices that have been found to be safe and beneficial should be used when indicated. Harmful, ineffective or unnecessary practice should be avoided.”

    To emphasize these ideas, to give them even more weight, I hand out a paper from the ACOG Committee on Ethics, a bit of which I quote here (ACOG Statement of Ethics in Medicine, The Hastings Center Report 11/28/09;39(5)21-23): “Informed consent lies at the heart of the physician-patient relationship. It is grounded in the principle of respect for persons, which affirms an individual’s consequent right to autonomous decision-making…freedom from coercion…and accurate, good-faith disclosure of information by the physician”. When mothers see these words, they can really feel that their autonomy is to be respected since they’ve learned about evidence-based care for themselves and their babies.

    As example of one way to use their knowledge, once my classes learn about of the benefits of that first golden uninterrupted hour with their newborns, and are already aware of their very real autonomy in labor and birth, they feel really empowered to employ the following strategy to good effect: several times during labor women will have to answer a formula questionnaire. It will ask the mother’s name, the date of her last period, about any drug allergies, etc.…we are all acquainted with these questions. Nowadays, political correctness has prompted an additional question in most hospitals: “do you have any cultural preferences?” Everyone in my classes answers this question with a resounding “yes!”. They will make sure that the questionnaire notes that their “cultural” preference is that their baby be allowed to let its cord finish pulsing before clamping and that the baby stay on the mother’s body until at least the first nursing before any routine treatments or hospital protocols. The mother might say “in my family” or “in my country” or “in my traditions this is what we do.” This request is now in writing at least once in current hospital records, and furthermore, each time a mother has some routine check, she, her partner or other person with her, reminds the caregiver of these written preferences. Everyone is now aware of the mother’s wishes and even the “efficient” or rushed or burnt-out or poorly -informed nurse has been reminded of the mother’s written and reiterated wishes. If the mother doesn’t encounter the “cultural preference” question, we practice asking caregivers to make some plans for the birth. They are asked to incorporate these “plans” into their protocols: 1-to allow the cord pulse to its natural conclusion, and 2 – to leave her baby with her, S2S, until the first feed with no interruption. Reminded by both mother and her support people to remember to “plan”, nurses and caregivers respond with a kind of recognition…the word “plan” seems to resonate with hospital staff. They will respect her rights as they are taught to do when so obviously informed. So, at least for the mothers I teach, it seems that evidence-based care is best requested and most effectively achieved when the mother is well-versed in and confident of her rights. And thanks, Cara, for your great question.

  3. June 29th, 2011 at 20:18 | #3

    Thank YOU for a well-written, detailed answer! This is a topic that hits close to home with me, because in my last birth (with my 2nd child), the nurses took my son away from me shortly after he was placed on my stomach to perform the routine tests. I barely had a chance to register what his face looked like before they took him, and what was worse, is that they took an unusually long time to get him back to me. For no other reason than simply because they were taking a long time to complete their procedures. I said out loud — at least 3 times — “Can I have my baby back?” Upon saying it for the 3rd time, with an increasingly angry tone, my midwife piped up and directed the nurses to hand back my child and that their procedures could wait.

    As I sit here 33 weeks pregnant with my 3rd child, the concern of uninterruped S2S is what I think about most when imagining this next birth. I will have a doula this time, which has boosted my confidence some. But I know that when it comes down to it, my husband & I are the ones who will need to express and reiterate our requests about how things are handled post-birth. I now feel better knowing some tactics for communicating with hospital staff.

    I would love to share this information with other women on the Giving Birth with Confidence blog — this truly is a valuable, must-read for all expectant moms and dads.

  4. avatar
    Jacqueline Levine
    June 30th, 2011 at 11:08 | #4

    Your rights, a birthing mother’s rights, really are paramount. The dicta of the ACOG Committee on Ethics that I mentioned in the piece includes these words: “Informed consent is essentially a process to insure that information animates free choice.” OK, now we know how docs are supposed to behave, what their understanding is, and knowing the “ethical” rules they’ve set up for themselves, we should all feel really confident and easy about insisting on evidence-based care. Things do happen very quickly as the baby is being born, staff shifts can change and information may not be passed on as we hope, so, yes, vigilance is required of those who stay with us during birth. Just a few rehearsals can have a big payoff. I tell women to have their partners write just a few simple cues on the back of one hand in ball-point: walk,eat/drink, push upright,wait 4 cord to stop, no routine suction, S2S. Those cues hit the high points of all we’ve learned in class together, and we rehearse little speeches out loud for each cue so that parents-to-be have a real and clear mental picture and of what they want. When I say mothers should ask the staff to “plan,” I mean specifically that they discuss hospital protocols ahead of time and say, “OK that’s where we want you to wait….etc.” Now the nurses are on notice in a very “detailed, orderly” way, as they may not be if just handed a birth plan or told ahead of time. Of course, staff must still be reminded often of our wishes, but that’s part of what we must do in most hospital births. So, Cara, I wish you a safe and joyous birth, and of course, please share whatever you think has value.

  1. July 12th, 2011 at 09:00 | #1
  2. December 19th, 2011 at 19:26 | #2