THE RATIONALE FOR SKIN-TO-SKIN CONTACT AT BIRTH AND ROOMING INDR VARSHA ATUL SHAH

Lecture 4

Skin to skin contact and Breast crawl

http://breastcrawl.org/video.htm

Skin to skin contact

• SSC positions build on the Tummy to Mummy

position• The baby lying on top of the mother• Mother does not have to hold the baby• Gravity maintains baby position• Baby’s chest is in close contact with mum’s tummy• Unrestricted access to breast

Advantages of Skin to skin contact- for baby

• Warmth- prevents hypothermia• Comfort- baby cries less• Metabolic adaptation- less hypoglycaemia• Quality of attachment-bonding

Advantages of Skin to skin contact- for mother

SSC releases oxytocin (hugging, love hormone)•Expulsion of placenta•Reduce post partum hemorrhage•Makes mother calm•Lower heart rate•Higher pain threshold•Higher social interaction•Less anxious•Reduces use of oxytocin, entomox •and anesthetics for episiotomy suture

Rooming in

A hospital arrangement where a mother/baby pair stay in the same room day

and night, allowing unlimited contact

between mother and infant

Slide 4.7.2

Rooming in

• Routine separation should be avoided.

• Separation should only occur for an individual clinical need.

• If separation of a mother and her infant is required because of a medical situation, document the reason for this separation in the mother/baby record

Rooming-in. Why?

• Helps establish and maintain breastfeeding

• Baby sleep better and cry less

• Reduced exposure to infection

• Helps mother to learn about her baby’s feeding and behavioral patterns

• Reduces costs

Slide 4.7.3

Helps establish and maintain breastfeeding

• Study on effects of Rooming in on breastfeeding frequency for first 24 hours.

• Findings: The frequency of breastfeeding per 24 hours was significantly higher in rooming-in than non-rooming-in infants from day 2 to day 7 (p<0.01).

• This study demonstrated that rooming-in infants had significantly higher breastfeeding frequencies than non-rooming-in infants during the first week of life.

Adapted from: Yamauchi Y, Yamanouchi I . The relationship between rooming-in/not rooming-in and breastfeeding variables. Acta Paediatr Scand, 1990, 79:1019.

Effect of rooming-in on frequency of breastfeeding per 24 hours

Adapted from: Yamauchi Y, Yamanouchi I . The relationship between rooming-in/not rooming-in and breastfeeding variables. Acta Paediatr Scand, 1990, 79:1019.

Slide 4.7.5

Effect of the maternity ward system on the lactation success

of low-income urban Mexican women

Slide 4.5.5

From: Perez-Escamilla R, Segura-Millan S, Pollitt E, Dewey KG. Effect of the maternity ward system on the lactation success of low-income urban Mexican women. Early Hum Dev., 1992, 31 (1): 25-40.

NUR, nursery, n-17

RI, rooming-in, n=15

RIBFG, rooming-in with breastfeeding guidance, n=22

NUR significantly different from RI (p<0.05) and RIBFG (p<0.05)

Determinants of lactation performance across time in an urban population from Mexico

• Milk came in earlier in the hospital with rooming-in where formula was not allowed

• Milk came in later in the hospital with nursery (p<0.05)

• Breastfeeding was positively associated with early milk arrival and inversely associated with early introduction of supplementary bottles, maternal employment, maternal body mass index, and infant age.

Adapted from: Perez-Escamilla et al. Determinants of lactation performance across time in an urban population from Mexico. Soc Sci Med, 1993, (8):1069-78.

Slide 4.6.5

Baby is exposed to less infections

• Study on positive impact of rooming-in policy on prevention of infectious disease when infants rooming-in were compared to newborns not rooming-in with their mothers (Soetjiningsih et al.).

• Average length of newborn hospitalization after roomimg in is 1,8 days compared to 3.2 days for babies not roomed in

Average length of newborn hospitalization Sanglah Hospital, Indonesia

3.2

1.8

0

0.5

1

1.5

2

2.5

3

3.5

Before rooming-in After rooming-in

Day

s

Transparency 6.15

1.4 days

0.8 days

Adapted from:Soetjiningsih and Sudaryat Suraatmaja. The advantages of rooming-in. Paediatrica Indonesiana, 1986, 26:229-35.

