Touching scene: why skin-to-skin care is best for newborns . . . and parents

Some 86 per cent of all healthy, term babies born in Irish hospitals now receive skin-to-skin care after delivery, according to latest figures from the HSE.

"There is no reason it couldn't be 100 per cent," says consultant neonatologist Dr Anne Doolan of the Coombe Women and Infants University Hospital in Dublin. "There is no reason a healthy, term [born between 37 and 42 weeks] baby can't lie on a mum's chest" – or on the non-birthing partner if, in rare cases, the mother is too unwell.

But the data supplied to the HSE suggests sometimes hospital practices, or parental preferences, prevent skin-to-skin happening, despite the proven physical and mental-health benefits. These include bonding, stabilising of the baby’s temperature and heart rate and lowering of stress, with less crying.

Although it may still be associated in the public’s mind primarily with encouraging initiation of breastfeeding, or for the care of premature babies, experts are keen to stress it is a process of utmost importance for all babies, regardless of when they’re born or how they are going to be fed.

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It is not only important for all babies but also for all parents, says Sue Jameson, president of the Association of Lactation Consultants Ireland. "That is the unspoken benefit" – it raises the levels of the feel-good hormone oxytocin in both mothers and fathers and creates more nurturing behaviour.

While skin-to-skin “used to be the territory of the brown rice and sandals brigade”, she says, “now it is absolutely mainstream because the evidence is good”.

Similar benefits have been shown whether the skin-to-skin care is done by the mother or the non-birthing partner. In the case of the latter, it “encourages the person who hasn’t given birth to the baby to understand that they are now a parent – there are lower anxiety scores, lower depression scores and better role attainment,” reports Doolan. Therefore, it is very much encouraged for partners too “but normally the mum gets the first go, to be honest”.

Premature babies

When dealing with premature babies and others needing special care, there is always a judgement call to be made on delivery. Sometimes, medical staff need to advise parents that it isn’t appropriate to do it immediately but that it will be prioritised as soon as possible, or when the baby is in the neo-natal unit, says Doolan.

Even if the baby is being whisked away for care, staff will make sure the infant sees their parents first. “There is no baby who is too sick to meet their parents – it’s really important,” she stresses.

An hour of skin-to-skin time immediately after delivery is recommended.  That recommendation is to ensure the baby gets at least an hour of uninterrupted time, says Doolan “but there is no reason to stop”.

Even if that “golden hour” can’t be achieved, any time is valuable. “Sometimes, we might have a baby who has a cardiac lesion that is going to need surgery and they do need to come to the neo-natal unit. But if that baby is stable, some skin-to-skin is still shown to be beneficial – even just five minutes.”

The earliest scientific research validating the practice, which is often called “kangaroo care” within neonatal units, came from studies of premature babies. But it is a natural thing for mammals like us to do.

“If there was an uninterrupted birth process, the most normal thing in the world is that you would put your baby on your chest after they have been born,” says Doolan, who also notes how it has been shown to reduce interventions.

“When healthcare staff are kept away from the baby, it is probably a good thing,” she says. “For a healthy baby who has just been born, the most important people to be involved is the baby’s family.”

Caesarean section

For healthy babies, the situation in which they and their mothers are more likely to miss out on skin-to-skin straight after delivery is when there has been a Caesarean section. But, generally, hospitals do try to prioritise it here too.

Lactation consultant and midwife Margaret Hynes, who is former co-ordinator of the Baby Friendly Hospital Initiative in University Hospital Limerick, recalls how a new policy was introduced there to put leads (to monitor heart rate etc) on a mother's back instead of her chest after a Caesarean, to facilitate her taking the baby. A local knitting group also got involved in supplying little blankets and hats for babies to wear in the theatre, where air-conditioning keeps the temperature lower than in the delivery wards.

A midwife should facilitate skin-to-skin by the non-birthing partner if the baby can't do it with the mother. Hynes, who now works privately, says she always advises fathers she meets antenatally to make sure they go into a labour ward wearing a shirt that buttons down the front, so they can do this.

Maternity care expert and chair of the Association for Improvements in the Maternity Services (AIMS) Ireland, Krysia Lynch, disputes the HSE figure of 86 per cent of healthy babies receiving skin-to-skin.

“Is that skin-to-skin or is that skin-to-towel? A lot of women report back that they are given what seems to be skin-to-skin but somebody is making a decision that they don’t want their slippery, gloopy baby directly on their private-consultant-paying chests – or whatever, the mum might not like it. So, they very kindly put a towel down, and baby goes on the towel. The mum is touching the baby’s skin all right but the baby’s front is not on the mum’s skin and the whole point of skin-to-skin is that it’s actually skin-to-skin.”

She recommends all mothers-to-be and their birthing partners to say “no towel”. She also advises any woman going into theatre for a Caesarean to try to ensure there is enough room left in front of the screen for her to take the baby on her chest after delivery.

The screen tends to be very close to your face, she explains. Mothers should also request not only that monitoring leads are put on their backs but that all drips be put on their non-dominant hand, so they have their dominant hand to hold their baby.

“Obviously, if you don’t give birth to a well baby, you might have to play it a bit by ear,” she says. While it is normal for paediatricians to want to do checks immediately, sometimes these can be done while the baby is on the mother’s chest, she suggests.

When all the stitching is finished, the mother will be transported from theatre to recovery. “At that point, the partner should be waiting there for her with the baby and the mum should now be having skin-to-skin with the baby.” However, “you do get a lot of push-back here from various people in various hospitals”.

