Observation of Skin-to-Skin Contact and Analysis of Factors Linked to Failure to Breastfeed Within 2 Hours After Birth

Abstract

Background:

Successful breastfeeding at birth seems to be associated with skin-to-skin contact between mother and newborn and newborn suckling, both within the first 2 hours of life. In practice, knowledge about the number and cause of interruptions of this contact has to be increased.

Objective:

To measure the actual time of skin-to-skin contact in the first 2 hours after birth, study the events that occur during this period, and search for factors linked to failure to breastfeed.

Materials and Methods:

Thirty women wishing to breastfeed gave their consent for us to observe and analyze the first 2 hours of the baby's life during skin-to-skin contact.

Results:

Mean total duration of skin-to-skin contact for the 30 newborns during the first 2 hours was 90.4 ± 25.0 minutes; 17 (56.7%) were interrupted at least twice during this time, mainly for neonatal care. The first interruption took place before the first breastfeed in 60% of cases. Mean time before the first breastfeed was 44.6 ± 21.1 minutes. Seven infants did not breastfeed in the first 2 hours (23.3%). The factors linked to this failure were nulliparity, lower umbilical arterial pH at birth, and early interruptions in skin-to-skin contact. Among them, only early interruptions of skin-to-skin contact appear to be modifiable.

Conclusion:

In the first 2 hours of life, early interruptions of skin-to-skin contact should be discouraged as they reduce the chances of early breastfeed.

Introduction

Several authors have shown that early skin-to-skin contact between the mother and her baby at birth contributes to earlier and more effective breastfeeding.^1–5 It also increases the rate of breastfeeding at 1^2,4,6,7 and 4 months^6,8 and prolongs the total duration of breastfeeding by about 2 months.^9,10 The Baby-friendly Hospital Initiative, based on 10 conditions for successful breastfeeding defined by the joint WHO-UNICEF declaration, recommends that skin-to-skin contact with the mother be established immediately after birth for at least 1 hour.^11,12

In spite of this, the prevalence of breastfeeding at birth in France remains one of the lowest in Europe.¹³ Recent French data show a breastfeeding rate of just 68.7% immediately postpartum, of which 60.2% was exclusively breastfeeding.¹⁴ Similarly, although most maternity hospitals are committed to acquiring Baby-friendly Hospital Initiative status for better care of newborns in some countries, especially Nordic countries (100% of maternity units have this status in Sweden), French maternity hospitals are still reticent and few of them are seeking to acquire this status. France has the second lowest accreditation rate in Europe (3% in 2012). Only 20 maternity hospitals in France were designated baby-friendly at the end of 2013, and only one was a level 3 unit.

As part of our effort to improve our practices and obtain this designation, we conducted an observational study of the first 2 hours of life of newborns in our university hospital. The aim was to measure objectively the time the baby actually spent in skin-to-skin contact with the mother and to describe the events that took place during these 2 hours, particularly the number and causes of interruptions of this contact. We also sought to identify any factors linked to the infant's failure to breastfeed during this period.

Materials and Methods

We conducted a prospective, descriptive, and analytical study over four consecutive months (120 days) in a level 3 university maternity hospital. Women with a singleton term pregnancy and vaginal delivery of a live-born child were included if they were placed in skin-to-skin contact with the baby and consented to our observation. Conversely, women with a cesarean delivery, a preterm (before 37 weeks of gestation) vaginal delivery, multiple pregnancy, medical termination of pregnancy, or in utero death were excluded, as were those who could not or did not wish to breastfeed and/or have skin-to-skin contact with their baby.

Before the study, we arbitrarily chose to perform 30 observations. Women who agreed to participate were selected consecutively during the study period during times when one of the investigators was present in the delivery room. Women who provided oral consent were interviewed in the delivery room, before the birth, and then observed with their newborn after the birth, and for the next 2 hours. We also asked if we could film short sequences during the 2 hours as visual support for the results of the study and training to improve hospital practices. Mothers provided written consent for all the dyads filmed. The French Ethical Review Committee for Research in obstetrics and gynecology approved this study (CEROG OBS 2014-09-08).

