Uninterrupted Skin-to-Skin Contact Immediately After Birth

Newborn & Infant Nursing Reviews

The Sacred Hour

Uninterrupted Skin-to-Skin Contact Immediately After Birth

Raylene Phillips MD, IBCLC, FAAP

Disclosures

NAINR. 2013;13(2):67-72.

Abstract and Introduction

Abstract

The manner in which a new baby is welcomed into the world during the first hours after birth may have short- and long-term consequences. There is good evidence that normal, term newborns who are placed skin to skin with their mothers immediately after birth make the transition from fetal to newborn life with greater respiratory, temperature, and glucose stability and significantly less crying indicating decreased stress. Mothers who hold their newborns skin to skin after birth have increased maternal behaviors, show more confidence in caring for their babies and breastfeed for longer durations. Being skin to skin with mother protects the newborn from the well-documented negative effects of separation, supports optimal brain development and facilitates attachment, which promotes the infant’s self-regulation over time. Normal babies are born with the instinctive skill and motivation to breastfeed and are able to find the breast and self-attach without assistance when skin-to-skin. When the newborn is placed skin to skin with the mother, nine observable behaviors can be seen that lead to the first breastfeeding, usually within the first hour after birth. Hospital protocols can be modified to support uninterrupted skin-to-skin contact immediately after birth for both vaginal and cesarean births. The first hour of life outside the womb is a special time when a baby meets his or her parents for the first time and a family is formed. This is a once-in-a-lifetime experience and should not be interrupted unless the baby or mother is unstable and requires medical resuscitation. It is a “sacred” time that should be honored, cherished and protected whenever possible.

Introduction

The power of first impressions is well known. None may be more significant than the first experiences of a newborn baby exiting mother’s womb. Our first impression of life outside the womb, the welcome reception we receive immediately after birth, may color our perceptions of life as difficult or easy, hostile or safe, painful or comforting, frightening or reassuring, cold and lonely or warm and welcoming. The events surrounding birth have the potential to set the stage for patterns of subconscious thought processes and behaviors that persist for a lifetime.

Second only to the experience of dying, the experience of being born may be the most mysterious. Since most adults have no conscious memory of what it was like to be a newly born infant, let alone what it was like to be a fetus in the womb, most have not bothered to speculate about the birth process from the baby’s perspective. Yet, when the unconscious memory is open to recall during hypnosis, vivid and detailed memories of prenatal life, the birth experience and early events as a newborn infant readily emerge for many.

While the mechanism for how a fetus or a newborn can create such fully formed memories with such immature brains remains unknown, the reality of prenatal, birth and newborn memories cannot be denied. There are many accounts of young children (usually up to about age 3–5 years) who remember events that occurred around the time of their birth and feelings they experienced. The perceptions and interpretations are sometimes skewed, but the vividness and accuracy of specific details and events are often astounding.

In his groundbreaking book, “Babies Remember Birth,” David Chamberlain, PhD, shares his research, which compared the birth stories of 10 different mothers with the birth memories of their children. During separate sessions under hypnosis, mothers and their children were asked to describe the birth process. Although the children, some now adults, had not been told about their birth history, their accounts of the events surrounding their births contained many specific and unique details in common with their mother’s accounts, validating the accuracy of the children’s birth memories.[1] Dr. Chamberlain’s newest book, “Windows to the Womb” documents the large body of research exploring the many and varied ways that unborn and newly born babies are able to show us their capacities for learning and memory.[2]

Why is this important? If babies and even fetuses are, indeed, capable of forming memories that remain in their subconscious for life, how they are treated at birth and their early experiences outside the womb matter much more than we have been led to believe!

Because the first hour after birth is so momentous, we have named it “The Sacred Hour” at our hospital. Every culture has occasions and ceremonies it holds sacred that are honored, cherished and protected. In most cultures, for example, a wedding ceremony is considered a sacred occasion. This special event honors the symbolic union of two individuals who have chosen to share their lives together. No one would think of interrupting a wedding ceremony to give the bride and groom details about the flight arrangements for their honeymoon. Everyone recognizes that this information can wait until after the ceremony is completed. Birth is another sacred event. It is a time when a new member of the family arrives, is greeted for the first time and welcomed by his or her parents. Yet, in many hospital settings, this once-in-a-lifetime process is routinely interrupted for details that can easily wait until after the new baby has had time to adjust to life outside the womb in the loving arms of the mother, and after the baby and parents have had time to meet each other as a new family.

