A renewed interest in the first minutes, hours, and days of life has been stimulated by several provocative behavioral and physiologic observations in both mother and infant. These assessments and measurements have been made during labor, birth, the immediate postnatal period, and the beginning breast feedings. They provide a compelling rationale for major changes in care in the perinatal period for both mother and infant. Surprisingly, these findings form a novel way to view the mother-infant dyad.
To understand how these observations fit together, it is necessary to appreciate that the period of labor, birth, and the ensuing several days can probably best be defined as a “sensitive period.” During this time, the mother and probably, the father, are especially open to changing their later behavior with their infant depending on the quality of their care during the sensitive period.
Winnicott also described this period. He reported a special mental state of the mother in the perinatal period that involves a greatly increased sensitivity to, and focus upon, the needs of her baby. He indicated that this state of “primary maternal preoccupation” starts near the end of pregnancy and continues for a few weeks after the birth of the baby. A mother needs nurturing support and a protected environment to develop and maintain this state. This special preoccupation and the openness of the mother to her baby is probably related to the bonding process. Winnicott wrote that “Only if a mother is sensitized in the way I am describing, can she feel herself into her infant’s place, and so meet the infant’s needs.” In the state of “primary maternal preoccupation,” the mother is better able to sense and provide what her new infant has signaled, which is her primary task. If she senses the needs and responds to them in a sensitive and timely manner, mother and infant will establish a pattern of synchronized and mutually rewarding interactions. It is our hypothesis that as the mother-infant pair continues this dance pattern day after day, the infant will more frequently develop a secure attachment, with the ability to be reassured by well-known caregivers and the willingness to explore and master the environment when caregivers are present.
This chapter describes studies of the process by which a parent becomes attached to the infant, and the physiologic and behavioral components in the newborn, and suggests applications of these findings to the care of the parents of a normal infant, a premature or malformed infant, and a stillbirth or neonatal death.
Pregnancy
A mother’s and father’s actions and responses toward their infant are derived from a complex combination of their own genetic endowment, the way the infant responds to them, a long history of interpersonal relations with their own families and with each other, past experiences with this or previous pregnancies, the absorption of the practices and values of their cultures, and probably most importantly, how each was raised by his or her own mother and father. The parenting behavior of each woman and man, his or her ability to tolerate stresses, and his or her need for special attention differ greatly and depend on a mixture of these factors. Figure 8-1 is a schematic diagram of the major influences on paternal and maternal behavior and the resulting disturbances that we hypothesize may arise from them.
Included under parental background are the parent’s care by his or her own mother, genetics of parents, practices of their culture, relationships within the family, experiences with previous pregnancies, and planning, course, and events during pregnancy. Strong evidence for the importance of the effect of the mother’s own mothering on her caretaking comes from an elegant 35-year study by Engel et al. that documented the close correspondence between how Monica (an infant with a tracheoesophageal fistula) was fed during the first 2 years of life, how she then cared for her dolls, and how as an adult she fed her own four children.
Included under care practices are the behavior of physicians, nurses, and hospital personnel, care and support during labor, first days of life, separation of mother and infant, and rules of the hospital.
Included under parenting disorders are the vulnerable child syndrome, child abuse, failure to thrive, and some developmental and emotional problems in high-risk infants. Other determinants—such as the attitudes, statements, and practices of the nurses and physicians in the hospital, whether the mother is alone for short periods during her labor, whether there is separation from the infant in the first days of life, the nature of the infant, his or her temperament, and whether he or she is healthy, sick, or malformed—will affect parenting behavior and the parent-child relationship.
The most easily manipulated variables in this scheme are the separation of the infant from the mother and the practices in the hospital during the first hours and days of life. It is here, during this period, that studies have in part clarified some of the steps in parent-infant attachment. A diversity of observations are beginning to piece together some of the various phases and times that are helpful for this process ( Box 8-1 ). Pregnancy for a woman has been considered a process of maturation, with a series of adaptive tasks, each dependent on the successful completion of the preceding one.
Before pregnancy
Planning the pregnancy
During pregnancy
Confirming the pregnancy
Accepting the pregnancy
Experiencing fetal movement
Beginning to accept the fetus as an individual
Labor
Birth
After birth
Touching and smelling
Seeing the baby
Breast feeding
Caring for the baby
Accepting the infant as a separate individual
Many mothers are initially disturbed by feelings of grief and anger when they become pregnant, because of factors ranging from economic and housing hardships to interpersonal difficulties. However, by the end of the first trimester, the majority of women who initially rejected pregnancy have accepted it. This initial stage as outlined by Bibring is the mother’s identification of the growing fetus as an “integral part of herself.”
