Active Management of Newborn Transition: An Invisible and Untested Package of Care

There’s a new study out in the current issue of Birth that bolsters the already remarkable body of evidence favoring skin-to-skin care (rather than placing the baby on a warmer or swaddling it) right after birth. Russian researchers exposed mothers and their babies to some skin-to-skin time in the first two hours, and compared their behavior 12 months later to other women and their children who had been clothed or swaddled and held.

At one year, children who had been clothed or swaddled or who hadn’t nursed in the first hour were more likely to exhibit symptoms of dysregulation (irritable, emotionally labile, aggressive, impulsive, or unable to self-regulate). In addition, when researchers observed them at play and performing a structured task, the mothers in this group were more likely to have a flat/constricted affect, lack enthusiasm, or simply seem out of sync with their infants.

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Newborn Feet, by Sean Dreilinger
(Used with permission under a Creative Commons License)

Those of us who advocate for skin-to-skin contact after birth cite studies like this one when we say that letting mothers and babies interact the way nature intended is healthy and safe, and disrupting the normal transition should be done only when absolutely crucial and with dignity and efficiency. But it turns out that in the majority of studies that evaluate early skin-to-skin contact, the mothers and babies are separated and manipulated – sometimes for an extended period of time – before the “dose” of skin-to-skin time occurs. Consider this description of the “compulsory” routines to which all mothers and infants in the trial (even those in the skin-to-skin group) were subjected:

According to the Russian tradition at the time of the study, all mothers were lying on their backs during the first 2 hours after birth, and all mothers received intravenous administration of methylergometrine in connection with birth of the babies’ head. The umbilical cord was clamped 10 to 15 seconds after birth, and all babies were immediately put on an examination table with a radiant heater above. The infants were carefully dried, wrapped in a dry sheet, and left on the examination table while the attending midwife took care of the mother. The infants were then washed under warm (skin-temperature) tap water, dried, and cared for by a midwife according to hospital routines, including weighing, taking anthropometric measurements, and dripping 30 percent sulfacyl natrium into the babies’ conjunctivas for prophylaxis of gonococcal ophthalmia. To prevent cord infection, Xeroform powder or 1 percent iodine solution was applied to the umbilical cord stump and on the baby’s skin folds Before the infants were brought to the maternity ward, a pediatrician examined them. Provided no bleeding was present, the suturing of vaginal ruptures, episiotomies, or both was postponed until 2 hours after delivery.” (p. 101)

When I first began putting my nose in the medical literature about newborn transitional care, I was astonished to see researchers randomizing women and babies to skin-to-skin care only to bombard them with a battery of procedures and disruptions before initiating that care. That’s to say nothing of the fact that once the “dose” of skin-to-skin care was administered, routine care including prolonged separation, swaddling, and who-knows-what-else ensued. Studies commonly cut off or limited the supply of skin-to-skin contact for the remainder of the hospital stay.

Here are just a few of many, many examples of disruptive care in the “skin-to-skin” arm of trials included in the Cochrane Systematic Review of early skin-to-skin contact (SSC).

Regarding Bystrova 2003:

All infants were immediately placed under a radiant warmer, dried, washed, weighed, given eye prophylaxis and cord care during the first 20 min postbirth. 1) SSC group = babies were placed prone and SSC on mother’s chest for 90 min.

Regarding Mizuno 2004:

SSC group = extensive SSC (M = 63.7 min) immediately postbirth with effective suckling. Then mothers and infants were separated for 24 hours and infants were fed formula. After 24, hours rooming-in with…breastfeedings [every three hours]

Regarding Moore 2005:

SSC group = infant placed prone SSC on mothers abdomen. Baby moved to warmer after cord cut. [The duration of the separation not specified.] Then infant placed prone on mother’s bare chest between breasts. Moved to cross cradle nursing position when infant displayed early hunger cues

Much less (if anything) about the mother’s care is described in these studies, but we can assume that such care often if not routinely involved vigorous “massage” of the woman’s uterus, injection of artificial oxytocin and IV fluids, episiotomy repair, and the use of prewarmed blankets. The studies exclude women having cesarean surgery altogether, so we cannot measure its effects, which are likely to be significant and long-lasting. And when mothers and infants first come together – regardless of how long they’ve waited and what has occurred in the interim, they are almost invariably in cold, brightly-lit environments filled with strangers.

So what are the lessons here?

