Skin To Skin Contact For Mothers And Their Babies Whilst On Transitional Care And The Neonatal Unit - Guidelines In Relation To

Publication: 27/06/2011  --
Last review: 17/04/2020  
Next review: 17/04/2023  
Clinical Guideline
CURRENT 
ID: 2579 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines in relation to skin to skin contact for mothers and their babies whilst on transitional care and the neonatal unit

Background

Kangaroo Care is where a new born infant is nursed in a vertical position between the mother’s breasts or against the partner’s chest. The practice occurs intermittently during the infant’s care, but should take place from as early as possible and for prolonged periods [1]. Skin to skin contact, in an unhurried environment, for an unlimited period, immediately after delivery is important for the well being of mother and baby [2,3], but there are situations where it is  contraindicated for a newborn to spend time skin to skin with its mother in the immediate postnatal period e.g. if physiologically unstable owing to prematurity, low birth weight or has required resuscitation. Physical contact between preterm and otherwise unwell/unstable infants and parents is often delayed.

A growing body of evidence has been documented on the benefits, safety, efficacy and feasibility of kangaroo care as an intervention for medically stable, preterm infants and their mothers [1]. Early, prolonged and continuous skin to skin contact for the neonate at any age, once physiologically stable, has been shown to reduce mortality, severe illness and length of hospital stay as well as having significant long term effects;

  • It maintains baby’s body temperature and can correct hypothermia [2,4,5,6]
  • It assists in regulating baby’s respiratory and heart rate [4,5] and decreasing episodes of apnoea [7,8] It assists in maintaining and improving oxygen saturation [8,11,12]
  •  It improves sleep organisation and increases quiet sleep [9,10]
  • It improves infant metabolic stability [13,14]
  • It reduces pain response during procedures [10,23,24] maintaining autonomic stability therefore avoiding adverse physiological effects in major organ systems [25].
  • It enables colonisation of baby’s skin with mother’s bacteria [15]
  • It improves weight gain [16]
  • It enable’s the mother to establish positive contact with her baby [17,18,19] and triggers hormonal responses which help with mother-baby interaction [19,20]. In addition the promotion of mothers oxytocin release induces a sense of well being and promotes mother – infant attachment [19,20] .
  • A traumatic birth experience can be softened by early skin contact.  An early period of closeness, bonding and a successful first breastfeed maybe emotionally restorative for mother [26]

It promotes mothers prolactin release which, in turn, promotes mothering behaviour and calmness [20] Preterm birth is associated with increased levels of maternal stress and anxiety which can later lead to depression and interfere with the mother-infant relationship [21], skin to skin can therefore assist in reducing this. It increases prolactin, therefore promoting an adequate milk supply for a breastfeeding mother [5] and, particularly, a mother who is expressing breast milk for a baby who is not ready to feed solely from the breast.

  • It promotes meaningful early contact for parents, with their baby which helps diminish the perceived loss of their parental role [21,27,28,29]. Early kangaroo care is thought to trigger earlier parental involvement in their baby’s care, improving their confidence in recognising behavioural cues and participating in the care for their infant [10, 27,29].
  • The importance of supporting a close and loving relationship from parents to their baby has been emphasised by the UNICEF Baby Friendly Initiative and the BLISS Baby Charter Standards [33,34]. They encourage the active promotion of comfort and emotional support for the baby using skin to skin contact and positive touch particularly in relation to its positive impact on brain development
  • There is a growing body of knowledge relating to the long lasting neurological, social and behavioural benefits of regular kangaroo care.  [30]
  • Skin to skin promotes a baby’s breast seeking and suckling behaviour therefore increasing the incidence of effective breastfeeds [3,4,22] It encourages a higher incidence of exclusive breastfeeding [12] Skin to skin contact can also play a part in overcoming breastfeeding difficulties at any stage.