The second stage is a growing perception of the fetus as a separate individual, usually occurring with the awareness of fetal movement. After quickening, a woman generally begins to have some fantasies about what the baby may be like; she attributes some human personality characteristics, and develops a sense of attachment and value toward the baby. At this time, further acceptance of the pregnancy and marked changes in attitude toward the fetus may be observed; unplanned, unwanted infants may seem more acceptable. Objectively, the health worker usually finds some outward evidence of the mother’s preparation in such actions as the purchase of clothes or a crib, selecting a name, and arranging space for the baby.
The increased use of amniocentesis and ultrasound has appeared to affect parents’ perceptions of babies in a rather unexpected fashion. Many parents have discussed the disappointment they experienced when they discovered the sex of the baby. Half of the mystery was over. Everything was possible, but once the amniocentesis was done and the sex of the baby known, the range of the unknown was considerably narrowed. However, the tests have the beneficial result of removing some of the anxiety about the possibility of the baby having an abnormality. We have noted that, following the procedure, the baby is sometimes named, and parents often carry around a picture of the very small fetus. This phenomenon requires further investigation to understand the significance of these reactions to the bonding process.
Cohen suggests the following questions to learn the special needs of each mother :
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How long have you lived in this immediate area, and where does most of your family live?
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How often do you see your mother or other close relatives?
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Has anything happened to you in the past (or do you currently have any condition) that causes you to worry about the pregnancy or the baby?
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What was the father’s reaction to your becoming pregnant?
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What other responsibilities do you have outside the family?
When planning to meet the needs of the mother, it is important to inquire about how the pregnant woman was mothered—did she have a neglected and deprived infancy and childhood or grow up with a warm and intact family life?
Labor and Delivery
Newton and Newton noted that those mothers who remain relaxed in labor, who are supported, and who have good rapport with their attendants, are more apt to be pleased with their infants at first sight.
A recent Cochrane review looked at the importance of continuous support for women during childbirth. Looking at 21 trials involving 15,061 mothers, the results showed that women who had continuous social support during labor and birth had labors that were significantly shorter, were more likely to have a spontaneous vaginal birth, and less likely to have intrapartum analgesia. They also were less likely to have a cesarean section or instrumented vaginal birth, regional anesthesia, or a baby with a low 5-minute Apgar score. This low-cost intervention may be a simple way to reduce the length of labor and perinatal problems for women and their infants during childbirth.
Effects of Social and Emotional Support on Maternal Behavior
This short, but highly significant time in a woman’s life, has been explored in depth because the care during labor appears to affect a mother’s attitudes, feelings, and responses to her family, herself, and especially her new baby to a remarkable degree. In a well-conducted trial of continuous social support in South Africa, both mothers with and without doula support were interviewed immediately after delivery and 6 weeks later. Women who had doula support during labor had significantly increased self-esteem, believed they had coped well with labor, and thought the labor had been easier than they had imagined. Women who received this support reported being less anxious 24 hours after birth compared with mothers without a doula. Doula-supported mothers were significantly less depressed 6 weeks postpartum, as measured on a standard depression scale, than mothers who had no doula. Also, doula-supported mothers had a significantly greater incidence of breast feeding without supplements (52% versus 29%), and they breast fed for a longer period.
The supported mothers said it took them an average of 2.9 days to develop a relationship with their babies compared with 9.8 days for the nonsupported mothers. This feeling of attachment and readiness to fall in love with their babies made them less willing to leave their babies alone. They also reported picking up their babies more frequently when they cried than did nonsupported mothers. The doula-supported mothers were more positive in describing the special attributes of their babies than were the nonsupported mothers. A higher percentage of supported mothers not only considered their babies beautiful, clever, healthy, and easy to manage, but also believed their infants cried less than other babies. The supported mothers believed that their babies were “better” when compared with a “standard baby,” whereas the nonsupported mothers perceived their babies as “almost as good as” or “not quite as good as” a “standard baby.” “Support group mothers also perceived themselves as closer to their babies, as managing better, and as communicating better with their babies than control-group mothers did,” the study reported. A higher percentage of the doula-supported mothers indicated that they were pleased to have their babies, found becoming a mother was easier than expected, and thought that they could look after their babies better than any other person could. In contrast, the nonsupported mothers perceived their adaptation to motherhood as more difficult and believed that others could care for their baby as well as they could.