Data on the mother and child were compiled from interviews and medical records. The following patient characteristics were studied: maternal age at start of pregnancy, gestational age, weight and body–mass index at start of pregnancy, ethnic origin, socioeconomic status, smoking during pregnancy, parity, and, for multiparous women, whether they had previously breastfed. Women were asked if they had received prenatal information on breastfeeding and skin-to-skin contact. Women who had decided to breastfeed before birth were differentiated from those who decided at birth. The infant's health was assessed by birth weight, 1- and 5-minute Apgar scores, umbilical arterial pH at birth, and transfer to a neonatal intensive care unit.

We studied the following events in the first 2 hours of life: time from delivery and starting skin-to-skin contact, who initiated this contact, how long it lasted, and newborn's initial position when placed on the mother. The number and length of interruptions in skin-to-skin contact were recorded, with their reason and the person causing the interruption. We also noted the time between delivery and the interruptions, their duration, and whether they took place before the first breastfeed. The duration of any skin-to-skin contact with the father was also examined. For the neonate, we looked for signs of readiness to feed and how long after delivery they appeared. They were defined by the following behaviors: mouth puckering, lip movements, fingers and hands to mouth, and sucking fingers and hands.¹⁵ We examined whether or not the baby was put to the breast and whether the breast was expressed, and if so, by whom (mother, nursing staff). We also noted whether or not breastfeeding took place in the delivery room. This was considered to occur when the infant opened the mouth wide, tongue was under the areola, and expressed milk from the breast with deep sucks.¹

The data were collected in an Excel file (Excel 2010 version 14.0; Microsoft), and the statistics were analyzed with R software, version 3.2.0 (Copyright © 2013 The R Foundation for Statistical Computing). Bivariate analyses were used to identify maternal, neonatal, and environmental factors linked to failure to breastfeed within 2 hours. Percentages were compared with the chi-square test or Fisher's exact test, as appropriate. Mean values were also compared with the Wilcoxon nonparametric test, except for groups larger than 25, when we used Student's t test. Percentages are shown in parentheses, and mean reported with the distribution standard deviation. Some variables are indicated with their interquartile range. Significance was defined by p < 0.05 and trend toward significance by p < 0.10.

Results

During the study period, there were 1,789 births at our center. After excluding the cesarean deliveries (n = 346), preterm births (<37 weeks gestation, n = 207), multiple pregnancies (n = 58), medical terminations (n = 30), and in utero deaths (n = 26), 1,237 dyads were eligible for our study (some women met several exclusion criteria). Five women refused to participate in the study, and skin-to-skin care was not possible for three (two newborns in incubators and one woman with a postpartum hemorrhage). In accordance with the study design, 30 mothers and newborns were studied for the first 2 hours under our protocol (2.4%). Ten of the 30 women also agreed to be filmed for short sequences during this time.

Table 1 summarizes the characteristics of mothers and infants, who were comparable with the 1,237 mother–infant pairs in our maternity hospital during this period. Over two-thirds of mothers were white (70.0%), most often nulliparous (60.0%). Most of the multiparas had breastfed previously (91.7%). Nearly all the mothers had received information about breastfeeding before the birth (93.3%), and 24 (80.0%) had decided before delivery to breastfeed. About a third of the mothers had not received any prenatal information about skin-to-skin contact. The newborns were all healthy neonates, with 1- and 5-minute Apgar scores of 10. The mean umbilical arterial pH was 7.23 ± 0.07, slightly lower among the children of nulliparous mothers (7.21 ± 0.07 versus 7.26 ± 0.07 for the multiparas, p = 0.07, results not shown). None of the newborns required secondary transfer to a neonatal intensive care unit.

Table 1.

