The Effect of Skin-to-Skin Contact on Placental Separation Time and Initiation of Breastfeeding

Abstract

Background:

The first hour and minutes immediately after birth are quite important for both the mother and the newborn. Ensuring skin-to-skin contact (SSC) during this period has a positive effect on the mother both psychologically and physiologically, and it is also important in starting breastfeeding.

Objective:

The study was conducted to examine the effect of SSC on placental separation time and initiation of breastfeeding.

Materials and Methods:

This is a randomized controlled study. The sample of the study consists of a total of 84 women with primiparous birth and vaginal delivery, including 42 experimental and 42 controls. Data were collected using a personal information form, a chronometer, and the LATCH scale. The placental separation time for those in the experimental and control groups was determined by using a chronometer. Initiation and assessment of breastfeeding were evaluated at the first and 24th hours of birth using the LATCH scale.

Results:

The signs of placental separation occurred earlier in the experimental group than in the control group. The mean placental separation time was found to be 7.05 ± 4.37 minutes in the experimental group and 13.41 ± 5.24 minutes in the control group. A statistically significant difference was found between the groups in terms of placental separation time (p = 0.0001).

Conclusion:

This study concludes that SSC in the third stage of labor ensures earlier separation of the placenta and is effective in initiating breastfeeding.

Introduction

Skin-to-skin contact (SSC) is the interaction between a mother and her newborn baby, which is initiated immediately after birth.^1,2 The World Health Organization emphasizes the importance of SSC within the first hour after birth for successful breastfeeding.³ The SSC has been a low-cost and simple method that has helped thousands of low birth weight babies to survive, particularly in underdeveloped and developing countries.⁴

In the literature, studies have shown that SSC reduces the need for formula supplementation in hospitals, increases the initiation and duration of breastfeeding, and leads to successful first breastfeeding experiences.^5–7

Initiating SSC and breastfeeding within the first hour after birth also positively impacts the mother's psychological and physiological well-being.⁸ During SSC, the baby's touch to mother's breast creates a massage effect that stimulates the release of oxytocin and prolactin hormones, which are crucial for lactation.⁹ The release of these hormones not only initiates lactation but also accelerates uterine involution, leading to the quick separation of placenta and reducing postpartum hemorrhage.¹⁰

After the childbirth, the mother's touching, seeing, and hearing the newborn stimulates the release of oxytocin, which helps the placenta detach more quickly. A study reported that the placenta detached an average of 9 minutes sooner in the group where SSC was applied for 2 hours immediately after childbirth. Another study on SSC found that the mother's plasma oxytocin level increased within 3 minutes after starting breastfeeding, suggesting that the rising oxytocin could have a positive effect on placental detachment.¹¹

The SSC reduces the risks of atony and postpartum bleeding that may occur during placental detachment.¹² Therefore, it is important to minimize these risks and facilitate placental detachment to protect maternal health and decrease mortality and morbidity during labor.

Supportive practices during childbirth and mother-baby bonding practices can also affect the duration and success of breastfeeding.¹³ The SSC, particularly during breastfeeding, positively affects the baby's thermoregulation and apgar score through the mother's touch and love.¹⁴

The study was conducted to examine the effect of SSC on placental separation time and initiation of breastfeeding.

Research hypotheses;

H₁ = Placental separation time is shorter in mothers who receive SSC.

H₂ = Newborns who receive SSC during the third stage of labor grasp their mother's breast earlier.

H₃ = Breastfeeding begins sooner in mothers who receive SSC during the third stage of labor.

Materials and Methods

Design and sample

This study was conducted as a randomized controlled trial. This study was conducted in the delivery room unit of a university hospital in Turkey between November 2020 and March 2021. The research population consisted of primiparous pregnant women who referred to the delivery room of the hospital between the dates of this study and met the inclusion criteria.