A most important aspect of emotional support during childbirth may be the most unexpected internalized one—that of the calm, nurturing, accepting, and holding model provided for the parents by the doula during labor. Maternal care needs modeling; each generation is influenced from the care received by the earlier one. Social support appears to be an essential ingredient of childbirth that was lost when birthing moved from home to hospital.
The Day of Delivery
Mothers after delivery appear to have common patterns of behavior when they begin to care for their babies in the first hour of life. Filmed observations reveal that when a mother is presented with her nude, full-term infant in privacy, she begins with fingertip touching of the infant’s extremities and within a few minutes proceeds to massaging, encompassing palm contact of the infant’s trunk. Mothers of premature infants also follow this sequence, but proceed at a much slower rate. Fathers go through some of the same routines.
A strong interest in eye-to-eye contact has been expressed by mothers of both full-term and premature infants. Tape recordings of the words of mothers who had been presented with their infants in privacy revealed that 73% of the statements referred to the eyes. The mothers said, “Let me see your eyes” and “Open your eyes and I’ll know you love me.” Robson has suggested that eye-to-eye contact appears to elicit maternal caregiving responses. Mothers seem to try hard to look “en face” at their infants—that is, to keep their faces aligned with their baby’s so that their eyes are in the same vertical plane of rotation as the baby’s. Complementing the mother’s interest in the infant’s eyes is the early functional development of the infant’s visual pathways. The infant is alert, active, and able to follow during the first hour of life if maternal sedation has been limited and the administration of eye drops or ointment is delayed.
Additional information about this early period was provided by Wolff, who described six separate states of consciousness in the infant, ranging from deep sleep to screaming. The state in which we are most interested is state 4, the quiet, alert state. In this state, the infant’s eyes are wide open, and he or she able to respond to his or her environment. The infant may only be in this state for periods as brief as a few seconds. However, Emde et al. observed that the infant is in a wakeful state on the average for a period of 38 minutes during the first hour after birth. It is currently possible to demonstrate that an infant can see, has visual preferences, has a memory for the mother’s face at 4 hours of age, will turn his or her head to the spoken word, and moves in rhythm to the mother’s voice in the first minutes and hours of life—a beautiful linking and synchronized dance between the mother and infant. After this, however, the infant goes into a deep sleep for 3 to 4 hours.
Therefore, during the first 60 to 90 minutes of life, the infant is alert, responsive, and especially appealing. In short, the infant is ideally equipped to meet his or her parents for the first time. The infant’s broad array of sensory and motor abilities evokes responses from the mother and begins the communication that may be especially helpful for attachment and the initiation of a series of reciprocal interactions.
Observations by Condon and Sander reveal that newborns move in rhythm with the structure of adult speech. Interestingly, synchronous movements were found at 16 hours of age with both of the two natural languages tested, English and Chinese.
Mothers also quickly become aware of their infant. Kaitz et al. demonstrated that after only 1 hour with their infants in the first hours of life, mothers are able to discriminate their own baby from other infants. Parturient women know their infant’s distinctive features after minimal exposure using olfactory and tactile cues (touching the dorsum of the hand), whereas discrimination based on sight and sound takes somewhat longer to develop. Fathers are good at quickly recognizing their newborn through visual-facial cues, though not quite as good as mothers at recognizing olfactory cues.
When Does Love Begin?
The first feelings of love for the infant are not necessarily instantaneous with the initial contact.
MacFarlane et al. helped to answer this question by asking 97 mothers, “When did you first feel love for your baby?” The replies were as follows: during pregnancy—41%; at birth—24%; first week—27%; and after the first week—8%.
In another study of two groups of primiparous mothers ( n = 112 and n = 41), 40% recalled that their predominant emotional reaction when holding their babies for the first time was one of indifference. The same response was reported by 25% of 40 multiparous mothers. In both groups, 40% felt immediate affection.
Care of the Normal Infant and Parents Following Birth
After birth, the newborn should be thoroughly dried with warm towels so as not to lose heat, and once it is clear that he has good color and is active and appears normal (usually within 5 minutes), he can go to his mother. At this time, the warm and dry infant can be placed between the mother’s breasts or on her abdomen or, if she desires, next to her. The new NRP guidelines emphasize that babies who do not need resuscitation should not be separated from their mother.
