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Evidence for Common Interventions during the Newborn's Golden Hour
Rebecca Dekker, PhD, RN, APRN
Learning Objectives: 1. Describe evidence for two best practices
for newborns in the golden hour • Skin-to-skin • Delayed cord clamping
2. Discuss evidence for procedures that often take precedence over skin-to-skin and bonding • Suction, hatting, bathing • Hep B, Vitamin K, eye ointment
For which group was the term “Golden Hour” first used? A. Term infants B. Preterm infants C. Trauma patients D. Heart attack
patients
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What % of infants in WA are ever breastfed?
A. 80% B. 84% C. 92% D. 95%
How many WA infants are exclusively breastfeeding at 6 months?
A. 20% B. 30% C. 40% D. 50%
What about Baby-Friendly? � Global initiative of the World Health
Organization (WHO) and the United Nations Children's Fund (UNICEF)
� “Ten Steps to Successful Breastfeeding” � Extensive process before hospitals are
designated as baby-friendly � What % of babies in WA are born at baby-
friendly hospitals? https://www.babyfriendlyusa.org/
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History of Cord Clamping � Several decades ago, hospitals began using
immediate cord clamping (ICC) � Part of active management of the 3rd stage:
Giving oxytocin
Clamping and cutting within 30 seconds
Gentle downward traction
� New evidence shows the ICC part of the package is unnecessary and harmful!
Placental Transfusion � When cord clamping is delayed (1-5
minutes), infants receive fluid volume, red blood cells, and millions of stem cells
� Rapid cord clamping = lose access to 1/3 of blood supply
� Blood helps with fetal transition = lungs go from receiving 10% of blood supply pre-birth to 45-55% post-birth
DCC does not lead to Jaundice � Cochrane review = 4.4% jaundice with DCC
vs. 2.7% with ICC1 Based on one unpublished dissertation study
Did not report bilirubin levels; unblinded
� Another systematic review did not include this study and found NO relationship between DCC and jaundice2
1. McDonald, Middleton (2008). Cochrane Review. 2. Hutton, Hassan (2007). JAMA
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Effects of DCC on Babies � Higher hemoglobin (Hgb) levels at birth � Higher Hgb and hematocrit at 24 hours � Higher iron levels at 3-6 months � NO increased risk of:
� Thick blood
� Low Apgar scores
� NICU admission
� Breathing problems
Effects of DCC on Mothers � DCC is a harmless practice for mothers � No increased risk of:
Postpartum hemorrhage
Low hemoglobin
Blood transfusion
Length of third stage of labor
What is the #1 barrier to DCC for your clients??
A. Staff go on auto-pilot B. Need for resuscitation or
suctioning C. Physician fear of gravity D. Cord blood banking
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Types of skin-to-skin � Birth or immediate = starts in first minute � Very early = within 30-40 minutes � Early = any skin-to-skin in first 24 hours
Rates of skin-to-skin are lowest in the
Southeastern U.S. and highest in the Pacific
What % of WA hospitals provide ≥30 minutes skin-to-skin in the first hour after an uncomplicated vaginal birth?
A. 98 B. 92 C. 88 D. 84
Evidence for skin-to-skin (S2S) � Systematic review of 34 randomized trials � Babies randomly assigned to early S2S were
2x more likely to be EBF at 3-6 months
The benefits of skin-to-skin care are so clear that in 2003 the World Health Organization
recommended ALL newborns receive skin-to-skin care, no matter the baby’s weight, gestational age,
birth setting, or condition at birth.