Often, the argument is made that the recovery area is a shared space and there might be a woman there who had lost a baby and would be upset. In fact, Lynch contends, research shows that if you ask any mother who has just lost a baby is it okay that another woman wants her newborn with her, every one will say yes.

Just because they have had a horrific, sad experience, they don’t want another baby and woman to be denied, she adds. “Women are like that.”

While skin-to-skin should be done, as far as is practical, for the first hour after birth, “there is no time when you can’t start” says Jameson. In her work as a private lactation consultant, she meets people in their homes who may ask on day three, am I too late?

‘It’s never too late’

“It’s never too late,” she says, pointing out that adoptive mothers do it routinely, for the bonding, calming effects. “This is not about breastfeeding – this is about nurture and parenting.”

However, it facilitates breastfeeding because “if the baby is on your skin between your boobs, it is going to start rooting”, she says. It simulates breast function because the baby’s hands are touching the breasts, “promoting waves of oxytocin, which promotes waves of prolactin, which in turn promotes milk”.  Skin-to-skin should be continued for all babies in the early months at home too, as will happen naturally during breastfeeding. Making a conscious effort to do it “is probably of more benefit to babies who are less likely to be in skin-to-skin contact because they are not being breastfed,” she points out.

“It is really calming,” Jameson continues. “The thing that is not said so often is that it is calming for the parent as well. So, if the parent is feeling a bit stressed and a bit uptight getting to grips with the new role thrust upon them, putting their baby skin-to-skin and smelling the new baby smells really brings down their stress hormones level.

“There is never a time when babies are not calmed and comforted by having their cheek or their whole body in contact with their parents’ body. That is how we are meant to be.”

All vertical mammals, Jameson adds, carry their babies vertically, or slightly obliquely across the body, naturally. “When babies are in that alignment, they are at their most stable.”

It has just taken humans’ higher intelligence to come up with the science to prove nature is right.

The five Bs of skin-to-skin

Consultant neonatologist Dr Anne Doolan of the Coombe Women and Infants University Hospital, Dublin, on five benefits of skin-to-skin care:

Bonding: After you've had a baby, the first people the baby should meet is you and your family, rather than being taken by a healthcare professional. The infant should go straight onto a parent's chest and that bonding can start. There is evidence that it also "helps parents feel like parents" and reduces their stress scores, as it prompts the release of oxytocin, the feel-good hormone.

Breathing: It is clinically proven that being on the mother's chest regulates the baby's breathing pattern, as well as temperature and heart rate.

Breastfeeding: Babies who have skin-to-skin time are more likely to feed earlier, which keeps up their blood glucose levels (see below).

Blood glucose: Babies who have had skin-to-skin time are more likely to have normal blood glucose than those who have been separated from their mother. This is a knock-on effect from a more stable temperature, less stress and being more likely to feed earlier.

Bacteria: You should be populated by healthy bacteria that will live on your skin "and the best bacteria for you to be populated with is your own family's bacteria, rather than the bacteria from a healthcare facility".

Invitation to breastfeed

The placing of babies in skin-to-skin contact with their mothers for at least an hour immediately after birth is one of the 10 evidence-based steps to successful breastfeeding.

Although the Department of Health has recorded an almost 10 per cent increase in breastfeeding rates reported at discharge from hospital here over the decade 2006-2017, they are still among the lowest in the world.

The latest figures from the HSE on breastfeeding (exclusive and non-exclusive) rates here are:

- 59.9 per cent of babies breastfed on discharge from hospital;
- 55.5 per cent of babies breastfed at time of first visit by a public health nurse;
- 40.1 per cent of babies breastfed at three-month check-up.

In contrast, breastfeeding initiation rates are 90 per cent in Australia, 81 per cent in the UK and 79 per cent in the US, according to figures quoted in the Health Service Breastfeeding Action Plan 2016-2021.

The Baby Friendly Hospital Initiative, which is built on the WHO/Unicef 10 steps, had its funding removed in Ireland after a review in 2016 recommended that a revised model be developed in line with the action plan and the national maternity strategy. All maternity units continue to work on these 10 steps, says a HSE spokeswoman ahead of National Breastfeeding Week (October 1st to 7th).

Another of the 10 steps specifies that newborn infants be given “no food or drink other than breast milk, unless medically indicated”. But the Association for Improvements in the Maternity Services (AIMS) Ireland is concerned that “top-ups” of formula are too readily being used for breast-fed babies while still in hospital.

There is “very little trust in breastfeeding”, says its chairwoman, Krysia Lynch. She attributes the anecdotally reported widespread use of top-ups to various factors, including lack of staff on post-natal wards, where breastfeeding is low on the agenda, when there are more medical needs as Caesarean rates continue to rise.

“No one is going to sue you for not enabling breastfeeding,” she says. There is also more testing of babies’ blood glucose levels and she understands that, with earlier discharges of mothers, hospital staff have to make sure the baby is going to be fed and nourished, so may err on the side of caution to recommend top-ups. But it is hard for a mother to build her milk supply if the baby is being fed from another source, so this increases the likelihood of breastfeeding difficulties.

More than 100 events have been organised to celebrate National Breastfeeding Week, including a visit by breastfeeding mothers and their babies to Áras an Uachtaráin. To find out about an event in your area, contact your local breastfeeding support group, details of which are on MyChild.ie.

Voluntary breastfeeding support organisations include: Cuidiú and La Leche League of Ireland.