Morbidity of newborn babies at Sanglah Hospital before and after rooming-in

Adapted from: Soetjiningsih, Suraatmaja S. The advantages of rooming-in. Pediatrica Indonesia, 1986, 26:231.

Slide 4.7.4

0%

2%

4%

6%

8%

10%

12%

Acute otitismedia

Diarrhoea Neonatal sepsis Meningitis

% o

f ne

wb

orn

bab

ies

6 months before rooming-in

6 months after rooming-in

n=205

n=17

n=77

n=11

n=61

n=17n=25

n=4

Morbidity of newborn babies at Sanglah Hospital before and after rooming-in

• Prospective study in Bali, Indonesia, over one year in which this study examined morbidity, mortality, amount of milk formula and IV fluid consumed, and length of hospital stay in the maternity ward and newborn nursery for the 6 months pre and post rooming in policy instituted

• Diarrhoeal diseases, otitis media, neonatal sepsis, and meningitis decreased in low-birthweight and normal full-term infants

• Mortality due to infection decreased (41 or 2.21% vs. 16 or 0.81%); whereas deaths due to other causes did not greatly change during this period (58 or 3.13 % versus 51 or 2.59%).

• Need for milk formula decreased from 105.6 tins to 25.6 tins per month (400 g tin of powdered milk formula).

• Need for IV fluid dropped from 135.8 bottles to 74.1 bottles per month (500 cc/bottle).

• Number of days in the hospital was reduced from 4.2 to 1.8 days

Babies sleep better and cry less

• A study to compare the state behavior of newborns who roomed-in with their mothers at night with those who were cared for by the traditional nursery-at-night method.

• Infants in the mother's room had significantly, p less than.001, more quiet sleep (33% vs. 25.4%), less indeterminate (4.8% vs. 11.2%), and less crying (0.6% vs. 7.5%) states than infants who remained in the nursery.

• Adapted from:Keefe MR,Nursing Research (1987,36(3):140-144

Cost savings of rooming-in compared to separate recovery rooms at the Clinical Hospital of the

Catholic University of Chile13.5

$3.57 $3.57

9

$2.35 $3.05

0

2

4

6

8

10

12

14

16

Full-time nursesand aides

Personnel cost perpatient per day

Personnel + capitalcosts* per patient

per day

Separate recovery

Rooming-in

Transparency 6.19

14% savings34% savings

Adapted from Valdes et al. The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment. Journal of Tropical Pediatrics. 1993, 39:142-151.

Cost analysis of maintaining a newborn nursery at the Dr. Jose Fabella Memorial Hospital

Transparency 6.20

Hospital Statistics:

Average daily deliveries: 100 babies

Daily newborn census: 320 babies

Adapted from: Gonzales R. Cost Analysis of Maintaining a Newborn Nursery at Dr. Jose Fabella Memorial Hospital, Manila. (Transparencies presented in meeting in Manila, Philippines), 1990.

Summary of costs for maintaining a newborn nursery

Transparency 6.21

Feeding bottle sets/year124,800 x 20 P = 2,496,000 P

Milk formula cans/year17,521 x 36 P = 630,720 P

Salary of nursing staff/year900 x 3,000 P x 12 = 3,240,000 P

Salary of formula room staff/year6 x 2,000 P x 12 = 144,000 P

________________________________________

Total 6,510,720 P (310,037 USD)

Possible barriers to rooming in

• Concerns that mothers are tired

• Taking babies back to nursery for procedure

• Babies need to be monitored

• Mothers ask for their babies to be taken to Nursery

Concerns that mothers are tired

• Ward routines - to facilitate the mother’s rest with quiet times

• Make sure that staff knows how to help mothers who have had Caesarean sections choose breastfeeding techniques and positions that are comfortable and effective.

The impact of infant rooming-in on maternal sleep at night.

• A two-group comparison study was designed to investigate differences in sleep patterns for a group of mothers who roomed-in with their infants at night as compared with a group who was separated from their infants at night.