Moore (2012). Cochrane Database. 5: CD003519
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Risks of NOT having early S2S � Risks to Mothers
More breast engorgement/pain More anxiety More incisional pain after CS
� Risks to baby Instability of baby’s HR, RR, temp, and blood sugar 12 times more likely to cry
Moore (2012). Cochrane Database. 5: CD003519
Highly Unethical Study � Randomly assigned 124 infants in Russia to
early separation/swaddling OR early S2S � All babies were separated from mothers for
25 minutes for mandatory routine care � Half the babies were then returned to their
mothers’ arms; the other half were tightly swaddled and kept separate for 2 hours
� Babies were filmed playing with their mothers 1 year later
Bystrova et al. (2009) Birth 36(2): 97-108
Results at One Year � Babies who were separated were more
irritable and dysregulated, and mothers showed less reciprocity and mutuality
� Mothers of swaddled babies were less responsive to their infants
� S2S in the first hour of life is critically important for mother-infant bonding
� The risk of separation was not lessened by “rooming in” afterwards
Bystrova et al. (2009) Birth 36(2): 97-108
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Which of these procedures do you routinely see done in the 1st hour?
A. Suction B. Hatting C. Bathing D. Weighing E. Hep B F. Vitamin K G. Eye Ointment
Which of these procedures is almost always medically necessary for the 1st hour of life?
A. Suction B. Hatting C. Bathing D. Weighing E. Hep B F. Vitamin K G. Eye Ointment
Oronasopharyngeal suction � 170 healthy newborns at term, with head-
first positioning and clear amniotic fluid � Randomly assigned to:
Immediate suction after birth using a sterile plastic tube OR
Only visible material removed
� Placed into warmer and monitored pulse oxygenation and heart rate
Nejad et al. (2014) J Obstet Gynecol 34: 400-402.
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No Suction = Faster oxygenation � The no suction group reached 92% O2 by 9
minutes, compared to 11 minutes in the suction group
� Results are consistent with other randomized trials (Gungor 2005, Gungor 2006; Carrasco 1997)
� Additional trial showed suctioning did not prevent Meconium Aspiration Syndrome (Vain 2004)
Nejad et al. (2014) J Obstet Gynecol 34: 400-402.
Newborn Bath � Initial purpose = remove blood, fluids, and
pathogens Prevent outbreaks of staph infections in hospital nurseries
Prevent HIV and Hep B transmission
� Skin = largest organ in the body Very sensitive to environment
Colonization with normal flora creates barrier
Does Bathing remove Bacteria? � Randomized trial with 140 term vaginally
born newborns One group bathed with mild soap/water
One group bathed with water alone
� Infants were swabbed before the bath, 1 hour after the bath, and 24 hours after bath
� No difference between groups � Skin colonization is a function of time
Medves & O’Brien (2001). Birth 28(3): 161-165.
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Bathing and Breastfeeding � Boston Medical Center changed its protocol
Before = bath in nursery at 2 hours, then placed under warmer (n = 348)
After = bathed in mother’s room at 12 hours, then placed skin-to-skin (n = 354)
� Infants born after the protocol change were: 1.4X more likely to exclusively breastfeed, 1.6x more likely to near-exclusively breastfeed, and 2.7x more likely to have any breastmilk
Preer et al. (2013). Breastfeeding Med 8(6): 485-490
Academy of Breastfeeding Medicine
“Despite evidence that delaying postpartum interventions to the newborn is associated with
improved breastfeeding outcomes, many hospital policies still dictate immediate weighing, measuring, administering eye prophylaxis and vitamin K, and an early initial bath, all of which interfere with early and continued skin-to-skin and breastfeeding initiation.”
Holmes et al. (2013). “ABM Clinical Protocol.” Breastfeeding Med 8(6): 469-473
Hatting
� Research on hatting is almost all from the 1970s-1980s
� In one study, term newborns were separated from mothers and placed naked in a closed chamber (81 deg.) with a hat OR a similarly-sized pad on the abdomen
� Not surprisingly, wool-lined hats helped preserve body temperature
Stothers (1981). Archives of Disease in Childhood 56: 530-534.
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“Hats for the newborn” � Randomized controlled trial in England (n =
104 infants not under a warmer) � Baby was assessed, wrapped in blankets,
briefly given to the mother, then removed � Hats resulted in a smaller fall in
temperature in the first 30 minutes of life � On average babies were naked for 7
minutes Chaput et al. (1979). BMJ
2: 570-571.
