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Shannon Weldon

on 18 April 2014

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Transcript of SKIN TO SKIN

Peer Reviewed Articles supporting Skin to Skin contact

"Giving Birth Back to Mothers and Babies" (Dabrowski 2007).
Skin to Skin Contact Policy at Texas Children's Hospital, Pavillion for Women

Nursing and Patient Implications:Assessing Participant Readiness and Positioning
PICO question for further study of the policy
Dabrowski, G.A. Skin-to-skin contact: giving birth back to mothers and babies. Association of Women’s Health, Obstetric and Neonatal Nurses. 11(1), 64-71; 2007.

Skin to skin contact provides many benefits to healthy term infants including:
Easier Transition to Extra-Uterine Life
*Demonstrate greater self-regulatory behaviors including:
~Increased sleep states
~Higher optimal flexion scores
~Less extended movement scores
*Reduce the stress response from birth as evidenced by:
~Less crying
~Decreased vasoconstriction of the extremities

Improved interaction between mother and baby
*Provides maternal affection
*Tactile comfort
*Verbal interaction

Opportunity for breastfeeding
*Breastfeeding success increased
*Promotes early initiation of breastfeeding
*Increased ability to recognize mother’s milk by 4 days of age
*Increased mouthing movements
*Increased breastfeeding duration

Improved Thermoregulation
*Mother is preferred heat source
*Newborn placed skin-to-skin remains warmer during 1st 3 hours of life than newborn in radiant warmer
*More likely to maintain temperatures in the neutral thermal range
*Mother is uniquely adapted to the thermoregulatory needs of the newborn

Pain Management
*Effective analgesic during invasive procedures, such as heel stick pokes or injections
*Reduces the pain responses of crying, grimacing, and dramatic heart rate increases in newborns
~Demonstrate little or no response to pain
Bottom Line:
*Skin-to-skin contact enhances the birth experience for new parents
*Evidence supports the use of skin-to-skin contact in promoting breastfeeding and preventing pain during heel sticks and other interventions.
*Routine care practices (Apgar scores, initial physical assessment and placement of newborn identification bands can be performed immediately after birth while the newborn is in skin-to-skin contact with its mother.
*The benefits of skin-to-skin contact immediately after birth regardless of mode of delivery is important toward health promotion for the newborn.

Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No: CD003519.

*This study was a review to see if there was any impact of early skin to skin contact between the mother and her newborn baby on infant health, behavior, and breastfeeding.

*The review included 30 studies, 1,925 mothers and their babies.

Findings of the Study:
*Babies interacted more with their mothers
*Babies stayed warmer
*Babies cried less
*Babies were more likely to be breastfed and breastfed longer
*Babies were more likely to have a good early relationship with their mothers

In Summary:
The authors concluded that skin to skin contact may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long term negative effects.

Infants transitioning to extra-uterine life will be placed skin to skin with the mother immediately after birth provided the infant's temperature remains above 97.7F (36.5C) and other vital signs are stable.
Why Did We Choose This Policy?
After examining the benefits of skin-to-skin therapy for newborn care and postpartum mother care in lecture, we decided to investigate TCH’s policy on newborn guidelines for care immediately after birth. After confirming the policy we decided to research it further to expand our knowledge and to become patient advocates of this evidence-based practice
Introduction and Identification of the Skin to Skin Policy
*policy last updated February 2014

Clinical Context For Use of This Policy
This policy is currently used in all Labor and Delivery rooms in the Mother/Baby unit of TCH-Womens' Pavillion
This policy is applied for infants meeting the following criteria:

*35 weeks gestation
*Birth weight of 2000g (4lb 6.5oz)
*5 minute APGAR score of 6
*Infants with asymptomatic malformations
*Infants who have a limited life expectancy
*Stable vital signs:
HR 100-160
RR 30-60 with no increased work
T 97.7F (36.5C) or greater
Phillips R. Uninterrupted skin-to-skin contact immediately after birth. Newborn and Infant Nursing Reviews. 13(2), 67-72; 2013.

*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 have increased maternal behaviors, show more confidence in caring for their babies and breastfeed for longer durations if newborn is placed skin to skin.

*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.

*Being skin to skin with the mother is the best way for a stable baby to adjust to life outside the womb.

*Endorsed by multiple organizations responsible for the care and well-being of infants.

