Immediate and Sustained Skin-to-Skin Contact for the Healthy Term Newborn After Birth: AWHONN Practice Brief Number 5

Early Interventions to Achieve Thermal Balance in Term Neonates

Hypothermia is one of the most recognized and potentially avoidable reasons for transfer of a term neonate to the NICU. Physiologic and physical factors involved in the loss of heat affect a neonate's ability to thermoregulate in extrauterine environments. At the same time, these processes are interdependently affected by hypothermia, hypoglycemia, and respiratory distress. Underlying principles and preventive measures to avoid hypothermia are presented with practical application to practice. The implementation of best practices will decrease NICU admissions that separate mothers and neonates at this critical time. Preventive measures, competent assessment guides, and early interventions offer measures to avert avoidable hypothermia-related admissions to the NICU.

Twenty Years Baby-Friendly: Personal Reflections on Change

Background: Boston Medical Center (BMC) is an inner-city hospital located in Boston, Massachusetts. In 1995, like many maternity hospitals in the United States, BMC had policies that routinely separated mothers from their babies, limited breastfeeding education for staff, provided no hospital-funded lactation consultants, and did not initiate any limitations on the presence of the formula industry in the hospital. This all changed in 1999 when BMC became the first Baby-Friendly designated hospital in Massachusetts and the 22^nd in the nation. Objective: Describe challenges encountered on the hospital's journey to Baby-Friendly and subsequent re-designations and share strategies used to overcome them. Materials and Methods: Policy changes and new programs instituted over the twenty-year period are described as well as personal reflections on change by the author. Results: Over the time period chronicled, improvements in breastfeeding initiation and exclusivity rates were observed. From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90% and the exclusive breastfeeding rate increased from 6% to 50-60%. Delivery volume at the hospital increased from 1600 to 2850 births per year in the same time period. Following the Ten Steps is an important way to decrease racial disparity gaps. Conclusions: Change is possible in the hospital setting. Achieving and maintaining Baby-Friendly designation is a successful strategy to increase maternity unit breastfeeding rates.

Missed Nursing Care During Labor and Birth and Exclusive Breast Milk Feeding During Hospitalization for Childbirth

PURPOSE

The purpose of this study was to determine associations between missed nursing care and nurse staffing during labor and birth, and exclusive breast milk feeding at hospital discharge.

STUDY DESIGN AND METHODS

Labor and birth nurses in three states were surveyed about missed nursing care and their maternity units' adherence to the AWHONN (2010) nurse staffing guidelines for care during labor and birth, using the Perinatal Misscare Survey. Nursing responses were aggregated to the hospital level and estimated associations between missed nursing care, nurse staffing, and hospitals' exclusive breast milk feeding rates were measured using The Joint Commission's Perinatal Care Measure (PC-05).

RESULTS

Surveys from 512 labor nurses in 36 hospitals were included in the analysis. The mean exclusive breast milk feeding rate was 53% (range 13%-76%). Skin-to-skin care, breastfeeding within 1 hour of birth, and appropriate recovery care were on average occasionally missed (2.33 to 2.46 out of 4; 1 = rarely, 2 = occasionally, 3 = frequently, or 4 = always) and were associated with PC-05 [B(CI) -17.1(-29, -6.3), -17.9(-30.5, -6.2), and -15.4(-28.7, -2.1), respectively]. Adherence with overall staffing guidelines was associated with PC-05 [12.9(3.4, 24.3)]. Missed nursing care was an independent predictor of PC-05 [-14.6(-26.4, -2.7)] in a multilevel model adjusting for staffing guideline adherence, perceived quality, mean age of respondents, and nurse burnout.

CLINICAL IMPLICATIONS

Exclusive breast milk feeding is a national quality indicator of inpatient maternity care. Nurses have substantial responsibility for direct support of infant feeding during the childbirth hospitalization. These results support exclusive breast milk feeding (PC-05) as a nurse-sensitive quality indicator.

Initiative to Increase Skin-to-Skin Contact in the Operating Room After Cesarean

OBJECTIVE

To measure the increase in rates of skin-to-skin contact (SSC) for at least 15 minutes within the first hour of life in the operating room (OR) after cesarean birth after implementation of an SSC initiative. Our goal was to improve the rate of SSC from 20.3% to 50% for eligible newborns.

DESIGN

Quality improvement initiative with a pre-post-practice implementation design using surveys.

SETTING/LOCAL PROBLEM

A tertiary academic hospital in the U.S. Midwest with more than 12,500 births annually.

PARTICIPANTS

Nursing staff on a labor and delivery unit (N = 40).

INTERVENTIONS/MEASUREMENTS

We implemented nurse education, included SSC as part of the interdisciplinary team time-out (TTO) before procedures, and developed a new practice guideline to initiate SSC for at least 15 minutes within the first hour of life in the OR after cesarean birth. We measured nurses' knowledge and self-reported SSC practices with preimplementation and postimplementation surveys. We measured nurses' inclusion of SSC in the TTO and actual SSC practices in the OR with an audit tool.

RESULTS

We analyzed a total of 394 audit tool forms from the initiative. Nurses reported more use of SSC after implementation of the SSC initiative. Skin-to-skin contact was verbalized in 75.3% (70/93) of the TTOs after implementation, and SSC for 15 minutes in the OR was completed in 20.3% (16/79) of preimplementation and 24.7% (23/93) of postimplementation phases. Total SSC for any length of time within the first hour in the OR increased from 30.4% (24/79) to 61.3% (57/93) in eligible women and newborns after implementation of the initiative.