So are hats necessary? � Yes– if separated from the mother and/or
exposed to the environment � Large body of evidence shows that skin-to-skin
is highly effective at regulating temperature Example: Preterm twins skin-to-skin on mother– each breast temp vacillates depending on twin’s individual temp
� With skin-to-skin, no evidence that hats are necessary!
Ludington-Hoe et al. (2006). J Obstet Gynecol Neonatal Nurs 35(2): 223-231.
Vitamin K’s role: � Fat-soluble vitamin necessary for clotting –
activates certain molecules to help blood clot
� With low Vitamin K, blood less able to clot � At certain low point, blood can no longer
clot and spontaneous bleeding can occur
Shearer, M. J. (2009). “Vitamin K deficiency bleeding (VKDB) in early infancy.” Blood Rev23(2): 49-59.
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Patterns of Bleeding � Early Vitamin K Deficiency Bleed (VKDB): first 24
hours Bleeding usually in skin, brain, abdomen
� Classical VKDB: days 2-7 Vitamin K levels lowest; common bleeding sites: gastrointestinal system, umbilical cord site, skin, nose, and circumcision site
� Late VKDB: after first week, usually weeks 3-8 Bleeding in brain often first sign
Shearer, M. J. (2009). Blood Rev23(2): 49-59.
Late VKDB � If No Vitamin K at birth, late VKDB develops in Europe: 4.4-10.5 infants per 100,000 Asia: 1 infant per 6,000 � If Oral Vitamin K given at least three times in
infancy, then late VKDG develops in 1.4-6.4 infants per 100,000
� If Vitamin K shot at birth, virtually no cases of late VKDB
Shearer, M. J. (2009). Blood Rev23(2): 49-59.
Risk factors: � Exclusive breastfeeding
� Not receiving the Vitamin K shot
� Less common risk factors: Undiagnosed gallbladder/liver disease Cystic fibrosis Chronic diarrhea Antibiotic use
Virtually all cases of VKDB happen in infants who are exclusively breastfed and who have not received the
shot.
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What happened to these infants? Age/Sex Birth history Feeding Symptoms Diagnosis Outcome
5 month old male
Home birth, no Vitamin K, no circumcision
Exclusively breastfed
Vomiting, bruising, sleepiness, poor feeding
Brain bleed
Brain surgery, good outcome
2 month old female
Hospital birth, no Vitamin K
Exclusively breastfed
Vomiting, fever, lethargy
Brain bleed
Mild neuro delays
3 month old female
Home birth, no Vitamin K
Exclusively breastfed
Bloody stools
GI bleed No long term effects
What happened to these infants? Age/Sex Birth history Feeding Symptoms Diagnosis Outcome
6 week old male
Born in hospital, no Vitamin K
Exclusively breastfed
Fussiness, sleepiness, poor feeding
Brain bleed Brain surgery, stroke, severe deficits
7 week old male (twin)
Born in hospital, no Vitamin K
Exclusively breastfed
Fussiness, vomiting, pale, poor feeding
Brain bleed Transfusions, moderate deficits
3 month old female
Born in birth center, no Vitamin K
Exclusively breastfed
Vomiting and clay-colored stools
CT of head not done
Bile duct cyst removed
What did they have in common? � Parents declined Vitamin K � Exclusively breastfed � Normal vaginal births (no instruments, no
Cesareans) � Lab tests showed severe Vitamin K
deficiency � No antibiotics, no illnesses, no restrictive
diets of the mothers, no head trauma, no abuse
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Comparing Regimens Country Years Medication Incidence
Australia 1993-1994 1994-1995
Oral Vitamin K 3 times IM Vitamin K once at birth
2.5 per 100,000 0 per 100,000
United Kingdom
1988-1990 None Oral Vitamin K1 once at birth IM Vitamin K1 once at birth
4.4 per 100,000 1.5 per 100,000 0.64 per 100,000
Sweden 1987-1989 Oral Vitamin K1 once at birth IM Vitamin K1 once at birth
6 per 100,000 0 per 100,000
Switzerland 1986-1988 Oral Vitamin K1 once at birth IM Vitamin K1 once at birth
6.4 per 100,000 0 per 100,000
Shearer, M. J. (2009). Blood Rev 23(2): 49-59. Cornelissen et al. (1997) Eur J Pediatr156(2): 126-130.