The WHO state Kangaroo Care (skin to skin) as being a powerful, easy to use method to promote the health and well being of preterm infants [15].
Other studies suggest that skin to skin can be practised on infants who are being mechanically ventilated, infants being treated with phototherapy and infants suffering respiratory distress [1]

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Treatment / Management

  • The benefits of skin to skin contact should be discussed with all parents in the antenatal period. If this discussion, and skin to skin contact itself has not been possible during the immediate postnatal period, e.g. owing to a preterm delivery. The benefits of skin to skin contact should be discussed as soon as appropriately possible. This should be documented in the baby’s care plan. 
  • Parents should be given the opportunity to read the BLISS ‘skin to skin’ leaflet.
  • As soon as the baby is considered clinically stable, parents should be offered the opportunity to have unhurried periods of skin to skin contact. For a baby to be considered  physiologically stable enough to tolerate skin contact it must demonstrate:
  • Stability with any current respiratory support and
  • Ability to organise physiological responses i.e. (where monitoring indicated)
    • Rapid recovery of baseline vital signs during procedures
    • Minimal bradycardia or desaturations with handling 
    • Temperature stability
  • The assessment of physiological stability for kangaroo care should be an active point of consideration during the daily ward round and part of multidisciplinary discussion, although the decision for babies having kangaroo care can be between Nursing/Midwifery staff and parents. Any concerns relating to an infant’s suitability for skin to skin contact should be discussed with the neonatal medical team and Senior Nurses.
  • Parents should be provided with an appropriate, comfortable chair to sit in for kangaroo care
  • Baby should be placed undressed, apart from nappy and hat (optional), against the mother’s skin. This is usually with the baby prone, upright on the parent’s chest (This can be facilitated by a front opening gown, loose nightgown or T shirt that baby can be placed inside.)
  • Provide containment for the baby by encouraging flexion of the arms and legs with the knees tucked; effectively reducing random motor activity.
  • Support infants buttocks to prevent sliding using holder’s hands or a pillow/rolled blankets on the parents lap.
  • Consider the use of a clean warm blanket to place over mother/father and baby to keep baby warm.
  • Consideration should be given to the use appropriate covers, clothing and screens, on an individualised basis, in order to ensure dignity of the mother/father and other visitors to the ward.
  • Duration should be determined by both parent’s wishes and baby’s physiological stability. A discussion should take place which promotes prolonged periods of skin to skin contact which promote stability and comfort, rather than short sporadic episodes where inappropriate handling and disturbance can compromise the baby.
  • If baby is considered adequately stable, the nurse/midwife does not have to stay throughout the period of skin to skin contact. Leaving the family alone in a quiet atmosphere can be a positive action, providing the midwife/nurse is available to support where necessary.
  • In order to optimise the benefits of skin to skin, it is necessary for the midwife/nurse to assist the mother to recognise and respond to behavioural cues of their baby during holding e.g.
    • The display of signs of unrest during holding, not attributable to    hunger e.g. squirming when temperature rises.
    • The baby showing signs of readiness to feed; at which point all mothers should be offered help to breastfeed their babies.
  • Discuss observations with parents and provide reassurance to support the parent’s confidence
  • Plan the next skin to skin session with parents
  • It should be discouraged for neonatal unit/transitional care team members to disturb parent and infant during skin to skin, other than for purposes of assessing the infant’s stability.
  • Skin to skin contact should be documented in the neonatal notes, along with the infant’s tolerance of the event and the reason for ending this. Relevant ‘BadgerNet’ information on ‘skin to skin contact’ should be completed on a daily basis. 

