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Practice problem
On the mother–baby unit described in this paper, newborns are often dried, wrapped and weighed before being given to their mothers, and skin-to-skin contact is interrupted for routine care in the first hour. The unit's exclusive breastfeeding rate at discharge is below the hospital's target. The unit and its figures are illustrative.
PICOT question
In healthy term newborns after vaginal birth (P), does immediate, uninterrupted skin-to-skin contact for at least the first hour (I), compared with routine care in which the baby is dried, wrapped and examined first (C), increase exclusive breastfeeding at hospital discharge (O) during the birth hospitalization (T)?
Search
I searched CINAHL, PubMed and the Cochrane Library using the terms skin-to-skin, kangaroo care, newborn and breastfeeding, and limited results to systematic reviews and guidelines. The two sources below are the highest level of evidence I found.
Evidence
A Cochrane systematic review included 46 randomized trials with 3,850 mothers and infants in 21 countries. Compared with standard contact, mothers who had skin-to-skin contact were more likely to be breastfeeding 1 to 4 months after birth (risk ratio 1.24; moderate-quality evidence) and were probably more likely to be breastfeeding exclusively from discharge to 1 month (risk ratio 1.30). Their infants were more likely to breastfeed successfully at the first feed and had higher blood glucose levels (Moore et al., 2016). The reviewers rated no trial as high quality, because none could be blinded and most were small, and they found no difference in outcomes whether contact started within 10 minutes or later.
The World Health Organization and UNICEF's (2018) Ten Steps to Successful Breastfeeding include a step to facilitate immediate and uninterrupted skin-to-skin contact and to support mothers to start breastfeeding as soon as possible after birth.
Level and quality of evidence
The review is Level I evidence. Its findings are consistent with international guidance, but the trials' risk of bias and variation in how skin-to-skin was delivered mean the size of the benefit is uncertain. The intervention is low cost and low risk, so the balance favors a change.
Recommendation
The unit should adopt a protocol for immediate skin-to-skin contact for at least the first hour after vaginal birth, or until the first breastfeed:
- Dry the baby on the mother's chest and cover both with a warm blanket.
- Delay weighing, measuring and routine medications until after the first hour unless clinically needed.
- Keep a nurse at the bedside to monitor the baby's breathing, color and position, and the mother's alertness.
- Record the start and end times of skin-to-skin contact in the electronic record.
Evaluation
The unit will track the percentage of eligible births with an hour of uninterrupted skin-to-skin contact and the exclusive breastfeeding rate at discharge, monthly, for six months.
References
Moore, E. R., Bergman, N., Anderson, G. C., & Medley, N. (2016). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (11), Article CD003519. https://doi.org/10.1002/14651858.CD003519.pub4
World Health Organization & United Nations Children's Fund. (2018). Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative. https://www.who.int/publications/i/item/9789241513807