Best Oral Vitamin K Regimen � Since 1990, all infants in the Netherlands receive 1
mg oral VK after birth and breastfed infants receive 25 micrograms daily until the end of the 13th week
� In Denmark, they used 2 different regimens: Between 1994-2000, all infants received 2 mg oral Vitamin K after birth, then 1 mg orally weekly Since 2000, all infants received 2 mg IM at birth
� Danish regimens were more effective than the Dutch regimen at preventing VKDB in babies with gallbladder disease
Van Hasselt (2008). Pediatrics 121,e857.
What are reasons you’ve heard for declining Vitamin K?
A. It’s not natural B. It causes leukemia C. It’s full of toxins D. I eat a healthy diet E. My baby had a gentle birth F. My baby wasn’t circumcised G. My baby had delayed cord clamping
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Delayed cord clamping & gentle births � There is no evidence to support these claims � Delayed cord clamping raises iron levels, but cord
blood has very low levels of Vitamin K1 (less than 0.05 mcg/liter)
� Vitamin K1 is stored in liver, not bloodstream � This is why delayed cord clamping can improve
iron levels, but not Vitamin K levels � A “gentle” birth should not impact late VKDB
which can happen weeks or months later
Shearer, M. J. (2009). Blood Rev 23(2): 49-59.
Take-away point on supplements � In studies on maternal supplements, infants
received BOTH Vitamin K supplements and maternal supplements
� Would not be ethical to randomly assign an infant to a NO vitamin K group
� Postpartum supplementation, when combined with infant Vitamin K administration, is very effective at raising infant levels
� However, no studies on actual bleeding rates (b/c would require huge sample sizes)
Nishiguchi, T.,et al. (1996). Br J Obstet Gynaecol 103(11): 1078-1084.
Greer et al. (1997). Pediatrics 99(1): 88-92.
Who knows? � As early as the 1800s we know that babies died
from Vitamin K deficiency � Nothing in life is perfect! � Evolutionary continuum—survival of the fittest
means some will not survive � Infants’ clotting systems (like nervous and immune
systems) need time to develop and come into full strength
� Not always an answer to ‘why’ questions about evolution
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Hepatitis B (HBV) � Transmission
Infected blood (needles) Sexual transmission Mother-baby (90% chance if mom is +) Father-baby (65% chance if dad is +) Saliva (kisses, bites, sharing utensils) Lives on dry surface for 7 days
� Symptoms Clinical course varies from no symptoms (some are “carriers”) to complete liver failure/cancer 15-25% mortality rate in infants
Eradicating HBV
Long-term Immunity
� 76 high-risk infants in Thailand born to moms with HAV and HBV
� Received 4 doses of vaccine in infancy, plus one dose of immunoglobulins
� Twenty years later found 36 of the children: 64% very high levels of antibodies
92% had detectable levels of antibodies
Poovorawan et al. (2013). Hum Vaccin Immunother 9(8): 1679-1684.
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Systematic Review
� 46 studies measuring antibodies 5-20 years after HBV immunization
� Took into account mother’s status, dosage, and lag time between doses
� 90% of children have antibodies 17 years after being born to non-infected mothers
Schonberger et al. (2013). Pediatr Infect Dis J 32(4): 307-13.
What I still plan to cover:
� Risks/side effects of the vaccine � Separating myths from fact � How vaccines work in the body � Pros/cons of delaying the HBV vaccine
In Summary � The “golden hour” should be a time focused
on the parent-baby relationship � Instead we have many procedures that take
precedence-- none of which MUST be done in the first hour
� Birth professionals can play a role in educating families and health workers, and creating “space” for bonding and breastfeeding