Informed Birth Choices

Pop quiz: What is the fastest way to warm a new born baby?

a) Place it under a $5,000 infant warming system
b) Swaddle it tightly in multiple blankets
c) Place is directly onto it's mother's chest

If you answered a) guess again.  I recently worked on an "evidence based project" with a team of RNs from a Baltimore hospital. Evidence based practice is finding a renewed following in hospitals.  What!?  Don't we use scientific evidence in medical practice already?  Only a fraction of medical practices are based on evidence.  In recent decades babies were immediately taken to a warming tray, briskly cleaned and swaddled tightly in blankets.  In the case of this project we were researching the best way to regulate the newborns temperature.  Not surprisingly the answer was for the mother to hold the newborn skin-to-skin (STS).  STS, when implemented properly, had the added benefits of improved outcomes for the newborn, increasing moms' level of satisfaction, and promoting the establishment of breastfeeding.  Yet out of 14 surveyed area hospitals only 2 reported STS is routine.  Clearly we are doing our newborns a disservice.

Across the literature, evidence shows STS should be the cornerstone of thermoregulation in the newborn.  The Cochoran systemic review “Early skin-to-skin contact for mothers and their healthy newborn infants,” (Moore: 2009) recognizes the irony of STS being the intervention rather than the norm.  Proper STS consistently shows to be more effective at regulating the newborns temperature than radiant warmers (Galligan: 2003; Fransson: 2005).  Moreover STS showed to have no risk of over-heating infants as opposed to incubators (Christenson: 1998).  “In addition to aiding in maintaining temperature, infants who had skin-to-skin care in the first hour were found to sleep longer, spend more time in a quiet state, and were better organized at 4 hours of age” (Mercer: 2007).

Beyond the clinical goal of regulating the neonate’s temperature, STS improved maternal satisfaction by promoting close continuous contact between mother and infant (Moore: 2009; Mercer: 2007; Maura: 2006; Price: 2005).  One review found, “90% of the mothers who had  STS care were very satisfied and 87% would prefer STS care again, compared to only a 59% satisfaction rating by the mothers in routine care group (Mercer: 2007).”  A second review stated 86% of mothers who experienced early STS had a strong preference for similar care with future births, while only 30% of mothers who held swaddled babies indicated they would prefer that method in the future (Moore: 2009).

Similarly, rate and success of breastfeeding increased with the amount of time newborns spent in close STS contact with their mothers (Moore: 2009; Price: 2005; Mercer 2007).  Babies who were cared for with STS contact had an increased likelihood to be nursing at one to four months postpartum and nursed on average 43 days longer than babies who did not receive STS contact.  These findings were regardless of country or socioeconomic factors (Moore: 2009).

Much of the literature points to the proper education of both medical practitioners and mothers alike as being the key to effective STS contact (Price: 2005; Wallace: 2001; DiMenna: 2006).  Hospitals must establish a protocol for making STS in healthy newborns the new norm.  Additional factors that contribute to the thermoregulation of the newborns need to be explored.  While STS was by far the most effective means at stabilizing a newborn’s temperature, other means of regulation included: early breastfeeding, birth room temperature at or above 77 degrees, delayed bathing, and secure swaddling when not doing STS (WHO practical Guide: 1997, Takayama: 2000).

Bibliography:

1. Christenson, K.;  Bhat, G-J.; Ahmadi, BC; Erikson, B.,  Hojer, B.  Randomized study of skin to skin versus incubator care for rewarming low-risk hypothermic neonates. Lancet. 2000 Apr 15;355(9212):1364. 
   
2. DiMenna, Lisa, MS, NNP, RNC. Considerations for Implementation of a Neonatal Kangaroo Care Protocol. The Journal of Neonatal Nursing. v. 25 n.6 Nov/Dec 2006. pp. 405-412
   
3. Fransson AL, Karlsson H, Nilsson K.  Temperature variation in newborn babies: importance of physical contact with the mother. Arch Dis Child Fetal Neonatal Ed. 2005 Nov; 90(6): pp. 500-4.
   
4. Galligan M. Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN Am J Matern Child Nurs. 2006 Sep-Oct;31(5):298-304.
   
5. Hackman PS. Recognizing and understanding the cold-stressed term infant. Neonatal Network. 2001 Dec;20(8):35-41.
   
6. Mance, Marth J., Ms, RM, NN, CPNP; Mary. A Short RN, MSN. Foundation in Newborn Care: Keeping infants warm: Challenges if Hypothermia. Advances in Neonatal Care, Feb. 2008, vol. 8 n. 1; pp.6-12.
   
7. Meng-xia, Li; Ge, Sun; Henning, Neubauer. Change in the Body temperature of Healthy Term Infant over the First 72 Hours of life. Journal oF Zhejiang University - Science A  2004 5:4, 486-493.
   
8. Mercer JS, Erickson-Owens DA, Graves B, Haley MM. Evidence-based practices for the fetal to newborn transition.  Journal of Midwifery and Women’s Health. 2007 May-Jun; 52(3):262-72.
   
9. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2009, Issue 2.
   
10. Price, Mary; Johnson, Martian. Using action research to facilitate skin to skin contact. British Journal of Midwifery 13(3): 154 - 159 (Mar 2005)
    
11. Takayama, John I.; Teng, Weng; Uyemoto, Jill; Newman, Thomas B.; Pantell, Robert H.  Body Temperature of Newborns: What is Normal? CLIN PEDIATR September 2000 39: 503-510. 
    
12. Wallace H, Marshall D. Skin-to-skin contact. Benefits and difficulties. Pract Midwife. 2001 May;4(5):30-2. 
    
13. Department of Reproductive Health and Research (RHR), World Health Organization. Thermal Protection of the Newborn: A Practical Guide. World Health Organization: Geneva, 1997.