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Graceland University:
Evidence Based
Practice
In 38+ Week Newborns, Does Skin to
Skin vs No Skin Contact Promote
Overall Breastfeeding
Dawn Karr BSN, RN- 4/8/ AAbstract: Early skin to skin contact has well documented importance to the mother and the baby and is highly recommended. Breast milk has been found to provide species and age specific nutrients for the infant. It has been proven that the mother’s odor along with tactile stimulation and warmth provided by the mother during immediate skin to skin contact post-delivery stimulates the newborn to start rooting and suckling, therefore creating the optimal time to initiate breastfeeding.
Introduction Studies have shown that breastfeeding is a critical factor for an infant’s overall health and survival. Breastmilk provides species and age specific nutrients giving the infant the best nutritional balance. Studies have shown that early initiation of breastfeeding improves the nutritional status of young children, reduces morbidity and mortality and reduces neonatal mortality by one-fourth. (Sharma, 2016) The following information was obtained around the PICOT question: In 38+ week newborns, does skin-to-skin vs no skin contact promote overall breastfeeding? Using terms related to the PICOT question, a database search was completed in pubmed, and CINAHL, yielding four articles for inclusion. Each article was appraised for statistical significance towards skin-to-skin contact and optimal breastfeeding. The research in totality concluded that skin-to-skin contact is a safe and effective practice that is strongly encouraged. It was found to improve the infant’s thermoregulation, oxygenation, cardiovascular and respiratory stability and initiation of breastfeeding. (Bricker, Johnson, & & Stom, 2018) Evidence has shown physiologic, social and psychosocial benefits for both the mother and the baby when they have initiated skin to skin contact and early breastfeeding immediately post- delivery. During pregnancy babies receive warmth, food, protection and oxygen from their mother’s body. Then with birth of the infant there is a sudden change and they are without all of these essential needs. Therefore, placing the naked infant immediately on the mother’s bare chest between her breasts and covering them with a blanket or towel brings the infant closest to being back in the warmth and security of the womb. This technique also assists in building a platform for bonding with the mother and infant and improves the physiologic and neurologic development of the child as well as make the mother more confident in her own abilities to nurse her child. (GMA, et al., 2010) This practice should be maintained for at least the first hour of the infant’s life. When this occurs the infant uses its natural instincts to slowly find its way toward the mother’s breast and initiate suckling, latching on and breastfeeding. The dyad should be encouraged to continue the initial skin to skin contact until the first feeding is accomplished. (babygooroo, 2018) Background The term ‘skin to skin contact’ is defined as ‘naked newborn placed on his/her mother’s bare chest’. (Cantrill, Creedy, Cooke, & Dykes, 2014) In order to promote breastfeeding in healthy 38+ week infants best practice suggests that the infant be held to their mother's bare chest between her breasts and covered with a blanket for at least the first hour post-delivery and up to the infant's first feeding. (Cantrill, Creedy, Cooke, & Dykes, 2014) If the mother is not available to provide skin-to-skin with the infant the technique can still be initiated with any adult. This allows for optimal thermal regulation, nurturing touch and an enhanced opportunity to breast-feed. (Bricker, Johnson, & & Stom, 2018) Performing skin-to-skin contact with the infant
skin-to-skin contact, the benefits of and especially the significance of skin-to-skin contact and optimal breastfeeding. The research in totality concluded that skin-to-skin contact is a safe and effective practice that is strongly encouraged. I utilized the websites pubmed and CINAHL and using the keywords: skin-to-skin contact I came up with 25,397 results in pubmed and 939 in CINAHL, to narrow the search down I added to this search skin-to-skin contact after birth resulting in 268 articles in pubmed and increased the number to 958 in CINAHL. I then added the keyword breastfeeding to the search yielding 126 results in pubmed and 958 in CINAHL. To narrow it down more I added the word newborn to my keyword search, making my final search, skin-to-skin contact after birth newborn breastfeeding resulting in 105 articles in pubmed and still 959 in CINAHL. I narrowed this down even further in pubmed by selecting clinical trial, free full text, 10 years, humans, and English leaving me with 7 articles to work with. In CINAHL I narrowed the search to just journal articles resulting in 17 articles to work with. I then reviewed the articles that were left in my search and I was not able to use any of the articles left in CINAHL. Of the articles left for selection in pubmed I was able to utilize four of the articles (See Appendix A for further information