As Midwives and health professionals, we should all know the benefits of skin-to-skin contact (SSC) for premature babies (Bailey, 2015) and term infants (at least 37 weeks gestation) for that first golden hour – increased bonding, breastfeeding rates and physiological maintenance. It now forms part of the NICE guidelines and the baby friendly initiative. Kangaroo care was started in Colombia/ South America 25 years ago as a way of reducing morbidity and mortality in pre-term infants. There’s now evidence to suggest that SSC should be promoted for as long as possible not just after birth but for the first few months of life, and not just to improve breastfeeding rates. Skin-to-skin should not be something just for those intending to breastfeed.
SSC can be key in helping the brain on it’s way to maturity. This is because the brains of newborn infants are not fully mature, their brains are only 25% the size they will be in adulthood. While all cells are present in the brain, myelination and synaptic development are not fully complete. Schore (2001), an american neurobiologist has been exploring the role of attachment and brain development for many years and he explains that the amygdala is in a critical period of maturation in those first 2 months after birth. The amygdala is located deep in the center of the brain and forms part of the limbic system involved in emotional learning, memory modulation, and activation of the sympathetic nervous system. Skin-to-skin contact activates the amygdala via the prefronto-orbital pathway and therefore contributes to the maturation of this vital brain structure.
According to mammalian neuroscience, the intimate contact inherent in this habitat of skin-to-skin contact evokes neuro-behaviours ensuring fulfillment of basic biological needs. Their temperature, heart rate and blood pressure are maintained, and this applies to both vaginal and c-section births. This time frame immediately post birth may represent a ‘sensitive period’ for programming future physiology and behaviour. SSC should begin ideally at birth and should last continually until the end of the first breastfeeding (Moore, 2016), (AWHONN, 2016).
Skin-to-skin contact beyond birth
But what about in the first three months, beyond the hospital or birth centre setting? What are the long term benefits and how can we as health care providers convey these benefits and give practical, realistic advice that will help mothers and families become more confident and give better outcomes for their babies? I will be exploring the evidence for extended SSC versus little or none and how we can get the message accross to our patients and clients.
Does extended skin-to-skin contact promote breastfeeding rates?
In a study conducted by Bieglow (2014), which looked at the effects of skin-to-skin contact (SSC) on the maintenance of mothers’ decision to breastfeed, the effects of breastfeeding and SSC on mother-infant interactions, and whether maternal depressive symptoms mediate these effects were investigated over infants’ first 3 months; they discovered that the percentage of breastfeeding mothers and infants in the SSC group was stable over the first 3 months of life, yet fewer dyads in the control group were breastfeeding at the 2 and 3 month visits than at the 1 week visit. Breastfeeding dyads had higher Nursing Child Assessment Feeding scores – indicating more positive maternal interactions at 1 week, 2 and 3 months.
Full-term newborns who have immediate and sustained skin-to-skin contact with their mothers also demonstrate short and long-term improvements in breastfeeding, such as a shorter time to their first successful breastfeed, better suckling at the breast, and overall longer duration of breastfeeding. SSC is further associated with extended exclusive breastfeeding (Association of Women’s Health, Obstetric and Neonatal Nurses, 2016). Mothers who practiced SSC reported higher volumes of expressed milk (Bailey, 2015).
Other benefits of extended skin-to-skin contact: bonding, depression and anxiety
Bieglow (2012) also looked at the effect of mother/infant skin-to-skin contact on mothers’ postpartum depressive symptoms during the first 3 postpartum months and their physiological stress during the first postpartum month. They found that Mother/infant SSC benefits mothers by reducing their depressive symptoms and physiological stress in the postpartum period. This could be due to feeling more confident with their baby, connecting more and feeling like they have a solution that doesn’t involve feeding, to calm their babies. You know that new parents are often frightened of handling their newborns, the fear of ‘breaking’ them; skin-to-skin contact helps give them confidence to handle their newborn. In studies undergone with quantitative methodology, SSC was found to have positive effects on mother-infant attachment/bonding (Anderzen-Carlsson, 2014). A feeling of becoming a family was identified in the findings and mothers who completed SSC demonstrated increased family satisfaction.
Reduced pain for the neonate during procedures when practicing skin-to-skin contact
Alongside vitamin K injections, blood sugar monitoring, Newborn Blood Spot tests, vaccinations, the newborn is subjected to a lot of painful procedures. Skin-to-skin, alongside breastfeeding if possible, is proven to reduce the pain associated with these procedures and therefore reducing parental anxiety (Bailey, 2015). Give them this tool when you’re performing an uncomfortable procedure on the newborn, and they can take it forward for the future.
SSC reduces infant stress
When SSC is performed regularly, not only does it reduce the cortisol levels in the baby at the time, it could start to work as a buffer for future stress (Beijers, 2016).
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How to practice and teach skin-to-skin contact as health professionals?
Skin-to-Skin contact involves placing the dried, naked baby prone on the mother’s bare chest, often covered with a warm blanket. If the mother is not able or does not wish to provide SSC, it should be offered to the partner or grandparent as appropriate. It’s best without a nappy in that first instance, but ongoing at home, have the baby in just a nappy. A review by Moore (2012) showed that mothers who provided SSC showed less anxiety and more confidence about their abilities to take care of the infant after hospital discharge.
How long should we advise skin-to-skin contact for?