When newborns are kept close to their mother’s body or on their mother, the transition from life in the womb to existence outside the uterus is made much easier for them. The newborn recognizes his mother’s voice and smell, and her body warms his to just the right temperature. In this way, the infant can experience sensations somewhat similar to what he felt during the last several weeks of uterine life.
In the past, many caretakers believed that the newborn needs help to begin to nurse. So often, immediately after birth, the baby’s lips are placed near or on the mother’s nipple. In that situation, some babies do start to suckle, but most babies just lick the nipple or peer up at the mother. They appear to be much more interested in the mother’s face, especially her eyes, even though the nipple is right next to their lips. They most commonly begin, when left on their own, to move toward the breast 30 to 40 minutes after birth.
The Breast Crawl
One of the most exciting observations made is the discovery that the newborn has the ability to find her mother’s breast all on her own and to decide for herself when to take her first feeding. In order not to remove the taste and smell of the mother’s amniotic fluid, it is necessary to delay washing the baby’s hands. The baby uses the taste and smell of amniotic fluid on her hands to make a connection with a certain lipid substance on the nipple related to the amniotic fluid.
The infant usually begins with a time of rest and quiet alertness, during which he rarely cries and often appears to take pleasure in looking at his mother’s face. Around 30 to 40 minutes after birth, the newborn begins making mouthing movements, sometimes with lip smacking, and shortly after, saliva begins to pour down onto his chin. When placed on the mother’s abdomen, babies maneuver in their own ways to reach the nipple. They often use stepping motions of their legs to move ahead, while horizontally moving toward the nipple, using small push-ups and lowering one arm first in the direction they wish to go. These efforts are interspersed with short rest periods. Sometimes babies change direction in the midst of their journey. These actions take effort and time. Parents find patience worth every minute if they wait and observe their infant on his first journey.
In Figure 8-2 , one newborn is seen successfully navigating his way to his mother’s breast. At 10 minutes of age, he first begins to move toward the left breast, but 5 minutes later, he is back in the midline. Repeated mouthing and sucking of the hands and fingers is commonly observed. With a series of push-ups and rest periods, he makes his way to the breast completely on his own, placing his lips on the areola of the breast. He begins to suckle effectively and closely observes his mother’s face.
In one group of mothers who did not receive pain medication and whose babies were not taken away during the first hours of life for a bath, vitamin K administration, or application of eye ointment, 15 of 16 babies placed on their mother’s abdomen were observed to make the trip to their mother’s breast, latch on their own, and begin to suckle effectively.
This sequence is helpful to the mother as well, because the massage of the breast and suckling induce a large oxytocin surge into her bloodstream, which helps contract the uterus, expelling the placenta and closing off many blood vessels in the uterus, thus reducing bleeding. The stimulation and suckling also helps in the manufacture of prolactin, and the suckling enhances the closeness and new bond between mother and baby. Mother and baby appear to be carefully adapted for these first moments together.
To allow this first intimate encounter, the injection of vitamin K, application of eye ointment, washing, and any measuring of the infant’s weight, height, and head circumference may be delayed for at least 1 hour. More than 90% of all full-term infants are normal at birth. In a few minutes, they can be easily evaluated to ensure that they are healthy. They can then, after thorough drying, be safely placed on their mother’s chest if the parents wish.
The odor of the nipple appears to guide a newborn to the breast. If the right breast is washed with soap and water, the infant will crawl to the left breast, and vice versa. If both breasts are washed, the infant will go to the breast that has been rubbed with the amniotic fluid of the mother. The special attraction of the newborn to the odor of his mother’s amniotic fluid may reflect the time in utero when, as a fetus, he swallowed the liquid. Although it is not breast milk, amniotic fluid probably contains a substance that is similar to a secretion of the breast. Amniotic fluid on the infant’s hands probably also explains part of the interest in sucking the hands and fingers seen in the photographs. This early hand-sucking behavior is markedly reduced when the infant is bathed before the crawl. With all these innate programs, it almost seems as if the infant comes into life carrying a small computer chip with these instructions.
At a moment such as childbirth, we come full circle to our biological origins. Many separate abilities enable a baby to do this. Stepping reflexes help the newborn push against his mother’s abdomen to propel him toward the breast. Pressure of the infant’s feet on the abdomen may also help in the expulsion of the placenta and in reducing uterine bleeding. The ability to move his hand in a reaching motion enables the baby to claim the nipple. Taste, smell, and vision all help the newborn detect and find the breast. Muscular strength in the neck, shoulders, and arms helps newborns to bob their heads and do small push-ups to inch forward and side to side. This whole scenario may take place in a matter of minutes; it usually occurs within 30 to 60 minutes, but it is within the capacity of the newborn. It appears that young humans, like other baby mammals, know how to find their mother’s breast.