• The data collected from the mothers in the study indicated that mothers did not sleep longer or better when their infants were returned to the nursery during the night.

• Keefe MR ,Children's Hospital, Denver, CO 80218-1088.

Journal of Obstetric, Gynecologic, and Neonatal Nursing :

JOGNN / NAACOG [1988, 17(2):122-126]

Taking babies back to nursery for procedure

• Baby care should generally take place at the mother’s bedside or with the mother present.

• This can provide reassurance and teaching opportunities for the mother as well as providing comfort for the baby if distressed (Example: Weighing baby before and after breastfeeding) Other procedures can be performed in the mother’s room.

• Review advantages to mother and time saved by physician when he examines the infant in front of the mother.

Babies need to be monitored

• Baby can be observed next to the mother as easily as in a nursery

• Mother often notices change before a busy nurse notices them..

Mothers ask for their babies to be taken to Nursery

• Explain to the mother why the hospital encourages rooming-in

• Discuss the reason why the mother wants the baby taken to the nursery

• Address the benefits of rooming-in during antenatal contacts.

Case study• Carol had a long labour for her first baby and delivered her baby via forceps

delivery. When her baby was born, she had skin to skin contact with him for an hour and baby managed to latch on for twenty minutes.

• Staff nursed baby in nursery as Carol had verbalized she was very tired after the long labor The staff gave him a bottle of infant formula for the next two feeds as Carol had pain score of 5 early part of the night. She was given analgesia after which her pain score was reduced to 1 to 2.

• Carol's baby was brought to her early the next morning - 10 hours after birth. The nurse told her to breastfeed as her baby had been crying for about 5 to 10 mins. When she tried to breastfeed her baby took her breast and sucked a few times, then fell asleep.

• She had difficulty arousing baby and getting baby to suckle

Question 1- Circle the correct answer

• Based on Carols 'pain score and pain management she should be encouraged to breastfeed her baby instead of supplementation

True/ False• Baby should be nursed in nursery instead of rooming in because Carol would be

too tired to look after her baby True / False

• Infant formula Supplement increases protection from Breastfeeding – True/ False

• Based on pain management guidelines, Carol should be educated on importance of taking pain killers regularly to achieve better pain control True/ False

• Rooming in allows baby to be fed on early cues instead of feeding baby when he is crying which is a late indicator of hunger. True/ False

Question 2

• The benefits of rooming in include the following except:

-Increased immunity for mother- Reduce cost- Less exposure to infections for baby- Boost confidence for mum in handling

baby- Allows mum to feed baby on cue and

establish breastfeeding earlier

Question 3

When staff wants to inform a pregnant woman the benefits of rooming in she needs to tell mother the following except:

1.Better bonding with her baby2.She can feed baby any time she wants3.She learns to recogbaby nize baby’s feeding cues4.She becomes more confident in handling her baby5.Baby will be safer with her

References• Keefe M. R. Comparison of neonatal nighttime sleep-wake patterns in nursery versus

rooming-in environments. Nursing Research. 1987;36(3):140–144. [PubMed]

• Keefe M. R. The impact of infant rooming-in on maternal sleep at night. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 1988;17(2):122–126.

• Flores-Huerta S, Cisneros-Silva I. Mother-infant rooming-in and exclusive breast feeding. Salud Publica de Mexico. 1997;39(2):110–116. [PubMed]

• O'Connor S, Vietze P. M, Sherrod K, Sandler H. M, Altemeier W. A. Reduced incidence of parenting inadequacy following rooming-in. Pediatrics. 1980;66(2):176–182. [PubMed]

• Yamauchi Y, Yamanouchi I.Acta Paediatr Scand. 1990 Nov;79(11):1017-22. PMID: 2267917 [PubMed - indexed for MEDLINE]

• Reference: Soetjiningsih and Suraatmaja S. The advantages of rooming-in. Pediatrica Indonesia,1986, 26:229-23

• Yamauchi Y, Yamanouchi L.Breastfeeding frequency during the first 24 hours after birth in full term neonates.Paediareics 1990,86(2):171-175