What might the first moments after birth be like for the newborn infant? If a fetus has been fortunate enough to spend his fully allotted 266 days in the womb since conception, he has had the luxury of having all his emerging developmental needs met. The uterus and the placenta have provided warmth, protection, nutrition and oxygen, as well as close and continual proximity to the mother’s heart and voice. Being in the womb is the “natural habitat” for the unborn fetus. After birth, the mother’s body and breasts take over the function of the uterus and placenta in providing warmth, protection, nutrition, and support for optimal oxygenation, as well as close and continual proximity to the mother’s heart and voice. Being skin to skin with the mother is the newborn infant’s “natural habitat” — the one place where all his needs are met.

This is true for all mammals and can readily be seen in the animal world. Everywhere one looks in nature, mother and newborn mammals are as close as they can get to each other skin to skin or fur to fur. Nature is wise and provides instincts that drive behaviors designed to assure survival of the species.

There are many well-documented benefits of skin-to-skin contact between a newborn infant and its mother. Skin-to-skin contact improves physiologic stability for both mother and baby in the vulnerable period immediately after birth, increases maternal attachment behaviors, protects against the negative effects of maternal–infant separation, supports optimal infant brain development, and promotes initiation of the first breastfeeding, resulting in increased breastfeeding initiation and duration rates. Although a complete review of all the benefits of early postpartum skin-to-skin contact between mother and newborn is beyond the scope of this article, we will briefly explore several of them.

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Uninterrupted Skin-to-Skin Contact Immediately After Birth

Raylene Phillips MD, IBCLC, FAAP

Disclosures

NAINR. 2013;13(2):67-72.

Skin-to-Skin Contact After Cesarean Births

While more hospitals have implemented skin-to-skin care after vaginal births, very few have extended this practice to the operating room (OR) after cesarean births. Yet, stable mothers and babies deserve to experience the same short- and long-term benefits of early skin-to-skin contact after cesarean births, as do those who have vaginal births. Indeed, mothers who have had a cesarean delivery often mourn the loss of a normal vaginal birth they had hoped for and are especially disappointed by not having their baby with them immediately after birth.

Many other mothers have enthused at how easy breastfeeding was when their baby had an opportunity to go skin to skin immediately after cesarean birth in the OR compared to their struggles with breastfeeding after separation with their previous cesarean delivery This is reflected in lower breastfeeding rates after most cesarean deliveries.[27]

Obstetricians, anesthesiologists and those responsible for newborn care must be educated about the evidence-based rationale for introducing skin-to-skin contact in the OR, including the many benefits for stable mothers and babies. Knowing that they will have immediate veto power if any concerns arise goes a long way toward reducing anxiety about beginning the practice of placing babies skin to skin in the OR.

After the practice has begun, anesthesiologists are often amazed by how stable mothers are immediately after cesarean delivery when their babies are skin to skin. Because mothers are so focused on their new baby, their perception of pain is often diminished and their anxiety levels are significantly decreased, resulting in increased stability of heart rates and blood pressures. In addition, mothers and babies keep each other warm, resulting in increased temperature stability for both.

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Postpartum Skin-to-Skin Contact is Endorsed By Many Organizations

The benefits of skin-to-skin contact immediately after birth for stable mothers and babies is so well documented, it is recommended by all major organizations responsible for the well-being of newly born infants, including The World Health Organization (WHO), the American Academy of Pediatrics (AAP), the Academy of Breastfeeding Medicine (ABM), and the Neonatal Resuscitation Program (NRP).

The WHO advises that, given the importance of thermoregulation, skin-to-skin contact should be promoted and “kangaroo care” encouraged in the first 24 hours after birth. The AAP recommends that healthy infants be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished.[29]

The ABM Protocol #5, Revision 2008 states, “The healthy newborn can be given directly to the mother for skin-to-skin contact until the first feeding is accomplished. The infant may be dried and assigned Apgar scores and the initial physical assessment performed as the infant is with the mother. Such contact provides the infant optimal physiologic stability, warmth, and opportunities for the first feeding. Delaying procedures such as weighing, measuring and administering vitamin K and eye prophylaxis (up to an hour) Skin-to-Skin Contact Provides Physiologic Stability

Being skin to skin with mother stabilizes the newborn’s respiration and oxygenation, increases glucose levels (reducing hypoglycemia), warms the infant (maintaining optimal temperature), reduces stress hormones, regulates blood pressure, decreases crying and increases the quiet alert state.[3]

Thermal synchrony is a phenomenon whereby the temperature of mother’s chest increases to warm a cool baby and decreases to cool an overly warm baby. While often seen with premature infants who are skin to skin in kangaroo care, this phenomenon is equally important for the newborn infant who has just exited the warmth of mother’s womb into the cooler extra-uterine environment, wet and easily chilled. In a study done with babies after cesarean delivery, babies held skin to skin by their fathers had higher temperature and glucose levels compared to those of babies left alone under warmers.[4]

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enhances early parent–infant interaction.”[30] (p 2).