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Safety

  • Parents should be made aware of
    • How to recognise good colour and easy regular breathing
    • How to maintain a safe position (use of a small mirror may be encouraged if parents have difficulty in assessing baby’s position)
    • How to call for emergency help if the baby’s colour or breathing becomes abnormal.
  • Lighting in the room must be adequate for the baby’s colour and breathing to be easily observed.
  • It is vital that the mother or father is capable of observing and assessing the baby, or parents are accompanied by a vigilant supporter during this period.  The monitoring of mother and baby must continue to be overseen by a Nurse/Midwife during this period. Due consideration should be given that mothers may be very tired, and may have taken prescribed or non prescribed drugs which may sedate them. Babies may also be compromised owing to prematurity, sepsis or other relevant conditions which have warranted their admission to NNU or Transitional care
  • The midwife/nurse has a responsibility to assess the parent’s competence to observe and handle their baby.  In circumstances where parenting capacity may be diminished e.g. with permanent or temporary physical disability or learning disability, sedation, an individual assessment of risk needs to be taken into account with regards to the parent’s ability to safely observe and handle their baby.  
  • If the midwife/nurse judges that parents are unable to observe their baby, or parents feel unable to observe their baby, skin to skin contact may warrant the presence of a vigilant observer (this may be a competent birth partner/supporter or member of staff). Staff should make every effort to identify a staff member or supporter who will assist the parents in observing a baby who is in skin contact with mother and can also provide support to the mother on an individualised basis. 
  • If a mother and baby cannot maintain skin contact for any reason, the best alternative is skin contact between the baby and father. 
  • If parents are not able to observe their baby, and no supporter or staff member is available to help, the safest option is to delay skin contact until a vigilant observer is present.

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2 (i) TRANSFER

  • A major factor affecting physiological stability is transfer technique. This is the greatest contributing factor to heat loss and increased stress, resulting in tachycardia, desaturations and episodes of apnoea [31,32].
  • It is important to discuss with the parent their role during the transfer, giving them clear guidance.
  • It is important to assess the clinical environment  around the baby’s incubator/platform, prior to the manoeuvre, in order to minimise risk on transfer e.g. position of chair, presence of obstacles, movement of IV lines, monitor wires etc.
  • More than one nurse may be required to assist the parent in the moving the infant. This will ensure that the process is swift, thus reducing heat loss or distress. Involving several nurses minimises the risk of extubation, or monitoring leads and intravenous lines becoming dislodged, and decreases the amount of time that a ventilation system may be disconnected (if in use) [31,32].
  • Nurses should ensure that the baby’s head is supported. Intravenous lines, cables and tubing should be actively secured and checked prior to transfer and care taken to prevent dislodging on transfer and once the baby is with the parent.
  • Monitoring should continue as reasonably practicable during transfer, although it is acceptable that some leads may require momentary disconnection for ease of movement and safe repositioning. Any monitoring discontinued during transfer should be reconnected once the baby is in situ.
  • Periods of skin to skin should be assessed by parents and Nurse to confirm that baby able to maintain body temperature whilst in skin to skin, and to ensure airway protection.

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2 (ii) TEMPERATURE

Staff should consider putting a hat on the infant for transfer and during the episode of skin to skin in order to prevent heat loss.
The infant’s baseline temperature should be noted prior to transfer to skin to skin, and then 10 minutes after transfer. Any change in temperature should initiate appropriate action being taken e.g. decreasing/increasing covering

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2 (iii) AIRWAY/CIRCULATION

  • Cardiorespiratory and oximetry monitoring should be continued
  • Monitor the infant for neck flexion that may contribute to airway obstruction. When in skin contact mother and baby should be in a supported in a position that ensures the baby’s airway is open and nostrils not occluded
  • For the ventilated infant, avoid neck hyperextension, a position that often contributes to accidental extubation.

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Contraindication

Skin to skin contact may not be considered suitable in the following situations, however, all babies should be assessed, on an individualised basis. Any concerns should be discussed with senior medical or nursing staff in order to facilitate skin to skin contact as soon as possible.