on selected articles). I determined that these articles were appropriate on the grounds that they specifically discussed the practice of immediate skin-to-skin contact in healthy newborn infants, the benefits of such and the impact it has on successful breastfeeding in the moment and long term. All of the articles that I have chosen have either been peer reviewed or a randomized control trials. All of the articles are in regards to healthy neonates with a gestational age of 38+ weeks and the effects of skin-to-skin contact and the promotion of breastfeeding and each article discusses possible limitations. Critical appraisal I used the rapid critical appraisal tools found in Evidence-Based Practice in Nursing & Healthcare; A Guide to Best Practice to critique the articles that I collected information from. (See Appendix B for the critique of each article.) Each of the studies that I chose to use broach the subject of immediate skin-to-skin contact in healthy newborns and the benefits that this technique provides the newborn and mother. I was especially focused on the effect on breastfeeding and how it affected it in the moment and later on. Every article I chose to utilize discussed this topic and helped me to answer my PICOT question: In 38+ week newborns, does skin-to-skin vs no skin contact promote overall breastfeeding? All but one of the studies were performed by observation and video recording the first hour post-delivery allowing observation of the practice of skin-to-skin contact, noting the response of the infant and how the infant moved through Widstrom’s different stages that are reported to occur during skin-to-skin contact. The study that did not use this technique was focused on the staff and their ability to initiate and resume the practice. I feel that all of the studies had good sample sizes for the method of their study and chose the best type of sampling
method to work with the type of study being performed. Each study took the time to discuss the inclusion process, but not necessarily the exclusion process. They all discussed their results and if there were any barriers noted during their study. Each study reflected on the importance of skin-to-skin contact and the results that one would see in the infant when exposed to skin-to-skin contact in the first hour of life along with the long- term benefits that the infant would experience. In order to stress the importance of skin-to-skin contact in the first hour of an infant’s life the studies were performed to continue to prove best practice for infant and mother. All of the studies were appropriate for the patient situation and led to appropriate data collection in regards to the PICO question, if one was present, being addressed. The focus of all of the studies was appropriate for the information that was being sought. There were control groups that made it possible to note differences between findings in the skin-to-skin contact group vs findings in the no skin contact group. It was noted specifically in the studies that immediate skin-to-skin contact at least for the first hour of the infant’s life encouraged the infant to seek out the mother’s breast and initiate suckling. In all of the studies collected evidence states that skin-to-skin contact is beneficial to both the infant and the mother and that it encourages early initiation of breastfeeding and in turn promotes long term breastfeeding. In all of the studies it is suggested that there may be need for further research on the topic. There were also suggestions on what might benefit a future study: larger facilities, different types of facilities, facilities with more diversity, etc… Collective results The results of the studies I have chosen to use gave a clear answer to the PICO question, In 38+ week newborns, does skin-to-skin vs no skin contact promote overall breastfeeding? All of the studies found that immediate initiation of skin-to-skin contact for at least the first hour of the infant’s life allows the infant to make their way toward the mother’s breast and perform the initial latch on and suckling. (babygooroo, 2018) There currently continues to be controversy in regards to this topic. Some practitioners are set in their ways and want the infant to be removed for their initial examination while they examine the mother. However, best practice shows that immediately post-delivery the infant should be laid in a prone position between the mother’s breasts on her bare chest and then covered with a blanket, while the practitioner is delivering the placenta and examining the mother post-delivery. Therefore, further education on the topic is strongly encouraged in the studies to further understanding of this being best practice in this situation. Results showed the differences on the efficacy of skin-to-skin contact on the rate of exclusive breastfeeding between two groups (95% CI 1, 16, p=0.04). The researchers used similar methods in 3 of the 4 studies. In each of the studies they found that skin-to-skin contact is beneficial to both the infant and the mother as long as the infant is a healthy term (35-40 weeks) infant. These findings point toward this being best practice in these settings.