Characteristics of the Patients and Neonates in the Study (n = 30) Compared with Patients and Neonates Born in the Same Period in Our Maternity Hospital

	Study sample n = 30	Interquartile range	Maternity n = 1,237	p
Maternal age (years)	29.1 ± 4.8	[26–33]	30.2 ± 5.2	0.25
Gestational age (WG)	39.3 ± 1.3	[38–40]	39.5 ± 1.2	0.37
Weight (kg)	62.4 ± 9.8	[57.5–69.5]	65.3 ± 14.5	0.28
BMI at start of pregnancy	23.0 ± 3.3	[20.5–25]	23.8 ± 5.2	0.40
Ethnic origin
White	21 (70.0)
North African	8 (26.7)
Other	1 (3.3)
Low socioeconomic status	5 (16.7)
Smoking during pregnancy	4 (13.3)
Nulliparity	18 (60.0)		582 (47.0)	0.16
Previous breastfeeding in multiparas	11 (91.7) 11/12
Antenatal information about breastfeeding	28 (93.3)
Decision to breastfeed before birth	24 (80.0)
Antenatal information about skin-to-skin	19 (63.3)
Weight of neonate (g)	3,430 ± 450	[3,220–3,700]	3,380 ± 470	0.56
1 minute Apgar score <7	0 (0.0)		22 (1.8)	>0.99
5 minutes Apgar score <7	0 (0.0)		5 (0.4)	>0.99
Arterial pH at birth	7.23 ± 0.07	[7.19–7.26]	7.23 ± 0.07	>0.99
Transfer to NICU	0 (0.0)		17 (1.4)	>0.99

BMI, body–mass index; NICU, neonatal intensive care unit.

Events occurring in the first 2 hours after birth are described in Table 2. Skin-to-skin contact was most often initiated by the midwife, most frequently 2 minutes after birth, for a duration of 90 minutes. It was interrupted 1.7 times on average, most often for routine after delivery care practices (50.0%) or an intervention by the father (24.0%). In total, 17 dyads (56.7%) were interrupted at least twice during the 2 hours. The first interruption to the skin-to-skin contact occurred on average 42 minutes after it started, before the first breastfeed in 59.2% of cases, and lasted an average of 11 minutes. Any subsequent interruptions were longer on average. Skin-to-skin contact with the father took place in about one-third of cases and for an average duration of 25 minutes.

Table 2.

Description of Events Taking Place in the First 2 Hours of Life

	N	n (%)	Interquartiles
Time between birth and skin-to-skin ≤2 minutes	30	21 (70)
Person placing baby on skin-to-skin	30
Midwife		23 (76.7)
Pediatric auxiliary nurse		5 (16.7)
Doctor, intern		2 (6.6)
Initial position of neonate on mother	30
Chest to chest, between breasts		24 (80.0)
On the breast		6 (20.0)
Total duration of skin-to-skin contact (minute)	30	90 ± 25	[83–108]
Number of interruptions of skin-to-skin	30	1.7 ± 0.9	[1–2]
Interruptions of skin-to-skin ≥2	30	17 (56.7)
Reasons for interruptions^a	50
Neonatal care		25 (50.0)
Interventions from the father		12 (24.0)
Dressing the neonate		9 (18.0)
Medical care for mother		2 (4.0)
Other		2 (4.0)
Skin-to-skin contact with the father	30	9 (30.0)
Duration of skin-to-skin with the father (minute)	9	25 ± 19	[10–30]
Time between skin-to-skin and interruption 1 (minute)	27	42 ± 41	[10–88]
Interruption 1 before first breastfeed	27	16 (59.2)
Person causing interruption 1	27
Pediatric auxiliary nurse		22 (81.5)
Father		3 (11.1)
Midwife		2 (7.4)
Duration of each interruption (minute)
No. 1	27	11 ± 11	[6–9.5]
No. 2	17	19 ± 16	[6–26]
No. 3	6	21 ± 19	[12.3–16.8]
Total	27	27 ± 22	[10.5–37]
Presence of signs of readiness	30	29 (96.7)
Time between birth and signs of readiness (minute)	29	27 ± 10	[20–32]
Baby put to the breast	30	28 (93.3)
Person putting baby's mouth to nipple	28
Pediatric auxiliary nurse		15 (53.6)
Midwife		6 (21.4)
Mother		6 (21.4)
Doctor		1 (3.6)
Expressing the breast	30	15 (50.0)
Person expressing the breast	15
Midwife		5 (33.3)
Pediatric auxiliary nurse		5 (33.3)
Mother		5 (33.3)
First breastfeed accomplished	30	23 (76.7)
Time between birth and first breastfeed (minute)	23	45 ± 21	[32–54]