The study inclusion criteria were determined separately for pregnant women and newborns. The inclusion criteria for pregnant women were as follows: having primiparous pregnancy, vaginal delivery, delivery between 37 and 40 weeks, and head presentation delivery.

The inclusion criteria for newborns were as follows: being healthy, having an Apgar score of >7, and having no health condition that interferes with sucking such as frenulum (tongue tie) or palate problem.

The study exclusion criteria were as follows: having risky pregnancy, adolescent pregnancy, preterm delivery, and any complications during pregnancy and delivery.

As a result of the power analysis (G*Power 3.1.9.2) performed to determine the sample size of the study (α = 0.005 error, 95% test power, and d = 0.7175 effect size), a total of 84 pregnant women, including 42 experimental and 42 control, were decided to include in the study.

Due to the possibility of data loss, a total of 96 pregnant women were included in the study, including 52 pregnant women in the experimental group and 44 pregnant women in the control group. However, 10 pregnant women in the experimental group were excluded from the study due to complications during delivery [fetal distress (4), interrupted delivery (3) and non-progressed labor (3)]; and two pregnant women in the control group were excluded from the study due to placental anomaly.

Therefore, the study was completed with a total of 84 pregnant women, including 42 experimental and 42 controls. When the power of the study was calculated after the end of the study, the Gpower of the study was found to be 0.95.

Data collection

Data collection tools

Data were collected using a personal information form, a chronometer, and the LATCH scale (Breastfeeding Assessment Tool).

Personal information form: The form includes questions about the pregnant women's sociodemographic characteristics and obstetric information and consists of two parts and a total of 13 questions. In the first part, there are five questions about their sociodemographic characteristics and pregnancy. In the second part, it consists of eight questions evaluating the initiation of breastfeeding in newborns, the stages of birth, and the signs of placental separation.

Breastfeeding assessment tool (LATCH): The scale was developed by Deborah Jensen and Sheilla Wallace (1993). Its Turkish validity and reliability study was performed by Demirhan and Pek (1997). The lowest and highest total score on the scale are 2 and 10, respectively. A higher scale score indicates greater success of breastfeeding.¹⁵

Chronometer: In the study, a digital chronometer was used to determine placental separation time and initiation of breastfeeding (in minutes).

Study procedure

The pregnant women included in the study were randomized using single-blind randomization. For this purpose, balls of the same type made of cardboard and with no visible inside, labeled A (experimental) and B (control), were placed into a box. There were a total of 84 balls in the box, 42 of type A and 42 of type B. Each pregnant woman randomly selected a ball from the box, and the selected ball was placed back into the box. If the selected ball was type A, the pregnant woman was assigned to the experimental group, and if it was type B, she was assigned to the control group. The process continued until the desired number of participants in each group was reached.

Experimental group

In the third stage of labor, the newborn was placed toward the mother's abdomen and below the xiphoid process before the umbilical cord was clamped. The researcher who observed the separation of the placenta started the chronometer while the obstetrical provider who delivered the baby ensured SSC between the mother and baby without clamping the umbilical cord.

After all, the signs of placental separation were observed and the placenta was confirmed to be in the vagina by vaginal examination, and the umbilical cord was clamped and cut. The delivery of the placenta and its appendages was ensured, and the chronometer was stopped. The umbilical cord was clamped after the separation of the placenta.

In the fourth stage of labor, the mother and newborn were taken to the postpartum room for follow-up. The LATCH breastfeeding assessment tool was used to evaluate the initiation of breastfeeding in newborns who received SSC in the postpartum room at the 1st hour and 24th hour of birth.

Control group

In the control group, routine hospital procedures were followed without any intervention on the mother or newborn. During the third stage of labor, while the obstetrical provider who assisted the delivery clamped and cut the umbilical cord, the researcher who observed the separation of the placenta started the chronometer.

The chronometer was stopped as soon as all signs of placental separation were observed, and the delivery of the placenta and its appendages was ensured. In the fourth stage of labor, the mother and newborn were taken to the postpartum room, and the newborn and mother were observed using the LATCH breastfeeding assessment tool to evaluate the initiation of breastfeeding at the 1st hour and 24th hour of birth (Fig. 1).