breasts immediately post-delivery it promotes early latch on and suckling of the newborn. There are many other benefits to this practice as well such as: promotes heart and lung function, stabilization of body temperature, regulation of blood sugar, initiation of breastfeeding, transfer of good bacteria, reduction in crying, relief from pain for both the mother and the infant, enhancement of mom-baby communication, easy transition from the womb and boost in maternal-child bonding. (babygooroo, 2018) When implementing a new practice, it is important to make it known why it would be beneficial to the patient’s and the facility. The right people will need to be convinced that the change is necessary, to promote a better overall outcome for the infant and the mother. A team needs to be established when implementing a new practice to make sure that there are no weak areas within the proposal. A vision change will need to be developed by the team. The team needs to make sure to point out the importance of why this change will benefit the patient’s and the facility. A strategy needs to be in place to help implement the change, such as some sample schedules and what type of education will be needed for all of the providers in order to get everyone on the same page. When trying to implement a new practice it is important to have a speech prepared that you and your team all agree on. With said such speech you communicate your proposed change, talking about the concerns others might have while being completely open and honest about all pros and cons. This is when you will show them how the change will benefit everyone in the end. Be prepared to discuss obstacles and how you would handle these obstacles. For instance: are there nurse managers that refuse to support the change, are there physicians that need further education on the benefits of the practice or are there nurses refusing to cooperate. The quicker you remove these barriers the better the success for implementing the change will be. When implementing a practice change you want to shoot for small wins, making specific goals and trying to reach them quickly and as efficiently as possible. Then you must anchor these changes, make them stick, make sure everyone continues to follow the guidelines and they don’t fall back into old habits. Reevaluate the success of the new practice and make these findings public and often to promote the importance of continuing the new practice. (Mind Tools: Essential skills for an excellent career, 1996-2015)
Appendix A Evaluation Matrix Indicator Definition How is it calculated Data Source How will it be measured? Frequency How often will it be measured? Responsible Who will measure it? Reporting Where will it be reported? Goal 100% implement- ation of skin- to-skin contact in all healthy infants gestation age 38+ weeks for at least one hour after birth Number of deliveries with successful skin-to-skin contact for a full hour after birth Chart monitor-ing Monthly initially then every 6 months after 6 months of success and then annually after a year of success Project team members Team meetings and leadership meetings Outcomes Successful breastfeed- ing Mother is able to successfully breastfeed the infant within the first 24 hours after birth Data recorded from follow up calls to the mother in regards to how she is doing, how breast- feeding is going and if she has any questions One-time call made two weeks after discharge from the facility Nurses Unit meetings, team meetings and leadership meetings outputs successful breastfeed for the first 6 months of infant’s life Number of mothers that have success- fully continued to breast-feed for the first Data recorded from 6- month lactation follow up call to see if the mother One-time call made 6 months after discharge from the facility Lactation consultant Unit meetings, team meetings and leadership meetings
breastfeeding in term neonates: a randomized
controlled trial. Afri Health
Sci, 16(3), 790-797.
Appendix B Barriers and enablers to skin-to-skin contact at birth in healthy neonates – a qualitative study The study participants in this study were all health care workers stationed in the labor room of the hospital. Two authors familiarized themselves with the data by reading and rereading the transcripts ensuring ease of accessibility to the transcript at a later stage. The focus group discussions and interviews were independently coded to ensure credibility and trustworthiness. By consensual agreement of all authors any inconsistencies in the coding were later resolved. In this study it was found that the staff were the foundation for the barriers to skin-to-skin contact. It is stated that further education may help in the future to encourage all staff to be sensitive to these needs and would increase the competency in the staff in these situations. The work is plausible and covers both barriers and enablers therefore making the findings believable. The writer does a good job of describing the experience and even uses quotes or descriptions of situations provided by the staff to describe the situations in question. The researcher starts by describing the hardship a newborn goes through when entering the extra uterine life and the importance of skin-to-skin contact to help them adjust to their traumatic experience. The language of the article is consistent with the content of the article. I feel that the way the authors collected the data and analyzed the material was appropriate. This is a fairly new concept therefore it is important to get more information out there to prove the importance of the practice. This specific study was focused on the barriers and the enablers of the practice and focused on understanding the barriers and the fact that the primary barrier is at the health care workers level and that there needs to be more education for these personnel. The sample selection was well thought out for this specific focus. Participants were healthcare workers stationed in the labor room of the hospital. Each participant was contacted in person and agreed to participate in the study. The researcher did control the selection of the sample. I do feel that the sample size and the composition of the participants was adequate for this study. The collection procedure and