The NRP says that skin-to-skin care can be used to provide routine resuscitation for all normal newborns. The changes included in the updated 2011 NRP indicate that even the vigorous meconium-stained newborn need not receive initial steps at the radiant warmer, but may receive routine care (with appropriate monitoring) with the mother. It clarifies that routine care includes staying with the mother in skin-to-skin contact to ensure warmth. It also specifies that suctioning following birth (including bulb suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive pressure ventilation.[28]

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Uninterrupted Skin-to-Skin Contact Immediately After Birth

Raylene Phillips MD, IBCLC, FAAP

Disclosures

NAINR. 2013;13(2):67-72.

Skin-to-Skin Contact Supports Optimal Brain Development

The brains of newborn infants are not fully mature. The human brain of a newborn is only 25% the size it will be in adulthood. While all cells are present, myelination and synaptic development are not yet complete. Allan Schore, PhD, a neurobiologist from UCLA, and others have been exploring the roll of attachment and brain development for many years and explain that the amygdala is in a critical period of maturation in the first 2 months after birth. The amygdala is located deep in the center of the brain and is part of the limbic system involved in emotional learning, memory modulation, and activation of the sympathetic nervous system. Skin-to-skin contact activates the amygdala via the prefronto-orbital pathway and thus contributes to the maturation of this vital brain structure.[13]

[15]

Based on the work of Harlow, Mason and Berkson, James Prescott, PhD, a neuropsychologist and health scientist administrator at the National Institute of Child Health and Human Development (NICHD), one of the institutes of the United States National Institutes of Health (NIH) from 1966 to 1980, asserted that touch and motion were the most important senses for normal brain development. He was the first to identify that touch and motion were critical for normal neurointegration of the cerebellum–limbic–prefrontal cortex.[16]

In addition to his own research, Dr. Prescott examined the research of anthropologists who had provided detailed descriptions of primitive cultures. After evaluating the data about 49 primitive cultures, Dr. Prescott was able to predict which cultures were peaceful versus violent cultures with a simple observation. Cultures in which babies were carried on mothers’ bodies throughout the first year after birth were more peaceful cultures and those that did not were more violent cultures. Interestingly, he also identified an association between longer duration of breastfeeding (greater than 2 1/2 years) and low or absent suicide rates in 26 primitive cultures. Dr. Prescott speculated that there is a sensitive period during infant brain development when pleasurable touch and movement are necessary and protective against depression and violence.[17] John Bowlby, the famous attachment psychologist, also claims that infant carrying and direct body contact are essential for normal infant development. Being skin-to-skin during the first hour after birth sets a pattern of behaviors between mothers and infants that supports continued body contact and carrying, and thus normal brain development of the infant.[18]

Mother–infant attachment is important in the development of the newborn’s ability to self-regulate and maintain homeostasis. At first, the mother is the baby’s regulator. The dyadic interaction between the mother and the newborn controls and modulates the newborn’s exposure to environmental stimuli and by doing so serves as a regulator of the developing individual’s internal homeostasis.[19] One-year old infants, who had spent the first 1–2 hours skin-to-skin with their mother, were found to have better self-regulation when evaluated in a research setting during a structured play session. They were less easily frustrated and better able to calm themselves.[21]

Dr. Schore asserts that the brain is designed to be sculpted into its final configuration by the effects of early experiences and that these experiences are embedded in the attachment relationship.[22] He and others who study attachment and brain development emphasize that early interpersonal events can positively and negatively impact the structural organization of the brain. Early experiences may shape brain structure and function in a manner that is designed to provide the individual with the type of brain best suited to the environment he or she is born into. A traumatic or hostile environment would require a brain designed for caution and defense, whereas a supportive environment would allow for a brain designed to grow and thrive. If the attachment relationship is, indeed, a major organizer of brain development, then attachment is far more important than simply providing a fundamental sense of safety or security.[23]

If the birth process did not go as planned and the baby’s first impressions of life outside the womb are less than ideal, all is not lost. Bonding and attachment are so critical for survival that nature has made it possible for both to occur at any time during a lifetime. However, the longer after birth the process is begun, the more difficult it is and greater is the risk of incomplete bonding or insecure attachment. Fortunately, human beings are capable of recovering from most types of trauma with appropriate insight, support, and healing techniques. The bottom line is — whatever supports early mother–infant attachment, supports infant brain development!

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NAINR. 2013;13(2):67-72. © 2013  Elsevier Science, Inc.

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According to PHYSICIANS

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