When the mother and infant are resting skin-to-skin and gazing eye-to-eye, they begin to learn about each other on many different levels. For the mother, the first minutes and hours after birth are a time when she is uniquely open emotionally to respond to her baby and to begin the new relationship.
A sensitive period?
Many studies have focused on whether additional time for close contact of the mother and infant alters the quality of attachment. These studies have addressed the question of whether there is a sensitive period for parent-infant contact in the first minutes, hours, and days of life that may alter the parents’ later behavior with their infant. In many biological disciplines, these moments have been called sensitive periods. However, in most of the examples of a sensitive period in biology, the observations are made on the young of the species rather than on the adult. Evidence for a sensitive period comes from the following series of studies. Note that in each study, increasing mother-infant time together or increased suckling improves caretaking by the mother.
In six of nine randomized trials of only early contact with suckling (during the first hour of life), both the number of women breast feeding and the length of their lactation were significantly increased for early contact mothers compared with women in the control group.
In addition, studies of Brazelton and others have shown that if nurses spend as little as 10 minutes helping mothers discover some of their newborn infant’s abilities, such as turning to the mother’s voice and following the mother’s face, and assisting mothers with suggestions about ways to quiet their infants, the mothers become more appropriately interactive with their infants face-to-face and during feedings at 3 and 4 months of age.
O’Connor et al. carried out a randomized trial with 277 mothers in a hospital that had a high incidence of parenting disorders. One group of mothers had their infants with them for 6 additional hours on the first and second day, but no early contact. The routine care group began to see their babies at the same age but only for 20-minute feedings every 4 hours, which was the custom throughout the United States at that time. In follow-up studies, 10 children in the routine care group experienced parenting disorders, including child abuse, failure to thrive, abandonment, and neglect during the first 17 months of life compared with two children in the experimental group who had 12 additional hours of mother-infant contact. A similar study in North Carolina that included 202 mothers during the first year of life did not find a statistically significant difference in the frequency of parenting disorders ; 10 infants failed to thrive or were neglected or abused in the control group compared with seven in the group that had extended contact. When the results of these two studies are combined in a metaanalysis ( P = .054), it appears that simple techniques, such as adding additional early time for each mother and infant to be together and continuous rooming-in, may lead to a significant reduction in child abuse. A much larger study is necessary to confirm and validate these relatively small studies.
Swedish researchers have shown that the normal infant, when dried and placed nude on the mother’s chest and then covered with a blanket, will maintain his or her body temperature as well as when elaborate, high-tech heating devices that usually separate the mother and baby are used. The same researchers found that when the infants are skin-to-skin with their mothers for the first 90 minutes after birth, they cry hardly at all compared with infants who were dried, wrapped in a towel, and placed in a bassinet. It is likely that each of these features—the crawling ability of the infant, the decreased crying when close to the mother, and the warming capabilities of the mother’s chest—are adaptive features that have evolved to help preserve the infant’s life.
When the infant suckles from the breast, it stimulates the production of oxytocin in both the mother’s and the infant’s brains, and oxytocin in turn stimulates the vagal motor nucleus, releasing 19 different gastrointestinal hormones, including insulin, cholecystokinin, and gastrin. Five of the 19 hormones stimulate growth of the baby’s and mother’s intestinal villi and increase the surface area and the absorption of calories with each feeding. Stimuli for this release are touch on the mother’s nipple and the inside of the infant’s mouth. The increased gut motility with each suckling may help remove meconium with its large load of bilirubin.
These research findings may explain some of the underlying physiologic and behavioral processes and provide additional support for the importance of 2 of the 10 caregiving procedures that the United Nations International Children’s Emergency Fund (UNICEF) is promoting as part of its Baby Friendly Initiative to increase breast feeding: (1) early mother-infant contact, with an opportunity for the baby to suckle in the first hour, and (2) mother-infant rooming-in throughout the hospital stay.