CONCLUSION

SSC in the OR increased after a 4-month initiative to increase SSC through nurse education, inclusion of SSC in the TTO, and a new guideline to initiate SSC in the OR at least 15 minutes within the first hour of life.

Prevalence and Components of Newborn Assessment Policies Related to Sudden Unexpected Postnatal Collapse

OBJECTIVE

To describe, in a convenience sample, different hospitals' nursing care policies related to normal newborn assessment, to summarize common components of those policies related to sudden unexpected postnatal collapse (SUPC) of the newborn, and to correlate characteristics of the hospitals with the presence or absence of a normal newborn assessment policy.

DESIGN

Descriptive evaluative design.

SETTING

Hospital representatives were contacted to complete a questionnaire and provide a copy of their policies regarding normal newborn assessment.

PARTICIPANTS

Representatives from 39 hospitals that provide maternal/newborn services within the United States completed the questionnaire and/or provided the investigator with a written nursing care policy for normal newborn assessment.

INTERVENTION/MEASUREMENTS

Components of the hospitals' normal newborn assessment policies were evaluated according to the framework of recommended components outlined by the American Academy of Pediatrics in Feldman-Winter et al. (2016).

RESULTS

The four components most often included in the policies submitted by 26 hospitals were maternal/newborn dyad assessments (n = 25, 96%), sequence of events postpartum (n = 15, 58%), monitoring (n = 9, 35%), and skin-to-skin contact procedures (n = 8, 30%). Differences were noted based on the size of the hospital as defined by the number of births and number of beds and also by the type of unit.

CONCLUSION

Few policies in this study aligned with the recommended suggestions from the American Academy of Pediatrics outlined in Feldman-Winter et al. (2016). It is also important to note that these recommended suggestions relate to safe skin-to-skin contact and rooming-in practices, which may in turn affect the incidence of SUPC. There is much work to be done in terms of disseminating evidence and developing and implementing newborn assessment policies related to SUPC.

Systematic Review of Skin-to-Skin Care for Full-Term, Healthy Newborns

OBJECTIVE

To determine the effect of skin-to-skin mother-infant holding, touch, and/or massage on full-term, healthy newborns and their primary caregivers.

DATA SOURCES

A seven-member scientific advisory panel searched the databases PubMed, CINAHL, and Scopus using the search terms massage, skin-to-skin contact, kangaroo care, touch, therapeutic touch, and full-term newborns for research with human participants published in English with no date parameters.

STUDY SELECTION

The initial search yielded 416 articles. After reviewing titles and retaining only articles that met the review criteria, 280 articles remained. The panel co-chairs reviewed and discussed the abstracts of these articles and retained 90 for review.

DATA EXTRACTION

Each article was assigned to one panel member and one co-chair for review. Members of the panel met via teleconference to present articles and to determine whether they had scientific merit and addressed the research question. Articles that did not meet these standards were eliminated. Forty articles included relevant evidence: 33 articles on skin-to-skin holding and 7 on infant massage.

DATA SYNTHESIS

We created a table that included the purpose, design, and findings of each study. This information was synthesized into a feasibility report by the co-chairs.

CONCLUSION

Evidence supports recommendations for skin-to-skin care for all full-term, healthy newborns. Although there is inadequate evidence to recommend massage as standard care for all newborns, massage has been shown to help consolidate sleep patterns and reduce jaundice.

Management of asymptomatic neonates born in the setting of chorioamnionitis: a safety comparison of the well-baby and intensive care setting

BACKGROUND

Evaluate the safety of a change in care setting for asymptomatic neonates born to mothers with chorioamnionitis from the neonatal intensive care unit to the well baby nursery.Local problem:The neonatal intensive care unit evaluation and management of babies born to mothers with chorioamionitis often involves separation of the mother-baby dyad and more invasive interventions.

METHODS

A single-center pre/post-intervention study of neonates born from January 2011 to November 2016, comparing safety outcomes in the neonatal intensive care unit (pre-intervention) and well baby nursery (post-intervention), following initiation of a triage protocol.

INTERVENTIONS

A protocolized, systematic change was done in the practice location.

RESULTS

Groups were similar for time to first antibiotic administration, sepsis symptom development and positive blood cultures. Length of stay (median 73.5 vs 64.4 h, P=0.0192) and % of neonates with intravenous fluid exposure (50.4% vs 7.6%, P<0.0001) were lower in the post-intervention group. Exclusive breastfeeding rates improved (pre-7.3% vs post-46.1%, P<0.0001).

CONCLUSIONS

Asymptomatic neonates born to mothers with chorioamnionitis were safely treated in a well baby nursery under the guidance of a protocol for triage, thereby reducing NICU exposure for these neonates.

Value of Specialty Certification as a Kangaroo Caregiver

Kangaroo care (KC), also known as skin-to-skin contact, saves lives, but fewer than 50% of newborns and mothers in U.S. hospitals receive KC because of lack of knowledge and skill competency. Because nurses can increase knowledge and skill competency through a certification course, the value of certification as a kangaroo caregiver and administrative incentives for certification as a kangaroo caregiver were evaluated in 71 neonatal intensive care and maternal-newborn unit nurses who completed an electronic questionnaire and the Perceived Value of Certification Tool. Nurses highly valued their KC certification, agreeing with 17 of 18 positive value statements. KC certification increased salary for a few, but institution-based incentives for KC certification are still limited and recognition of KC certification is needed.