how the information was articulated was well explained in the article. I felt by having two authors look at and code the findings then relook at the information again as a whole was a good way of verifying the data and I feel that they did a good job of describing what the roles of the authors were. The authors state that they were able to perform purposive sampling and collect data from each of the groups as they had direct access to all health workers in the unit involved in conducting deliveries and administering perinatal care. They state that they did this until no new ideas emerged and they had reached data saturation and triangulation. They describe how they performed interviews with the staff and how they developed guides in regards to the interviews. Based on the interviews and group discussions there are several barriers that emerged, all of which kept skin-to-skin contact from being carried out as a routine practice. They also stated that were able to bring to light some solutions that could help promote skin-to-skin contact. The information is logical, consistent and easy to follow. The quotes provided do fit the findings. The results are presented with a breakdown of the sample group and the information that they received from the participants. It was found that the staff were the foundation of the barriers for skin-to-skin at birth. I do feel that the writing promotes understanding for the reader. These results are relevant to someone in a similar situation and to patient values. These results suggest further education on the subject of skin-to-skin contact for the health care workers would be beneficial to encourage them to implement the practice in every possible situation. (Melnyk, 2015, pp. 248-249) (Alenchery, et al., 2018) Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial The researchers had a random number sequence generated using a computer program. Block randomization was used with a fixed block size of four. They concealed the allocation by using serially numbered, opaque envelopes that were sealed. The neonate who is considered the participant in this study was blind to the study group, but the provider was aware of the study group, considering they were the only infants being placed skin-to-skin and the control group was going straight to the radiant warmer. The author went into detail stating that there were 853 neonates initially eligible, out of these 624 mothers were unable to come to a 6-week post-partum follow up and 29 refused consent, leaving 200 neonates that were enrolled. Out of the 200 neonates only one was lost from the control group. The follow up study was performed 6 weeks post-partum monitoring for exclusively breastfeeding, predominantly breastfeeding and mixed feeding. They were also monitoring for secondary effects of skin-to-skin as well. They were monitoring the heart rate, respiratory rate and temperature of the neonate at birth, 10 minutes, 30 minutes, 6 hours, 12 hours, 18 hours, and 24 hours. I feel that this amount of time is plenty of time to monitor the effects of skin-to-skin contact. The subjects were analyzed in the groups that they were assigned and the control group was appropriate. The thermometer used was the same for each participant. All of the participants were similar in demographics and baseline clinical variables. The intervention is very precise, the infant is placed naked in the prone position between the mother’s breasts on her bare chest for at least an hour post-delivery. All the clinically important outcomes were measured and recorded in the study. There are many benefits to doing the intervention noted. It has been found to be associated with greater level of maternal breastfeeding self-efficacy, satisfaction and confidence in mother’s ability to
good job in their description of data collection to where the reader can easily understand and that are appropriate for the study. The literature does support need for this type of study. Skin-to-skin contact is a fairly new concept and there needs to be continued research providing evidence of the benefits of this practice to encourage practitioners and staff to utilize the practice in their facility. This study contributes information in regards to information about skin-to-skin contact enhancing breastfeeding. The researcher did control the selection process and they did select a sample composition and size that reflected the study’s needs. The human experience was the mother experiencing initial skin-to-skin contact with her newborn infant for the first hour after birth and how this is beneficial to the infant as well as promoting that initial latch on and suckling of the infant. The data collection procedures for this study are clear and the author describes in totality their sources and how they verified the data as well as what their roles in the study were. The analysis did not guide the direction of sampling and when it ended. But data management processes are described. The authors discussed how many mothers were observed in the study and why they were unable to observe the rest of the mothers that were selected but not observed. Presentation of this study is logical, consistent and easy to follow. Results are presented using the data that was collected and described in the study. The study is well written and easy for the reader to follow and understand. I feel that the results of this study will encourage the reader to encourage the practice of skin-to-skin contact in the future. The results will also benefit the patient and their infant in the long run. The results of this study promote implementation of skin-to-skin contact in all births of healthy newborns for the first hour of their lives. (Melnyk, 2015, pp. 548-549) (Cantrill, Creedy, Cooke, & Dykes,