  • Any infant who is not physiologically stable enough to tolerate handling in order to achieve skin to skin.
  • Any infant where it would be considered unsafe to move e.g immediate post operative abdominal surgery,
  • Any infant where it would be considered  detrimental to their current treatment to participate in skin to skin e.g Infants receiving oscillatory ventilation, nitric oxide therapy, requiring humidity, undergoing cooling
  • Where an individual assessment of parenting capacity, regarding temporary or permanent physical or mental capability, has taken place, and it is considered that sufficient support to ensure safety of the baby is not available at that time.
  • If parents decline skin to skin
  • In the absence of competently experienced nursing staff

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Training Staff

  • Staff will undergo training for Baby Friendly Neonatal Standards within the first 6 months of employment on the NNU. This incorporates discussions surrounding the importance of breast milk feeding, kangaroo care and relationship building on the NNU
  • Staff should have supervised, hands on experiences in the facilitating skin to skin, particularly in methods of transferring the infant to and from the parents chest. Staff will therefore be taught on a one to one basis within the clinical area and in simulated scenarios.
  • When transfer and care of a baby requiring skin to skin is required, inexperienced staff will need to demonstrate that they can do so safely and are watched assisting skin to skin until a senior healthcare professional can ensure they are competent.
  • Transfers for skin to skin must not be performed by inexperienced staff, without adequate supervision, to ensure the safety needs of the baby

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Provenance

Record: 2579
Objective:

To ensure all mothers within the Transitional care and neonatal unit are given the opportunity for unhurried skin to skin contact with their baby as soon as possible after delivery.

It should enable staff to provide a safe and supportive environment that allows optimal skin contact between mother [or partner] and newborn within the neonatal unit and Transitional Care. This is with particular reference to preterm, small for gestational age and unwell babies where skin to skin has not always been possible during the immediate post delivery period.

Clinical condition:

Target patient group: Babies requiring admission to the Neonatal unit or Transitional care

Target patient group: All babies requiring admission to Transitional care and neonatal unit
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Midwives
Adapted from:

Evidence base

References  and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.