Following the introduction of the Baby Friendly Initiative in maternity units in several countries throughout the world, an unexpected observation was made. In Thailand, in a hospital where a disturbing number of babies are abandoned by their mothers, the use of rooming-in and early contact with suckling significantly reduced the frequency of abandonment from 33 in 10,000 births to 1 in 10,000 births a year. Similar observations have been made in Russia, the Philippines, and Costa Rica, where early contact and rooming-in were also introduced.
These reports are additional evidence that the first hours and days of life are a sensitive period for the human mother. This may be due in part to the special interest that mothers have shortly after birth in hoping that their infant will look at them and to the infant’s ability to interact in the first hour of life during the prolonged period of the quiet alert state. There is a beautiful interlocking at this early time of the mother’s interest in the infant’s eyes and the baby’s ability to interact and to look eye-to-eye.
A possible key to understanding what is happening physiologically in these first minutes and hours comes from investigators who noted that, if the lips of the infant touch the mother’s nipple in the first hour of life, a mother will decide to keep her baby 100 minutes longer in her room every day during her hospital stay than another mother who does not have contact until later. This may be partly explained by the small secretions of oxytocin (the “love hormone”) that occur in both the infant’s and mother’s brains when breast feeding occurs. In sheep, dilation of the cervical os during birth releases oxytocin within the brain which, acting on receptor sites, is important for the initiation of maternal behavior and for the facilitation of bonding between mother and baby. In humans, there is a blood-brain barrier for oxytocin, and only small amounts reach the brain via the bloodstream. However, multiple oxytocin receptors in the brain are supplied by de novo oxytocin synthesis in the brain. Increased levels of brain oxytocin result in slight sleepiness, euphoria, increased pain threshold, and feelings of increased love for the infant. It appears that, during breast feeding, elevated blood levels of oxytocin are associated with increased brain levels; women who exhibit the highest plasma oxytocin concentration are the most sleepy.
Measurements of plasma oxytocin levels in healthy women who had their babies skin-to-skin on their chests immediately after birth reveal significant elevations compared with the prepartum levels and a return to prepartum levels at 60 minutes. For most women, a significant and spontaneous peak concentration was recorded about 15 minutes after delivery, with expulsion of the placenta. Most mothers had several peaks of oxytocin up to 1 hour after delivery. The vigorous oxytocin release after delivery and with breast feeding not only may help contract the uterine muscle to prevent bleeding, but may also enhance bonding of the mother to her infant. These findings may explain an observation made in France in the 19th century when many poor mothers were giving up their babies. Nurses recorded that mothers who breast fed for at least 8 days rarely abandoned their infants. We hypothesize that a cascade of interactions between the mother and baby occurs during this early period, locking them together and ensuring further development of attachment. The remarkable change in maternal behavior with just the touch of the infant’s lips on the mother’s nipple, the effects of additional time for mother-infant contact, and the reduction in abandonment with early contact, suckling, and rooming-in, as well as the elevated maternal oxytocin levels shortly after birth in conjunction with known sensory, physiologic, immunologic, and behavioral mechanisms all contribute to the attachment of the parent to the infant.
Early and Extended Contact for Parents and their Infant
Although debate continues on the interpretation and significance of some of the research studies regarding the effects of early and extended contact for mothers and fathers on bonding with their infants, both sides agree that all parents should be offered such contact time with their infants. A recent Cochrane Review looked at 30 studies involving 1925 participants (mother-infant dyads) and concluded that early skin-to-skin contact for mothers and their healthy newborns reduced crying, improved mother-baby interaction, kept the baby warmer, and helped women to breast feed successfully.
On the basis of observations and the reports of parents, every parent has a task to perform during the postpartum period. The mother, in particular, must look at and “take in” her real live baby and then reconcile the fantasy of the infant she imagined with the one she actually delivered.
Evidence suggests that many of these early interactions also take place between the father and his newborn child. Parke has demonstrated that when fathers are given the opportunity to be alone with their newborns, they spend almost exactly the same amount of time as mothers in holding, touching, and looking at them.
How strongly should physicians and nurses emphasize the importance of parent-infant contact in the first hour and extended visiting for the rest of the hospital stay? Despite a lack of early contact experienced by many parents in hospital births in the past, almost all these parents became bonded to their babies. The human is highly adaptable, and there are many fail-safe routes to attachment. Parents who miss the bonding experience can be assured that their future relationship with their infant can still develop as usual. Mothers who miss out on early and extended contact are often those at the limits of adaptability and who may benefit the most—the poor, the single, the unsupported, and the teenage mothers.
