Presented Midwifery Today Conferences, Oregon, Denmark (2009); and at the Trust Birth Conference, California (2008)
Newborn care first moments
(© gail hart, gist of midwifery)
Transition after birth
The baby in utero sends almost half his blood supply through the placenta; most of it bypasses the lungs and kidneys (because the placenta is handling the jobs of oxygenation and blood-cleansing). When the umbilical cord is clamped, the circulation redirects a much greater portion of blood to the lungs and kidneys. The baby is born with lungs filled with fluids, but within minutes after birth the fluid is pushed into the circulatory system and the lungs are nearly clear. This process isn’t instantaneous: it requires some time for the baby to fully adapt.
(from Benson’s Handbook)
“For about thirty minutes the infant is active and alert, heart rate is rapid, and there may be nasal flaring, mild grunting and retracting, ausculatory rales, irregular respiratory movements, and mucus present in the mouth. Body temperature falls. During the subsequent one-half to two hours, the infant falls asleep, has decreased respiratory rates and bowel sounds are present. Then the neonate arouses,.. .. with labile heart rate and swift color changes due to vasomotor instability and a period of hemoconcentration at about six hours of age that contributes to his plethoric appearance.” This is all NORMAL behavior. Even a normal baby has some slight periods of ‘instability’. These periods of mild symptoms demonstrate the gradual adjustments which occur over those first few hours.
THE IMPORTANCE OF DELAYED CORD CLAMPING
From public site WORLD HEALTH ORGANIZATION REPRODUCTIVE HEALTH (http://www.who.int/reproductive- ealth/publications/MSM_98_4/MSM_98_4_chapter4.en.html)
<quote>The umbilical cord can be clamped immediately after birth or later. Late clamping after cord pulsations have ceased is the usual procedure in traditional births, and early clamping is common in institutions. The timing of cord clamping may have effects on both mother and infant.
The effects on the mother have been studied in some trials. Although there was some evidence that early clamping reduces the duration of the third stage of labour, there was no significant effect on the incidence of postpartum haemorrhage.i Early cord clamping should be avoided in rhesus negative women as it increases the risk of feto-maternal transfusion. However, allowing free bleeding from the placental end of the cord reduces this risk.ii
A number of observational studies and trials have been conducted on the effects of the timing of cord clamping on the neonate. Delayed cord clamping results in a shift of blood from the placenta to the infant. The volume transfused varies between 20% and 50% of neonatal blood volume, depending on when the cord is clamped and at what level the baby is held prior to clamping. iii Trials in which newborns were placed on the mother's abdomen or on the bed where she lay and the cord was clamped only when it stopped pulsating showed that these babies had blood volumes 32% higher than babies whose cords were clamped immediately after birth. Placental transfusion was about 80% at 1 minute and was practically completed at 3 minutes.
There have been concerns that the increase in the newborn's blood volume and red blood cell volume that is associated with delayed cord clamping could result in overload of the heart and respiratory difficulties. These effects have not, however, been demonstrated. In fact, there is probably a self-regulatory mechanism in the infant which limits the extent of placental transfusion. Moreover, there is evidence that the circulatory system of the newborn is capable of rapid adjustment to an increase in blood volume and viscosity by increased fluid extravasation and dilation of blood vessels. iv
Placental transfusion associated with delayed cord clamping provides additional iron to the infant's reserves and may reduce the frequency of iron-deficiency anaemia later in infancy. v This is of particular significance in developing countries where iron deficiency is common. Delaying cord clamping also favours early contact between mother and baby. In addition, it also reduces splashing of blood, which helps protect the birth attendant in areas where HIV infection is common.vi
Early cord clamping reduces the extent of placental transfusion to the baby and results in significantly lower haematocrit and haemoglobin levels in newborns. vii The physiological consequences of early as opposed to late cord clamping have been studied even less in the preterm infant than they have in infants born at term. One randomized trial found that vaginally delivered preterm infants who had been held 20 cm below the introitus for 30 seconds before the cord was clamped required fewer transfusions for anaemia and fewer high inspired-oxygen concentrations than infants whose cords had been clamped within 10 seconds.58 More trials are needed to compare the effects of early versus delayed cord clamping on the major adverse outcomes of preterm infants, such as respiratory distress syndrome, sepsis, intracranial haemorrhage and necrotizing enterocolitis. <end>
THE IMPORTANCE OF GENTLENESS
The just-born baby needs to be handled gently to help him adapt to extra-uterine life. (Some believe that rough handling “shocks” babies and may cause them to cry before their lungs have cleared. This may result in un-even filling and may contribute to respiratory distress. It’s also possible the newborn may be sensitive to emotional or psychological damage from the sudden shock of birth. It’s so easy for us to make birth gentler for the baby, and it seems a humane thing to do so )
After he emerges, he should be guided into his mother’s arms and observed. He should not be touched, rubbed, or stimulated – simply held gently by his mother.
Ideally, the room should be darkened, and everyone should be silent or speak very quietly, so that the newborn hears only his family’s voices.