The first lesson is that we cannot judge a study by its abstract. The abstracts of the studies discussed above don’t give a hint of the routine practices happening in the background of the “experiment,” and they often leave out other important information, too. Sometimes, the full-text papers themselves don’t describe routines of care, and we are left guessing. Advocating for increased open access to medical journals will help us judge for ourselves if a study is about what it says it’s about, and whether its findings are reliable or applicable.

The second lesson is that we most likely don’t know the extent of the harm the current package of newborn care causes because we haven’t measured it. When researchers observe “normal” newborn transition and mother-infant bonding behavior in a typical hospital environment, they are in fact observing how babies and mothers adapt to and overcome disruptions that may include early clamping of the umbilical cord, suctioning, and routine separation. However brief and benign these practices seem, they disrupt the normal adaptation that has been honed throughout evolution to ensure that our species survives. When “active management” of newborn transition is all we ever see, its effects become invisible. And when problems occur, these reinforce the dominant view that birth is intrinsically risky, when in fact these problems may arise from practices imposed on healthy women and babies right after birth – or, for that matter, in labor.

The final lesson relates to the second. Studies that measure the elements of physiologic care very often occur in contexts that are decidedly not physiologic. This context can drown out the effects of small changes we make in one element of care. Thinking back to the current study of skin-to-skin contact, If we didn’t see any difference in that trial, would it be because early maternal-infant contact doesn’t “work” to produce the desired outcome? Maybe. Or maybe it would have been because the harms of “compusory” practices dictated by tradition overwhelmed and obscured the beneficial effects of skin-to-skin care. Put another way, if we see such remarkable benefits of skin-to-skin contact in the studies we have (however flawed), just imagine what benefits we might see if the contact truly was immediate, prolonged, and undisturbed.

To my readers who have the opportunity to observe births, what are the practices and procedures you see in the moments and hours after babies are born? How can we prepare women to ask for – and get – truly undisturbed contact with their babies after birth?

Citation:
Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Mukhamedrakhimov, R., et al. (2009). Early contact versus separation: Effects on mother-infant interaction one year later. Birth, 36(2), 97-109.

9 Comments

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 6, 2009 07:00 AM by Laura N
I've only been to a couple births as I begin my training as a doula, but I did see most of those routine things - newborn suctioning and warming, fundal massage, tear repair. Also, both mothers received postpartum cytotec and "scraping" the inside of the uterus (in conjunction with a hurried delivery of the placenta). Discussion of procedures before the birth with the provider is the best way to ask for undisturbed contact. All these routine things are so habitual and come in rapid succession that it's hard to change much as it happens.

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 6, 2009 07:00 AM by TO Doula
I'm horrified to hear about what's happening to motherbabies in general, and what's happening in the context of studies as well. How can you assess the importance of skin-to-skin if you're not actually facilitating it??? This is a much-needed reminder to me that I need to make more of an effort to look at actual studies and not just rely on the abstracts that show up on Medscape. Here in Toronto (Canada) I've never seen things quite as bad as some of these studies, even going back to 1989. When I started working here in 2002, they would do SSC if asked, but the standard was 5-10 minutes of interruption while baby was dried, diapered, id banded and given eye ointment and vit k. Baby was given to mom heavily swaddled. After that there was (and is) full rooming in and no supplements without at least some form of consent. Now SSC is the norm, although some nurses are eager to snatch the baby away at the first opportunity. Others respect a 45-60 minute waiting period. SSC may mean baby birthed onto a sterile(!) towel on mom's belly unless mom pulls the towel off, but then after rubbing down the baby goes onto her skin. I have yet to see any staff willing to forgo the rubdown. Some places use hats, others not. Bathing does not happen until some hours after the birth.

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 6, 2009 07:00 AM by Reality Rounds
I have been to thousands of births (I am a NICU nurse, so I don't labor with moms, just catch babies, thus I go to many deliveries). What happens to the baby varies by the hospital, the provider, the nurse and the patient. Some babies are whisked away to the warmer immediately, some recover right on mom's chest, skin to skin. Mom's must be educated PRENATALLY about how they want their NORMAL baby recovered. If they want skin to skin, Great. Here is what I teach my new nurses and students: Everything that is needed for recovery of a normal infant can be done right on mom's chest. There is no need to remove the baby to the warmer. Drying, stimulating, meds, ID bands, abduction alarms, vital signs and assessments can all be done on mom. I tell students to think of the mom as a radiant warmer. The bath is delayed for at least an hour of life, it can be longer if requested. (There is a study by the WHO that states better breastfeeding rates and thermoregulation for infants who have their bath delayed for 4 hours with skin to skin, I will try and find the exact study). Some of these delays can be logistically hard in the task driven, hospital setting, but they are not impossible. I try to get nurses to realize that it is actually easier on their work load to let the baby recover on mom. The birth of a baby is often treated like a four-alarm fire (or a code in medical jargon), and this drives me crazy. I had planned on doing a study on newborn temperature differences of babies who had the full 4 hour recovery period on mom's chest, compared to a radiant warmer recovered group. It may just start out as a quality improvement project for now. Thanks for the post.