References

  1. Nyqvist.K.H et al. State of the art and recommendations to Kangaroo Mother care: application in a high tech environment. Acta Paediatrica 2010 (99) p812-819
  2. Moore.E.R, Anderson.G.C, Bergman.N. Early skin to skin contact with mothers and their healthy newborn infants. The Cochrane Database of Systematic Reviews. 2007 Issue 3
  3. Chaparro.C.M, Luther,C.K. Incorporating nutrition into delivery care: delivery care practices that affect child health. Maternal and Child nursing;2009; 5 (4) Oct
  4. Christensson.K et al. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin to skin or in a cot. Acta Paediatrica. 1992; 81 p488-493
  5. Christensson.K et al. Randomised study of ckin to skin versus incubator care for rewarming low risk hypothermic neonates. Lancet. 1998; 352 p1115
  6. McCall.E.M, Alderdice.F.A, Halliday.H.L Interventions to prevent hypothermia at birth in preterm and low birth weight infants. The Cochrane Database of Systematic Reviews. 2010. Issue 2 210
  7. Ludington Hoe.S.M et al. Birth related fatigue in 34-36 week preterm neonates: Rapid recovery with very early kangaroo (skin to skin) care. Journal of Obstetrics, Gynaecology and Neonatal Nursing; 28 p94-103
  8. Mitchell.A.J et al Effects of daily Kangaroo Care on cardiorespiratory parameters in preterm infants. Journal of Neonatal Perinatal Medicine 2013; 6 (3) p243-249
  9. Drosten-Brookes.F. Kangaroo care; Skin to skin contact in the NIVU. Maternal Chid nursing. 1993; 18 (5) p250-3
  10. Jefferies.A.L Kangaroo for the preterm infant and family. 2012; 17 (3) p141-143
  11. Fohe.K, Kropf.S, Avenarius.S. Skin to skin contact improves gaseous exchange in premature infants. Journal of Perinatology. 2000; 20 (5) p311-315
  12. Hunt.F. the importance of kangaroo care in infant oxygen saturation levels and bonding. Journal of Neonatal Nursing. 2008;14 (2) p47-51
  13. Bergman.N.J, et al. randomized controlled trial of skin to skin contact from birth vs conventional incubator for stabilization in 1200-2199g newborns. Acta Paediatrica. 2004; 93 (6) p779-85
  14. DeChateu.P, Wiberg.B. Long term effect on mother infant behaviour of extra contact during the first hour post partum. Acta Paediatrica Scandinavica. 1977; 66 p145-151
  15. World Health Organisation. Kangaroo mother care: a practical guide. 2003. Department of Reproductive Health. Geneva
  16. Ludington Hoe. Kangaroo care modifies preterm infant heart rate variability in response to heel stick pain. Early Human Development. 2009;85 (9) p561-567
  17. Widstrom.A.M et al. short term effects of early suckling and touch of the nipple on maternal behaviour. Early Human Development. 1990; 21 p153-163
  18. Klaus.M Mother and infant: early emotional ties. Paediatrics; 102 (5) p1244-46
  19. Urna.S, Morbert.K (2003) The oxytocin factor; tapping the hormona of calm, love and healing. Cambridge. MA Capa press
  20. Rosenblatt.J.S. Psychobiology of maternal behaviour: contribution to clinical understanding of maternal behaviour among humans. Acta Paediatrica. 1992; 81 p488-493
  21. Miles.R, Cowan.F, Glover.V. A controlled trialof skin to skin contact in extremely preterm infants. Early Human Development; 2006; 82 (7) p447-455
  22. Righard.L, Alade.M.O. Effect of delivery room routines on the success of the first breast feed. Lancet. 1990; 336 p1105-1107
  23. Johnston.CC, Filion.F, Campbell.M. Enhanced kangaroo mother care for heel lance in preterm neonates; a cross over trial. Journal of Perinatology; 2009; 29 (1) p51-6
  24. Ferber.S.G. Neurobehavioural assessment of skin to skin effects on reaction to pain in preterm infants; a randomized controlled within-subject trial. Acta Paediatrica;2008; 97 (2) p171-6
  25. Ludington-Hoe, Cong.X, McGain.G. Kangaroo care modifies preterm infantheart rate variability in response to heel stick pain. Early Human Development. 2009;85 (9) p561-567
  26. Finegan.V, Davies.S. ‘I just wanted to have him forever’; women’s lived experiences of skin to skin contact with their baby immediately after birth; RCM. Evidence based midwifery. 2004; 1(2) p59-65
  27. Lester et al.18-month follow-up of Infants cared for in a single-family room neonatal intensive care unit. The journal of paediatrics. 2016. July p1-6
  28. Blomqvist.Y.T et al Kangaroo mother care helps fathers of preterm infants gain confidence in the paternal role. Journal of Advanced Nursing. 2012; 68 9 p1988-1996
  29. Gibbs.D.P The acquisition of parenting occupations in neonatal intensive care: a preliminary perspective. Canadian journal of occupational therapy. 2016; 83 (2) 91-102
  30. Charpak.N Twenty-year follow-up of Kangaroo Mother care versus traditional care. Pediatrics. 2017; 139 (1) p1-10
  31. Black.K. Kangaroo care and the ventilated neonate. Infant. 2005; 1 (4) p127-128, p130-132
  32. Ludington Hoe.S.M, Ferreira.C.N, Swinth.J.Y. Safe criteria and procedure for kangaroo care with intubated preterm infants. Journal of Obstetrics, Gynaecology and Neonatal Nursing. 2003; 32 (5) p579-86 
  33. UNICEF Guide to the Baby Friendly Initiative Standards. 2013 UNICEF. London
  34. BLISS. The Bliss Baby Charter Standards. 2nd Ed. 2011 BLISS Publications. London

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Trust Clinical Guidelines Group

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