Most of the neonates had several interruptions.

The neonates showed signs of readiness on average 27 minutes after delivery. Almost all of them were placed mouth to nipple (28 among 30, 93%) by the pediatric auxiliary nurse in half the cases or by the mother herself or the midwife, each in 21.4% of cases. The breast was expressed manually in half of the cases (five by the midwife, five by the pediatric auxiliary nurse, and five by the mother). Seven neonates did not breastfeed at all during the 2 hours, one of these slept through the entire period with no signs of readiness (pH at birth: 7.21, thus not acidotic). The neonates who did breastfeed did so for the first time on average 45 minutes after birth.

A comparison of the seven babies who did not breastfeed during these 2 hours and the 23 who did breastfeed allowed us to study maternal, neonatal, and environmental factors linked to failure to breastfeed (Table 3). The mothers in these two groups did not differ for age, ethnic origin, socioeconomic status, smoking during pregnancy, or antenatal information on breastfeeding. However, the mothers who did not breastfeed their newborns were all nulliparous compared with only 11 of the 23 who succeeded in breastfeeding their newborns (100.0% versus 47.8%, p < 0.05). The newborns did not differ for gestational age at birth or birth weight, but those who did not breastfeed had a lower mean arterial pH (7.18 versus 7.24, p < 0.05).

Table 3.

Maternal, Neonatal, and Environmental Factors Linked to Absence of Breastfeeding in the 2 Hours Following Birth

	n	Did not breastfeed n = 7	Did Breastfeed n = 23	p
Maternal age (years)	30	26.6 ± 3.2	29.9 ± 5	0.14
Ethnic origin	30
White		6 (85.7)	15 (65.2)
North African		1 (14.3)	7 (30.4)	0.72
Other		0 (0.0)	1 (4.3)
Low socioeconomic status	30	0 (0.0)	5 (21.7)	0.30
BMI at start of pregnancy	30	22.7 ± 4.6	23 ± 2.9	0.46
Gestational age (weeks)	30	38.9 ± 1.2	39.5 ± 1.3	0.26
Smoking during pregnancy	30	0 (0.0)	4 (17.3)	0.55
Antenatal information on breastfeeding	30	7 (100)	21 (91.3)	1
Prenatal decision to breastfeed	30	5 (71.4)	19 (82.6)	0.60
Nulliparity	30	7 (100.0)	11 (47.8)	<0.05
Weight of neonate (g)	30	3,320 ± 310	3,460 ± 480	0.25
Arterial pH at birth	30	7.18 ± 0.09	7.24 ± 0.06	<0.05
Transfer to NICU	30	0 (0.0)	0 (0.0)
Birth to skin-to-skin ≤2 minutes	30	5 (71.4)	16 (69.6)	>0.99
Initial position of neonate	30
Between breasts, chest to chest		7 (100)	17 (73.9)	0.30
On the breast		0 (0.0)	6 (26.1)
Total skin-to-skin time (minute)	30	85 ± 31	92 ± 24	0.66
Number of interruptions in skin-to-skin	30	2.0 ± 1	1.6 ± 0.9	0.22
Duration of each interruption (minute)
No. 1	27	7 ± 3	12 ± 12	0.30
No. 2	17	21 ± 17	18 ± 18	0.73
No. 3	6	37 ± 33	13 ± 4	0.53
Au total	27	39 ± 30	24 ± 19	0.24
Time between first skin-to-skin and interruption (minute)	27	14 ± 8	50 ± 43	0.11
No. 1	17	29 ± 17	69 ± 38	<0.05
No. 2
Readiness signs	30	6 (85.7)	23 (100)	0.23
Time between birth and readiness signs (minute)	29	31 ± 9	26 ± 10	0.15
Baby put to breast	30	5 (71.4)	23 (100)	0.05