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 6, 2009 07:00 AM by Lori Swain
I teach Bradley childbirth ed classes and there is a video where the mom is holding the baby and the nurse approaches her and asks if she can take the baby to weigh him. I pause the DVD and point out that this is their cue as parents to say, "No." I don't think many women realize that they do have a choice and that they can politely request to delay the various procedures until they are ready. It's very simple, but it's an eye-opener. As a doula I have seen moms and babies left alone for an hour before initiating the newborn procedures, and I have seen babies whisked away as soon as the cord was cut to be returned half an hour later all wiped clean and bundled up. As a doula I have encouraged moms to ask for their baby back and then when a staffer shows concern that the mom might drop the baby, I reassure them that I will stand by her side and not let that happen. I'm in the suburbs of Chicago and some hospitals are wonderful at encouraging skin-to-skin and others are very set in their routines.

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 7, 2009 07:00 AM by Emily Ruth
Beautifully written.

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 8, 2009 07:00 AM by Amy M. Romano, RN,CNM
It's so interesting and frustrating to hear the variation across different hospitals and even within the same hospital. I've experienced this myself. I was recently attending births in a Baby-Friendly Hospital and found that I needed to discuss with each nurse the plans for immediate care of the newborn (assuming baby was vigorous). We had several clients successfully have uninterrupted skin-to-skin time in the hour or so after birth and keep their babies with them continuously throughout the hospital stay, but it was always with quite a bit of advocacy. Most others would endure some separation right after birth and again when they were transferred to the postpartum unit, as this was the standard practice to admit the baby to the nursery while the mother "got settled". I remember at one birth, I was talking to the nurse and reminding her that we were going to do immediate skin-to-skin. This was an experienced nurse who was in fact trained as a nurse-midwife, and again - this was a Baby-Friendly hospital. I literally found myself negotiating the number of minutes that the woman would be allowed with her baby before the nurse took him to the warmer to do her tasks. Her reasoning was that she "had to put the baby into the computer." I remember saying to her, "well, clearly you're not putting the *baby* in the computer, so tell me what *information* about the baby you need to put into the computer, and maybe we can figure out ways to get that information while keeping mom and baby together." It worked out just fine in the end, but it was one of many reminders I have had in my career that too often mothers and babies are expected to accommodate the system that is based on efficiency and productivity, when really the system should be accommodating the new family. Thanks for all your comments and wisdom, everyone!

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 8, 2009 07:00 AM by Tara
First of all, Lori, what video is it that you refer to? Secondly, in addition to the excellent reminders and suggestions already mentioned, these simple words whispered to the mother immediately after baby is born are very effective: "Mama, reach down and pick up your baby." I used this in the presence of a very domineering OB and it worked just fine. Don't wait for someone to hand baby to mommy! ;0) @Lori

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 13, 2009 07:00 AM by New Study into Skin-to-Skin Contact « Woman to Woman Childbirth Education
[...] Study into Skin-to-Skin Contact Posted on July 14, 2009 by Kathy This post by Science and Sensibility really says it all, but I will highlight something that I have thought [...]

Active Management of Newborn Transition: An Invisible and Untested Package of Care

July 15, 2009 07:00 AM by Gabriela
As a doula one practice I have noticed at hospital births that can delay the skin to skin contact is the suctioning of baby, especially in the case of meconium. The suctioning itself can take quite a few minutes, but the problem is that after the suctioning is done, instead of giving baby right to mom, the nurse then proceeds to do all the newborn care procedures, leaving mom without baby for at least 20 minutes. This can be very frustrating for the parents who knew about and wanted uninterrupted skin to skin contact time. It seems that once the nurse has the baby for a valid prcedure, it is difficult to get the baby back in a timely way. Also, I have been to home births where the suctioning happens while mom is holding baby skin to skin, leading me to believe that suctioning does not preclude skin to skin contact?

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