A dry towel or absorbent blanket can be gently placed over mother and baby to wick away moisture (rubbing is not needed to dry the baby. The baby doesn’t generally even NEED to be dried if he is kept skin-to-skin).
A normal baby will clear his lungs and begin to breathe within about 30 seconds, and may cry within the first minute. Some babies never cry even though they are breathing well. This is normal for them!
If the cord is kept intact, the transition to full lung breathing may occur without danger even over several minutes. The baby should have normal flexion, normal color, and normal heart rate during this time. The normal bluish/dusky birth color will rapidly change to pink – starting at the chest – although hands and feet may stay dusky for several hours or days.
If the baby is born limp or pale, or has any signs of asphyxia, then it needs to be suctioned and stimulated to breathe, and it may even need resuscitation. But the NORMAL baby benefits from a gentle transition without the added stimulation of touch or movement (rubbing, jiggling, suctioning etc).
The baby will naturally cool from the intra-uterine temperature. It is SUPPOSED to do this! Many modern US nurseries attempt to keep babies close to intra-uterine temperatures and actually over warm them. Overheating increases oxygen consumption and increases blood fragility. The natural physiologic cooling results in lower oxygen demand and may lower the risk of intra-cranial bleeds (deliberate cooling is a new method being used for premature babies. These babies are intentionally cooled to as low as 94 degrees without harm! The cooling seems to lower their risk of damage from asphyxia, and of Intraventricular hemorrhage).
The normal newborn will stabilize his temperature to his surroundings. We can easily heat them above physiologic normal by over-dressing them or wrapping them in blankets and hats.
The baby who is kept skin-to-skin will be at physiologic normal temperature (not too hot, nor too cold), will regulate his breathing faster, and will have higher blood sugars than the baby who is wrapped and placed in a warmer. Hats and clothing form a physical barrier between the mother and baby. The best ‘warmer” is the mother!
i . Pau-Chen W, Tsu-Shan K. Early clamping of the umbilical cord. A study on its effect on the infant. Chin Med J, 1960, 80:351-355.
ii . Moncrieff D et al. Placental drainage and feto-maternal transfusion. Lancet, 1986, 2:453.
iii . Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet, 1969, ii:505-8.
Yao AC, Lind J. Placental transfusion. Am J Dis Child, 1974, 127:128-141.
iv . Oh W et al. Further study of neonatal blood volume in relation to placental transfusion. Ann Ped, 1966, 207:147-159.
v . Michaelsen KF et al. A longitudinal study of iron status in healthy Danish infants: effects of early iron status, growth velocity and dietary factors. Acta Paediatr, 1995, 84:1035-44.
vi World Health Organization, Aids Prevention: Guidelines for MCH/FP programme managers, II. Aids and maternal child health. Geneva, WHO, 1990 (document WHO/MCH/GPA/90.2).
vii . Buckels LJ. Cardiopulmonary effects of placental transfusion. J Pediatr, 1965, 67:239-246.
. Daily W et al. Transthoracic impedance.V. Effects of early and late cord clamping of the umbilical cord with special reference to the ratio air to blood during respiration. Acta Paediatr Scand, 1970, (Supp 207):57-72.
is a Cochrane review abstract and plain language summary, prepared
and maintained by The Cochrane Collaboration, currently published in
The Cochrane Database of Systematic Reviews 2007 Issue 4, Copyright
© 2007 The Cochrane Collaboration. Published by John Wiley and
Sons, Ltd.. The full text of the review is available in The
Cochrane Library (ISSN 1464-780X).
This record should be cited as: Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2
version first published online: April 22. 2003
Date of last subtantive update: April 03. 2007
Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future behavior.
To assess the effects of early SSC on breastfeeding, behavior, and physiological adaptation in healthy mother-newborn dyads.
Cochrane Pregnancy and Childbirth Group's and Neonatal Group's Trials Registers (August 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (1976 to 2006).
Randomized and quasi-randomized clinical trials comparing early SSC with usual hospital care.
We independently assessed trial quality and extracted data. Study authors were contacted for additional information.
Thirty studies involving 1925 participants (mother-infant dyads), were included. Data from more than two trials were available for only 8-of-64 outcome measures. We found statistically significant and positive effects of early SSC on breastfeeding at one to four months postbirth (10 trials; 552 participants) (odds ratio (OR) 1.82, 95% confidence interval (CI) 1.08 to 3.07), and breastfeeding duration (seven trials; 324 participants) (weighted mean difference (WMD) 42.55, 95% CI -1.69 to 86.79). Trends were found for improved summary scores for maternal affectionate love/touch during observed breastfeeding (four trials; 314 participants) (standardized mean difference (SMD) 0.52, 95% CI 0.07 to 0.98) and maternal attachment behavior (six trials; 396 participants) (SMD 0.52, 95% CI 0.31 to 0.72) with early SSC. SSC infants cried for a shorter length of time (one trial; 44 participants) (WMD -8.01, 95% CI -8.98 to -7.04). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 35 participants) (WMD 2.88, 95% CI 0.53 to 5.23). No adverse effects were found.
Limitations included methodological quality, variations in intervention implementation, and outcome variability. The intervention may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-term negative effects. Further investigation is recommended...."