Similarly, the environmental factors for the two sets of dyads did not differ in the timing, during, or position of their skin-to-skin placement (Table 3). Interruptions for those not fed were neither more frequent nor longer, but they did tend to be earlier. This difference was, however, significant only for the second interruption (first interruption at 14 versus 50 minutes, p = 0.11, second interruption at 29 versus 69 minutes, p < 0.05). Neither the frequency of readiness signs nor the time they appeared differed between the infants who did and did not breastfeed during the first 2 hours. Finally, all neonates who were breastfed had been put mouth to nipple, with only five of the seven who did not breastfeed (100.0% versus 71.4% versus p = 0.05).

Discussion

Our observational study of 30 neonates placed in skin-to-skin contact showed that of the first 120 minutes after birth, about 90 were effectively spent in such contact. It also showed that more than half of these periods were interrupted at least twice during this time, mainly for neonatal care practices and before the first breastfeed. Early interruptions were one of the three risk factors for not breastfeeding in the first 2 hours, as were nulliparity and a lower birth pH. On the contrary, in our hospital, placement of the newborn's mouth to nipple was linked to early breastfeeding.

Skin-to-skin contact began within 2 minutes of birth for most of the dyads in our study, with a mean duration of 90 minutes. These results are consistent with the 10 steps for successful breastfeeding defined by the joint WHO and UNICEF declaration¹² on which the principles of the Baby-friendly Hospital Initiative are based.¹¹ One of them recommends placing the newborn in skin-to-skin contact with its mother immediately after birth for at least one hour. However, and contrary to a 2010 study,¹⁶ our study did not show a link between the duration of the skin-to-skin contact and first breastfeeding in the delivery room.

In our study, interruptions in skin-to-skin contact were mainly for neonatal care, particularly the first interruption, which occurred most often before the first breastfeed. Other authors have indicated the positive effects on breastfeeding of early skin-to-skin contact uninterrupted by neonatal care in the delivery room. In 1990, Righard and Alade¹ compared two groups of neonates, one placed in contact for at least 1 hour after birth or until the first breastfeed, without interruption, while in the other, skin-to-skin contact was established for 20 minutes, and then the neonates were separated from their mothers for routine care (routine tests, measurements, etc.). They were not returned until 20 minutes later. In the first group, 63% were breastfed properly, but only 21% sucked efficiently in the second (p < 0.001). The recommendations from WHO, as in France,^12,17,18 advise postponing this routine neonatal care as it interrupts the mother–baby bond and delays the start of breastfeeding.

The first breastfeed took place on average 45 minutes after birth. This time differs from study to study. Both Righard and Alade¹ and Mahmood et al.² reported times until the first breastfeed relatively similar to ours: the groups with the newborns were placed in skin-to-skin contact and were breastfed at 49 and 41 minutes, respectively. However, in a 2010 Swedish study, Widström et al.¹⁹ filmed 28 neonates and observed the first breastfeed at a mean of 62 minutes after birth, which is 15 minutes later than our observations and those previously mentioned.^1,2 In this Swedish study, the infants were left alone with their mothers in skin-to-skin contact, with no human intervention.¹⁹ None of the newborns were placed mouth to nipple—not by their mothers or by the staff: they had to find the breast unaided—and only 15 of these 28 neonates managed to breastfeed after the birth.¹⁹ In our study, on the other hand, 93% of neonates were placed mouth to nipple, which might partly explain the shorter period to the first breastfeed.