An implementation algorithm to improve skin-to-skin practice in the first hour after birth The title states that it is a study to implement an algorithm to improve the practice of skin-to-skin contact. The authors provide a great background in regards to skin-to-skin contact and do discuss briefly the inclusion process. They then discuss the process of collecting the data for the study and how they placed the infant on the mother’s bare chest immediately post-delivery and the dyad was observed and recorded for the first hour after birth. The setting is in a baby-friendly designated hospital in Japan and then the authors analyzed a study that was performed in Australia. The authors then discuss the method they used for analysis, they used an algorithm and the dyads were plotted individually. The algorithm is color coded-blue boxes with arrows that point to the pathway of best practice. Red shows how and when the dyad has left the best practice. Yellow indicates that the dyad has encountered situations that are not best practice but may not be precluded from the achievement of immediate, continuous and uninterrupted skin-to-skin contact in the first hour. Green boxes indicate best practice in each parameter. They discuss birth by C-section being a barrier to skin-to-skin contact in the first hour. The authors did discuss the results from the study in the Japanese trial compared to the results from the Australian analysis. During the discussion part of the paper they discuss what benefit the algorithm would have if implemented in the hospital. The goal of the algorithm is to encourage uninterrupted skin-to- skin contact for the first hour post-delivery with the goal of progressing to self-attached suckling followed by sleep. There is no PICO question addressed in this article. The authors do discuss the inclusion process, however does not discuss exclusion other than the fact that the participants had to have had uncomplicated pregnancies in women ≥18 and that the infants were healthy, born at term and had an Apgar score of ≥8 at one minute post-delivery. There is no rational specified for this search criteria. There is no mention of contact
with any other author’s, however they did compare their study with the analysis of a similar study performed in Australia. The mother and infant were observed by two research assistants that were trained to identify each of the 9 stages the infant was expected to go through according to Widstrom’s 9 stages of Newborn Behavior and video recorded the dyad for the first hour post-delivery, once the infant was placed on the mother’s bare chest. There is mention of the blinded video recordings being coded for the 9 stages using MAXQDA 11.0.2, 2013, which is a professional qualitative data analysis software. This study was done at the study level monitoring for the outcome. There is no mention of any risk ratio or difference in means in this article. There is a flow diagram in regards to the algorithm that is proposed in this article. But as far as a flow diagram for the study itself there is not one included. There is no follow up beyond the initial contact with the participants. There is no risk of bias noted about the study. There is talk about the appraisal procedure but no conflict resolution. There were 14 infants observed in the actual study and in the Australian analysis there were 21 infants. It discusses why these infants were included based on no complications and Apgar scores at one minute post-delivery. The only exclusion noted were infants born with issues. Citations are noted in the description of data collection. There are tables with summaries of the data provided for the group that was observed and for the analysis that it was compared to. The authors did a good job of summarizing the information that they attained focusing on the strengths of implementing the suggested algorithm to encourage skin-to-skin contact in all healthy deliveries with an Apgar ≥8 at one minute post-delivery. There are no limitations discussed in this study. They are suggesting the implementation of the algorithm discussed in the study to increase the use of skin-to-skin contact. They do suggest that doing this study with a larger sample size would likely assist the hospital staff further in understanding the barriers within more discrete populations of mothers. They suggest that since birthing facilities all have their own unique strengths and challenges that the use of the algorithm periodically will allow new barriers to be documented and progress celebrated. They feel that the algorithm could provide a far-reaching impact on the hospitals to make the technique visible, auditing and reporting practices enabling the achievement of best practice, as well as providing a consistent measure for future research. (Melnyk, 2015, pp. 542-543) (Brimdyr, Cadwell, Stevens, & & Takahashi, 2018) References ABM Protocol Commitee. (2010). ABM Clinical Protocol #7: Model Breastfeeding Policy. Breastfeeding Medicine , 173-177. Alenchery, A. J., Thoppil, J., Britto, C. D., Villar de Onis, J., Fernandez, L., & & Rao, P. S. (2018). Barriers and enablers to skin-to-skin contact at birth in healthy neonates - a qualitative study. BMC Pediatrics, 18 (48). babygooroo. (2018). 10 benefits of skin-to-skin contact. Retrieved from https://babygooroo.com: https://babygooroo.com/articles/10-benefits-of-skin-to-skin-contact Beck, C. T., & Polit, D. F. (2012). Nursing Research Generating and Assessing Evidence for Nursing Practice (10th ed.). Philadelphia: Wolters Kluwer.