FIG. 1.

Consort diagram of study.

Ethical considerations

This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by a university's Clinical Research Ethics Board (IRB B.30.2.ATA.0.01.00/472). The women were informed about the study, and their verbal and written consent was obtained. All women were explained that all collected data would be kept confidential.

Results

Considering the sociodemographic characteristics of pregnant women, no statistically significant differences were found between the groups (p > 0.05). Considering the differences in the means of the variables of intervention applied during latent phase, abortus, abortion, and gestational week, no significant differences were observed between the groups (p > 0.05). Pregnant women in the experimental and control groups were found to have similar characteristics (Table 1).

Table 1.

Comparison of Socio-Demographical and Obstetric Characteristics of Pregnant Women in the Experimental and Control Groups

	Experimental	Control	Test and p-value
	n (%)	n (%)	Test and p-value
Education
Illiterate	3 (7.14)	9 (21.40)	p = 0.078 χ² = 8.391
Primary education	22 (52.58)	25 (59.50)
High school	14 (33.36)	6 (14.30)
University and above	3 (7.11)	2 (4.80)
Intervention applied in the latent phase
Yes	3 (7.1)	5 (11.9)	p = 0.356 χ² = 0.553
No	39 (92.9)	37 (88.1)	p = 0.356 χ² = 0.553
	X ± SD	X̄ ± SD
Age	22 ± 4.0	23.40 ± 4.30	p = 0.125t = 1.551
Abortus	0.11 ± 0.40	0.22 ± 0.51	p = 0.453t = 0.754
Abortion	0.00 ± 0.20	0.00 ± 0.20	p = 1.000t = 0.000
Gestational week	38.5 ± 1.0	38.52 ± 1.1	p = 0.919t = 0.102

X̄ ± SD = mean ± standard deviation; n (%), number of people (%).

Table 2 evaluated the placental separation time, placental bleeding, and separation symptoms in pregnant women. Accordingly, placental separation symptoms occurred in the experimental group more quickly than in the control group. The difference between the control and experimental groups was statistically significant (p = 0.0001).

Table 2.

Evaluation of the Average Duration of Placental Separation Symptoms

	X̄ ± SD, minutes	Test and p-value
Separation bleeding
Experimental	6.49 ± 4.30	t = 5.327p = 0.018
Control	14.36 ± 2.35	t = 5.327p = 0.018
Schroeder's sign
Experimental	3.06 ± 2.09	t = 2.384p = 0.027
Control	4.12 ± 2.18	t = 2.384p = 0.027
Ahlfeld's sign
Experimental	6.02 ± 3.12	t = 4.791p = 0.0000^*
Control	10.12 ± 6.32	t = 4.791p = 0.0000^*
Küstner's sign
Experimental	6.18 ± 4.31	t = 4.756p = 0.000^*
Control	11.30 ± 5.05	t = 4.756p = 0.000^*

p < 0.001.

X̄ ± SD, mean ± standard deviation.

The mean time for placental separation was 7.05 ± 4.37 minutes in the experimental group and 13.41 ± 5.24 minutes in the control group. The placenta separated ∼6 minutes earlier in the experimental group. The difference in the placental separation time between the experimental and control groups was statistically significant (p = 0.0001).

To evaluate the time it took for newborns to grasp the breast for the first time, the experimental and control groups were compared. The mean time for newborns to grasp the breast was 1.29 ± 1.51 minutes in the experimental group and 3.39 ± 2.17 minutes in the control group. Newborns in the experimental group grasped the breast 2 minutes earlier. The difference in the time it took for newborns to grasp the breast between the experimental and control groups was statistically significant (p = 0.000).