The fact that almost all neonates had their mouths placed near or on the nipple in our hospital is a cause of concern. Placing the baby's mouth on the nipple around 45 minutes may have increased the chances of breastfeeding at that time, but it does not mean the baby would not have found the nipple on his own and self-attached if given a little more time.^15,19 The neonates were perhaps encouraged to breastfeed even though they may not have been ready. Consequently, our data cannot let us say that placement of mouth to the nipple was really increasing the chance for early breastfeed. French guidelines issued by HAS do not consider that breastfeeding is compromised if the baby does not suck immediately after birth.¹⁷

Our study showed that as we might logically expect, nulliparity and a low pH are associated with failure to breastfeed in the delivery room. It is not surprising that a low pH—which requires some recovery time—is associated with a longer time before breastfeeding or even a total lack of it in the 2 hours. Furthermore, the nulliparous women were considerably less knowledgeable about the signs of readiness to breastfeed than the multiparas and certainly more reticent to let the baby find the nipple spontaneously. Finally, low pH and nulliparity are known to be associated: infants of nulliparous mothers have a lower pH than those of multiparas^20,21 due to their longer labor,²² particularly during expulsion. The neonates in our study born to nulliparous mothers tended to have a lower pH than those born to multiparas. In any case, none of these factors can be modified to increase the chances of breastfeeding.

The number of interruptions in skin-to-skin contact was not identified as a factor linked to the absence of breastfeeding in our work. It is possible that this lack of difference is a result of the small size of our sample. Because we found no previous studies examining this criterion, we cannot compare our results with others. On the other hand, early interruptions did appear to be associated with the absence of breastfeeding, as Righard and Alade also reported.¹ These authors showed that prematurely interrupting the skin-to-skin contact disturbed the neonates' spontaneous movement toward their mothers' breasts: the sequence of signs of readiness was interrupted when they were separated from their mothers, and when they were returned, the lack of rooting reflexes delayed the initiation of the first breastfeed.¹ Furthermore, despite a very few contrary results,^23,24 the vast majority of studies have shown that early, uninterrupted skin-to-skin contact facilitates the start of breastfeeding in the delivery room.^2–5 The experts therefore unanimously agree on the need for early and uninterrupted skin-to-skin contact^11,12,17 at least until the first breastfeed.

Like any observational study, ours was at risk of bias. However, it had the advantage of being prospective, with a predefined methodology, which limited the risks of measurement bias. Only a few other authors^19,25,26 have performed this kind of observational work—meticulous and uninterrupted for 2 hours. We were also able to check that our sample did not differ from the eligible patients during the same period. Finally, although our study sample was too small to identify all the factors linked to the absence of breastfeeding, it did identify three: nulliparity, low pH, and early interruptions of skin-to-skin contact. It is, however, possible that a larger study sample would have enabled us to identify other risk factors associated with failure to breastfeed, and a larger-scale study with a similar methodology would be useful.

Conclusion

In total, our study showed that early interruption of skin-to-skin contact is linked to the absence of breastfeeding in the first 2 hours of life. Although the link between an early first breastfeed and long-term breastfeeding remains to be proven,²⁷ it is in keeping with previous studies, which indicate that skin-to-skin contact increases the chances of long-term breastfeeding.^2,4,6–8,10 We thus feel justified in postponing any interruptions of the skin-to-skin contact in the first 2 hours of life and especially in delaying routine care practices, such as weighing and umbilical cord care. Although postponing care for the neonate and the mother is already recommended in France^12,17,18 and despite the lack of data discussing the timing of weighing neonates in this country, these changes remain difficult to put in place. Our results encourage us to adopt these changes as soon as possible to ensure that early skin-to-skin contact is not unnecessarily interrupted before the first breastfeeding.

Footnotes

Acknowledgments

The authors thank the women and all the professionals who helped them during this study.

Disclosure Statement

No competing financial interests exist.

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