At least 60 minutes of early contact in privacy should be provided, if possible, for parents and their infant to enhance the bonding experience. If the health of the mother or infant makes this impossible, then discussion, support, and reassurance should help the parents appreciate that they can become as completely attached to their infant as if they had the usual bonding experience. The infant should only be with the mother and father if she is known to be physically normal and if appropriate temperature control is used. The baby should remain with the mother as long as desired throughout the hospital stay so that the mother and the baby can get to know each other. This permits both mother and father more time to learn about their baby and to gradually develop a strong tie in the first weeks of life.
From these many findings are the following recommendations for changing the perinatal period for mother and infant.
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Every mother should have continuous physical and emotional support during the entire labor by a knowledgeable, caring woman (e.g., doula, obstetric nurse, or midwife) in addition to her partner.
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Childbirth educators and obstetric caregivers should discuss with every pregnant woman the advantages of an unmedicated labor to avoid interference with the infant’s ability to interact, self-attach, and successfully breast feed.
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Immediately after birth and a thorough drying, an infant who has good Apgar scores and appears normal should be offered to the mother for skin-to-skin contact, with warmth provided by her body and a light blanket covering the baby. The baby should not be removed for a bath, footprinting, or administration of vitamin K or eye medication until after the first hour. The baby thus can be allowed to decide when to begin his first feeding.
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The central nursery should be used infrequently. All babies should room-in with their mothers throughout the short hospital course unless this is prevented by illness of mother or infant.
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Early and continuous mother-infant contact appears to decrease the incidence of abandonment and increase the length and success of breast feeding. All mothers should begin breast feeding in the first hour, nurse frequently, and be encouraged to breast feed for at least the first 2 weeks of life, even if they plan to return to work. Early, frequent breast feeding has many advantages, including earlier removal of bilirubin from the gut as well as aiding in mother-infant attachment.
The Sick or Premature Infant
Although parental visiting has been permitted in the intensive care nursery, a number of studies have revealed that most parents continue to suffer severe emotional stress. Harper et al. noted that, even when parents have close contact with their infants in the intensive care nursery, they experience prolonged stress.
Newman described “coping through commitment” as an intense yet variable involvement in the care of a low-birth-weight infant. In contrast, “coping through distance” was a slower acquaintance process in which the parents expressed fear, anxiety, and at times denial before they accepted the surviving infant.
Highly interacting mothers visit and telephone the nursery more frequently while the infants are hospitalized and stimulate their infants more at home. Mothers who stimulate their infants very little in the nursery also visit and telephone less frequently and provide only minimal stimulation to them at home. Most perceptively, Minde et al. noted that mothers who touched and fondled their infants more in the nursery had infants who opened their eyes more often. He and his associates observed the contingency between the infant’s eyes being open and the mother’s touching and between gross motor stretches and the mother’s smiling. They could not determine to what extent the sequence of touching and eye opening was an indication of the mother’s primary contribution or whether it was initiated by the infant. Thus, Newman and Minde et al. predict that mothers who become involved with, interested in, and anxious about their infants in the intensive care nursery will have an easier time when the infant is taken home.
Field has demonstrated the close connection between what a mother does and her infant’s arousal level. Whereas most mothers of full-term babies adopt a moderate level of activity that is associated with optimal arousal in their babies, some mothers of “preemies” either overreact or under-react. Field found that mothers of premature infants who were overreactive during early face-to-face interactions were more likely to be overprotective and over-controlling during interactions with their infants 2 years later.
Recent studies have found an alarmingly high rate of psychologic pathology and traumatic stress in parents of infants in the NICU. Lefkowitz et al. had 86 mothers and 41 fathers complete measures of acute stress disorder (ASD) and found that 3 to 5 days after the infant’s NICU admission, 35% of mothers and 24% of fathers met diagnostic criteria for acute stress disorder. Additionally, 30 days later, 15% of mothers and 8% of fathers actually met diagnostic criteria for posttraumatic stress disorder. In some units, a psychiatrist is available to regularly meet with parents who wish to speak with him/her; this is an extremely helpful and necessary program.
Interventions for Families of Premature Infants
Transporting the Mother to be Near her Small Infant
With the development of high-risk perinatal centers, an increasing number of mothers are transported to the maternity division of hospitals with a neonatal intensive care nursery just before delivery or shortly after. If there is not sufficient time to arrange for her transport before she gives birth, it is strongly recommended that the mother be moved as soon as possible.