When Table 5 was examined, a statistically significant difference was found between the experimental and control groups in terms of the evaluation criteria of the LATCH scale and the observations of the mother and newborn at the 1st and 24th hours of birth (p < 0.05). The LATCH total score was found to be significantly higher in the experimental group than in the control group.

Discussion

After the delivery process, when the mother touches and sees the newborn, and experiences happiness, it stimulates the release of oxytocin.^16–18 The increased oxytocin release accelerates the involution of the uterus and facilitates early separation of the placenta by increasing contractions.¹² During SSC, the legs and knees of the newborn provide a kind of uterine massage, which increases uterine contractions and reduces the risk of postpartum hemorrhage.⁸

This study demonstrates that the signs of placental separation occurred in a shorter period of time in the experimental group than in the control group. These results may indicate that the early contact between the mother and baby as a result of SSC application also increased oxytocin release. Therefore, the effect of increased oxytocin hormone may have contributed to the earlier signs of placental separation in the experimental group (Table 2).

One of the practices that affects placental separation is SSC, which is applied in the third stage of labor. The SSC increases oxytocin release and facilitates placental separation and birth.¹⁹ Essa and Ismail determined that after clamping the umbilical cord immediately after birth, SSC between the mother and baby resulted in the placenta separating an average of 9 minutes earlier in the group that received SSC.²⁰

Turan and Erenel found that the average placental separation time was 10 minutes in mothers who received SSC before clamping the umbilical cord until the pulse could not be felt from the umbilical cord.¹¹ This study found that the placental separation time occurred 6 minutes earlier in the experimental group than in the control group. This result is consistent with those in the literature (Table 3).

Table 3.

Comparison of Placental Separation Time in the Experimental and Control Groups

	X̄ ± SD	Test and p-value
Placental separation time (minutes)
Experimental	7.05 ± 4.37	t = 5.586p = 0.000^*
Control	13.41 ± 5.24	t = 5.586p = 0.000^*

p < 0.001.

X̄ ± SD, mean ±standard deviation.

In newborns born through normal delivery, the increased level of noradrenaline is effective in distinguishing the smell of the mother during SSC and developing the sense of smell.²¹ We speculated that this hormonal effect is helping the newborn easily find and grasp the nipple. Breastfeeding and SSC increase the mother's prolactin and oxytocin levels, increase milk secretion and production, and affect the endocrine development of the newborn, thereby promoting the developmental process. Thus, the initiation of breastfeeding occurs in a shorter period of time in newborns who receive SSC.²²

Chiou et al. have reported that SSC is effective in initiating breastfeeding. Essa and İsmail stated that 88% of mothers who had SSC initiated breastfeeding spontaneously.²⁰ Another study found that the duration between birth and the first breastfeeding was shorter for mothers who had SSC.²⁴ Karahan and Şimşek reported that 96% of newborns who had uninterrupted SSC for an hour did not experience any problems during the first breastfeeding.²⁵ Nimbalkar et al. found that 38% of newborns who had SSC were breastfed within an hour, whereas only 32% of newborns who did not have SSC were breastfed within the same time frame.²⁶

This study demonstrates that the time it took for newborns to grasp the breast was, on average, 2 minutes earlier in the experimental group. We hypothesize that the secretion of oxytocin and prolactin hormones during the early meeting of the mother and newborn in the experimental group through SSC contributed to the shorter time it took for newborns to grasp the breast (Table 4).

Table 4.

Evaluation of First Breast Grasp Time in the Experimental and Control Groups

First breast grasp time, minutes	X̄ ± SD, minutes	Test and p-value
Experimental	1.29 ± 1.51	t = 5.811p = 0.0000^*
Control	3.39 ± 2.17	t = 5.811p = 0.0000^*

p < 0.001.

X̄ ± SD, mean ± standard deviation.

Breastfeeding initiation and assessment were observed and evaluated twice using the LATCH scale immediately at the 1st and 24th hours of birth. As a result, the initiation and continuation of breastfeeding increased significantly in the experimental group after 24 hours of birth. This study demonstrates that the mothers in the experimental group were able to hold the newborn without assistance, which reduced postpartum pain.

