July 05, 2009
Active Management of Newborn Transition: An Invisible and Untested Package of Care
By: Amy M. Romano, RN,CNM | 0 Comments
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.
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?
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.
TagsHealthy Birth Practice Bias Labor/Birth Newborns Maternity Care Systems Help and Training Babies No Separation Skin-To-Skin Contact