Rooming-in for the Parent of a Premature Infant
When Tafari and Ross in Ethiopia permitted mothers to live within their crowded premature unit 24 hours each day, they were able to care for three times as many infants in their premature nursery, and at the end of 1 year, the number of surviving infants had increased 500%. Mother-infant pairs were discharged when the infants weighed an average of 1.7 kg, and most infants were breast fed. Before this, most of the infants had gone home and were bottle fed, and usually died of intercurrent respiratory and gastrointestinal infections. When the cost of prepared milk amounts to a high proportion of the parents’ weekly income, policies in support of the mother rooming-in and breast feeding in premature nurseries have a direct impact on infant mortality. In several other countries throughout the world, including Argentina, Brazil, Estonia, and South Africa, mothers of premature infants live in a room adjoining the premature nursery or they room in. This arrangement appears to have multiple benefits. It allows the mother to continue producing milk, permits her to take on the care of the infant more easily, greatly reduces the caregiving time required of the staff for these infants, and allows a group of mothers of premature infants to talk over their situation and gain from discussion and mutual support. This procedure is probably appropriate for 50% of the world.
Torres, in a special care unit in the slums of Santiago, Chile, achieved excellent, low perinatal mortality and morbidity rates by placing special care units for low-birth-weight infants in the maternity unit, thus maintaining babies under professional observation for only as long as necessary.
Technological improvements and the resulting ability to continuously monitor sick premature infants even from a distance has allowed single-room neonatal intensive care units (NICUs) to become a reality, and parents are encouraged to room-in with their babies in the NICU.
Nesting
In the United States, James and Wheeler first described the successful introduction of a care-by-parent unit to provide a homelike caretaking experience. Parents of premature infants received nursing support before discharge.
For several years “nesting” has been studied—namely, permitting mothers to live in with their infants before discharge. When babies reached 1.72 to 2.11 kg, each mother was given a private room with her baby where she provided all caregiving. Impressive changes in the behavior of these women were observed clinically. Even though the mothers had fed and cared for their infants in the intensive care nursery on many occasions before living-in, eight of the first nine mothers did not sleep during the first 24 hours so they could learn more about their infant’s behavior. However, in the second 24-hour period, the mothers’ confidence and caretaking skills improved greatly. At this time, mothers began to discuss the proposed early discharge of their infants and, often for the first time, began to make preparations at home for their arrival. Several mothers insisted on taking their babies home earlier than planned.
Early discharge, preceded by a period of isolation of the mother and infant, may help to normalize mothering behavior in the intensive care nursery. Encouraging the increasing possibilities for mother-infant interaction and total caretaking may reduce the incidence of mothering disorders among mothers of small or sick premature infants.
Parent Groups
A number of NICUs have formed groups of parents of premature infants who meet once each week or more often for 1- to 2-hour discussions. Documented clinical reports from these centers suggest that parents find support and considerable relief in being able to talk with each other and to express and compare their inner feelings.
Minde et al. in a controlled study of a self-help group, reported that parents who participated in the group visited their infants in the hospital significantly more often than did parents in the control group. The self-help parents also touched, talked, and looked at their infants more in the en face position and rated themselves as more competent than the control group on infant care measures. The mothers in the group continued to show more involvement with their babies during feedings and were more concerned about their general development 3 months after their discharge from the nursery.
Kangaroo Baby Care
Allowing a mother to hold the infant skin-to-skin for prolonged periods in the hospital is known as kangaroo care and it has salutary effects ( Fig. 8-3 ). Several trials have noted that, if the usual precautions are taken, such as hand washing, there is no increase in the infection rate or problems in oxygenation, apnea, or temperature control. A significant medical benefit appears to be a significant increase in the mother’s milk supply and success at nursing. A recent randomized controlled trial in Madagascar also found a significantly increased proportion of exclusive breast feeding at 6 months of age with earlier initiated continuous kangaroo mother care. Several studies noted that the mother’s own confidence in her caretaking improved along with an eagerness for discharge, and many women reported feeling an increased closeness to the infant compared with a control group of mothers. At the first skin-to-skin experience, the mother is usually tense, so it is best for the nurse to stay with her to answer questions and make any necessary adjustments in position and ensure that warmth is maintained. A few mothers find that one such experience is enough. However, most mothers find repeated kangaroo care experiences especially pleasurable. However, there is not adequate information to support discharge of appropriate-for-gestational-age (AGA) infants weighing less than 1700 g on solely kangaroo care without daily nursing visits.