*Safer for both babies and mothers

*Provides multiple short and long term beneficial effects

*Increases physiologic stability, promotes optimal psych-emotional well being, and supports structural and functional infant brain development

Evaluating this policy:
Should Skin to Skin Contact be Continued vs. Radiant Warmer?
*The literature supports skin to skin contact immediately following the birth of a healthy newborn.
*The literature from over 30 studies shows benefits of:
Mother-newborn bonding
Breastfeeding initiation
Better thermoregulation
Pain management
Easier transition to extra-uterine life
*Multiple organizations responsible for the care and well being of infants endorses skin to skin contact

Should the Skin to Skin Care Policy Be Updated?
*No the policy was recently updated 02/14
*The policy provides general information, procedures, assessments, and documentation requirements according to the latest research supporting the use of skin to skin care.
*The policy follows the recommendations of the World Health Organization (WHO), the American Academy of Pediatrics (AAP), the Academy of Breastfeeding Medicine (ABM), and the Neonatal Resuscitation Program (NRP) who all advise that skin to skin contact is beneficial.

Acceptable alternatives to the given policy
*The infant should be placed on the radiant warmer if there is an infant or maternal condition and skin to skin care cannot be initiated.

*If unable to place skin to skin with mother due to maternal problem, may initiate skin to skin with father for thermoregulation and paternal bonding.

Assessing Physiological Readiness in the Infant
Monitor Vital Signs
Vital signs that should be monitored in this assessment include:
heart rate
oxygen saturation
The best way to assess physiological readiness is to observe the infant at rest, and undisturbed in the incubator.
The following are contraindications to skin to skin care:
*Tachycardia in the absence of newborn agitation
*Bradycardia of less than 85 bpm that have occurred 4 or more times in 24 hours
*3 or more central apneic episodes of 4 or more seconds, separated by less than 20 breaths
*Oxygen saturation less than 88% that occur with a frequency of 4 or more per hour
*Hyperthermic state in incubator

Assessing Parental Readiness
Adequate knowledge needs to be provided to the parents about skin to skin care, in order to allow an informed decision to be made.
Readiness can be signaled by the mother when requesting to hold the newborn
If the parents are not observed bonding with the newborn, then the recommendation of skin to skin care would be appropriate at this time.
Sometimes, mothers may have feelings of guilt or hopelessness that are associated with previous miscarriages or pregnancies. This could interfere with the desire to participate in skin to skin care. Encourage the mother to share her concerns.
Assessing Institutional Readiness
Institutional readiness can be determined by looking at areas of physical, human, and educational resources available.

Assessing Physical Readiness of the Institution
Physical resources that need to be available are:
• Space
• Lounger/chair with foot support
• Screen
• Gown that closes in front for mother
• Receiving blanket
• Head cap.

Human Resources Readiness and Education
Human resources that should be addressed per institution include adequate nursing experience, staffing, and support. It has been found that nurses having 5 or more years of experience are more likely to do kangaroo care. Resources available to nurses wanting to gain experience with providing kangaroo care can enroll in one-day training sessions offered by the International Network of Kangaroo Mother Care, as well as conferences held every 2 years for credentialing as a Certified Kangaroo Caregiver.
In regards to adequate staffing, some transfers require two staff members, and novice practitioners may need a more experienced nurse. Support from obstetrics, neonatal medicines, nursing administration, and neonatal nurse practitioner, in conjunction with a policy, will help facilitate optimal implementation.
Human Resources, Cont.
Nursing Implications: Positioning
• Newborn should be positioned either between or directly on mother’s breast in upright position
• Mother reclined at a 30 to 45 degree angle
• Infant maintenance of flexed posture of upper and lower extremities, hands should be near the infants mouth
• Head in neutral position, to ensure patent airway
• Mother crossing her arms over the infants back
• Infant head turned so the side of ear is over heart of mother and infant’s face may be viewed

Women ages 20-35 who have given birth at Texas Children’s Hospital- Texas Medical Center, in Houston, Texas to AGA babies who have previous children and experienced postpartum depression afterward.

Population to Study
Research question & specific nursing intervention you’d focus on
The effects of mother/newborn skin-to-skin contact on postpartum depression
Comparison intervention
The effects of no skin-to-skin contact (radiant warmer) on postpartum depression

Mothers of both groups will take a survey or be interviewed concerning their postpartum status at 3 days postpartum, at two weeks postpartum, and at four weeks postpartum.
Outcome evaluation
Surveys will be analyzed based on the Likert Scale and compared.
Full transcript