In addition, it is believed that as the newborn smells the mother's scent, finds the nipple more easily, and is touched and felt by the mother during SSC, they feel safe, positively affecting the initiation and continuation of breastfeeding (Table 5).

Table 5.

Comparison of the 1st and 24th Hour Latch Scale Evaluation Criteria in the Experimental and Control Groups

		n	X̄ ± SD	Test and p-value
Breast grasp	Experimental	42	1.26 ± 0.45	t = −4.609
1 hour	Control	42	0.74 ± 0.59	p = 0.000^*
Breast grasp	Experimental	42	2.00 ± 0.00	t = −6.105
24 hour	Control	42	1.52 ± 0.51	p = 0.000
Swallowing	Experimental	42	1.21 ± 0.42	t = −4.766
1 hour	Control	42	0.74 ± 0.50	p = 0.000^*
Swallowing	Experimental	42	2.00 ± 0.00	t = −6.105
24 hour	Control	42	1.52 ± 0.51	p = 0.000^*
Nipple	Experimental	42	1.60 ± 0.54	t = −2.696
1 hour	Control	42	1.29 ± 0.51	p = 0.009^**
Nipple	Experimental	42	1.98 ± 0.15	t = −2.533
24 hour	Control	42	1.81 ± 0.40	p = 0.013^**
Comfort	Experimental	42	1.95 ± 0.22	t = −5.054
1 hour	Control	42	1.52 ± 0.51	p = 0.000^*
Comfort	Experimental	42	2.00 ± 0.00	t = −2.077
24 hour	Control	42	1.90 ± 0.30	p = 0.041^**
Grasp	Experimental	42	1.29 ± 0.55	t = −5.011
1 hour	Control	42	0.60 ± 0.70	p = 0.000^*
Grasp	Experimental	42	1.95 ± 0.22	t = −5.328
24 hour	Control	42	1.38 ± 0.66	p = 0.000^*
Total	Experimental	42	7.19 ± 1.63	t = −5.651
1 hour	Control	42	4.86 ± 2.13	p = 0.000^*
Total	Experimental	42	9.74 ± 1.25	t = −4.397
24 hour	Control	42	8.17 ± 1.95	p = 0.000^*

p < 0.001, ^**p < 0.05.

X̄ ± SD, mean ± standard deviation; n = number of people.

Conclusion and Recommendations

The study found that the signs and time of placental separation occurred earlier in the experimental group than in the control group, and that breastfeeding was initiated in a shorter time in the experimental group than in the control group, that is, the time for the newborns in the experimental group to start sucking their mother's breast was shorter than that of those in the control group.

It is important for obstetrical providers to provide information to women about SSC during pregnancy follow-ups. It is recommended to apply SSC in the third stage of labor by placing the newborn on the mother's chest and to initiate breastfeeding during the contact. It is recommended that the delivery team (obstetrical provider, obstetrician, neonatologist, etc.) receive training on SSC and initial newborn care to work together in a coordinated manner.

It is recommended to expand the use of SSC between the mother and baby during the third stage of labor and to implement SSC routinely in delivery rooms. The SSC is effective in promoting early maternal-infant bonding, facilitating early placental detachment and reducing postpartum bleeding. All of these outcomes are important for both newborn and maternal health. In addition, SSC and early placental detachment allow obstetrical providers to save time and facilitate earlier discharge of mothers from the delivery room.

It is recommended that SSC between the mother and baby be more widely adopted during the third stage of labor and routinely applied in delivery rooms.

Footnotes

Authors' Contributions

The authors contributed to the study conception and design. Material preparation and analysis were performed by Ü.G. and S.Ö. The first draft of the manuscript and data collection was written by Ü.G., and the authors commented on previous versions of the manuscript. The authors read and approved the final manuscript.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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