Once the parents are home with their newborns, it’s common to advise SSC when there are feeding issues, when the baby fails to latch. As we’ve seen above, there are so many more benefits than helping with breastfeeding. What we should be recommending is regular skin-to-skin contact in the first three months. A minimum duration to suggest is 20 minutes up to 1- 2 hours, 5 times a week. When you put it to them as a minimum of 20 minutes a day, that is easily achievable, and can be done during feeding (breast or bottle) or soothing to sleep. just as little as 20 minutes 5 times a week can make a difference. The key message for women is that the mother is all the baby needs, they are enough.
Don’t forget the Dads
Dads and same sex partners can do skin-to-skin contact too – it helps to settle babies and give the mother a rest. Fathers who practice SSC had a positive impact on the infants outcomes including pain, and physiological markers. It also made them consolidate their parental role, increased paternal interaction behaviour, and helped reduce paternal stress and anxiety (Shorey, 2016). Paternal outcomes, such as attachment, stress and anxiety were improved.
Safety measures for skin-to-skin contact
As always, we must teach parents about the dangers of smoking, drinking and drug taking whilst practicing skin-to-skin contact, and advise against falling asleep with baby on the chest, or whilst on a sofa or armchair. Do not overheat the baby with lots of layers on top, a single blanket or sheet over is usually enough as the baby’s temperature will be maintained by the mother. Make sure the baby’s head, nose and mouth are visible at all times – are they ‘close enough to kiss?’
When and how should we provide information on skin-to-skin contact?
The key time to promote and inform parents about SSC is antenatally. In a study done by Calais (2010 ) which looked at the factors that may promote or hinder skin to skin contact in healthy full term infants, previous knowledge of SSC promoted the use of it, however, information received at the hospital did not increase the use of SSC. This shows how important it is to provide quality, evidence based information to women and their families so they can make an informed choice. In my trust, skin contact is mentioned under the infant feeding conversation guide, this could then be expanded to talk a little about the benefits, how and when to do it, and who can help. Interestingly, in the study they found that Fathers did not do SSC for as long as mothers – we can help by ‘prescribing’ a time for them to do it for. The success of implementing early and continuous SSC depends on several factors, including the degree of satisfaction with the information and support concerning SSC. Women who provided SSC during the first few days following birth tended to be older – we should ensure that younger mothers have all the information and support they need to implement skin-to-skin contact.
Factors that hinder skin-to-skin contact:
- Visitors other than partners and siblings
- Fathers did not do SSC for as long as mothers.
- Breast exposure may reduce the willingness to do SSC depending on the culture.
There are ways to encourage skin to skin without exposing the breasts if the mother finds that uncomfortable. The use of a front fastening bra, or using a loose fitting vest top and shirt can help. Encourage women to limit their visitors, and if they arrive whilst breastfeeding or practicing SSC, the visitors can wait to hold the baby!
Factors that improve the uptake of SSC
- A longer duration of hospital stay > 8 hours
- Increased maternal age
- Prior knowledge of the technique and benefits
Resources to use for Skin-to-skin contact
This video shows women visually exactly how skin-to-skin contact works, and the immediate effect it can have on calming babies. It’s a good one to show in antenatal classes to show them the technique and why we advise it. Talk about practicalities, in a realistic and helpful way that they will remember.
If that video isn’t working, click here to watch on YouTube.
There’s a leaflet from The Public Health Agency, entitled Getting to Know Your Baby, which has a nice section on skin to skin amongst other useful information for postnatal mums. I would say to give this or a similar publication out either in antenatal classes or in a late third trimester appointment so they have a chance to assimilate the information. Your trust may have it’s own publication, make sure it includes the advise on skin-to-skin contact.
Schore A. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health J. 2001;22:7–66.
Phillips Uninterrupted Skin-to-Skin Contact Immediately After Birth DOI: NAINR. Newborn and Infant Nursing Reviews 2013;13(2):67-72.
Bailey, J Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. Paediatrics 2015;136(3):596-600
Bigelow et. al Breastfeeding, skin-to-skin contact, and mother-infant interactions over infants’ first three months. Infant mental health journal. 2014 Jan-Feb;35(1):51-62.
Bigelow et. al Effect of mother/infant skin-to-skin contact on postpartum depressive symptoms and maternal physiological stress. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN. 2012 May-Jun;41(3):369-82.
Anderzen-Carlsson et. al Parental experiences of providing skin-to-skin care to their newborn infant–part 1: a qualitative systematic review. International journal of qualitative studies on health and well-being. 2014;9:24906.
Anderzen-Carlsson et. al Parental experiences of providing skin-to-skin care to their newborn infant-part 2: a qualitative meta-synthesis. International journal of qualitative studies on health and well-being. 2014;9:24907.
Beijers et. al An experimental study on mother-infant skin-to-skin contact in full-terms. Infant behavior & development. 2016 May;43:58-65.
Calais E, et. al Skin-to-skin contact of fullterm infants: an explorative study of promoting and hindering factors in two Nordic childbirth settings. Acta paediatrica (Oslo, Norway : 1992). 2010 Jul;99(7):1080-90.
Shorey et. al Skin-to-skin contact by fathers and the impact on infant and paternal outcomes: an integrative review. Midwifery, 2016; 40:207-217
Disclosure: This article was commissioned by Water Wipes. All opinions are my own.