I want immediate skin-to-skin contact with my baby

In busy, modern labor and delivery units, the most important thing that has been lost to technology is an appreciation and respect for the blessed moment of welcoming new life into the world. In all the medical zeal and general angst that accompanies those first minutes after a baby is born, it is rare that the team slows down long enough to honor the moment and to allow space for the parents to experience and appreciate the first precious gaze of their new child. Parents are also guilty of rushing through the moment, often too busy worrying about getting a picture or notifying family to really take it in. But in truth, there is little that “needs” to be done in those first minutes. Weighing and footprints can wait. Babies are capable of coughing and sneezing in order to expel the fluid which nurses and doctors are so quick to suction. The cord can be left alone. Family in the waiting room or a few states away is capable of pacing in anticipation for a few minutes more. The first minutes that a parent spends with their child is a time which should be remembered and staff should count themselves privileged to witness it, not inconvenienced by the few extra minutes it takes to keep it sacred.

Skin-to-skin contact refers to the practice of placing the newly born, naked infant, directly to mother’s chest. The infant is placed “tummy to tummy” on the mother’s abdomen or chest, with only a warm blanket placed on top of the child. The mother’s body temperature maintains the baby’s body temperature at a thermoneutral range and the process of breastfeeding is initiated.¹ Any necessary infant care is performed on the mother’s chest, except in the event of a true emergency.

Until the twentieth century, skin-to-skin contact and limited separation of mother and child was the norm and essential for survival of the neonate in a time without formula or infant warmers. Immediate initiation of breastfeeding was also important for the mother, in order to facilitate uterine contraction post delivery and minimize uterine bleeding. However, as birth moved into the hospital and most mothers received significant amounts of anesthesia during their labors, separation became the standard. Infants were handed off to nursing staff immediately after delivery for initial resuscitation, followed by bathing, warming, and feeding. Mothers often did not see their children for several hours. It was felt that new mothers needed rest above all else and generally all infant care was performed by nurses in the hospital nursery for the mother’s entire hospital stay of up to a week.

This practice, however, is not natural by any definition of the word. Minimal separation of mothers and their young is observed across all mammalian species. The importance of skin-to-skin and keeping mothers and babies together was not really appreciated by the medical community; however, until the value of breastfeeding was accepted and ways to improve breastfeeding rates were explored. It is interesting that, for the medical community, skin-to-skin contact and minimal separation of women and their infants came to be considered the “intervention” to be studied, rather than the true intervention, that of removing the infant from the mother.

Nonetheless, there are several documented benefits of immediate skin-to-skin contact in the medical literature. In mammalian physiology, close contact between the mother and her baby is necessary in order to initiate the sequence of behaviors that lead to the first breastfeeding episode. Newborns have been observed to go through nine distinct behaviors during the initiation of breastfeeding²:

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  Birth cry

  
  
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  Relaxation

  
  
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  Awakening

  
  
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  Activity: looking at mother and breast, rooting, hand-to-mouth movements

  
  
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  Crawling: infant localizes the areola and nipple by smell and migrates toward it

  
  
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  Resting

  
  
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  Familiarization: touching and licking the nipple

  
  
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  Suckling

  
  
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  Sleeping

Separation of the mother and newborn interrupts this sequence and delays the initiation of breastfeeding. Even quickly taking the baby away for a few minutes to weigh, obtain footprints, and place identifying bands initiates a stress response that makes it less likely to achieve breastfeeding in that initial “golden hour” after birth. Babies, upon separation, will immediately offer a protest cry of distress and, while across the room from their mother, cry ten times more than babies on their mother’s chest.³ Maintenance of skin-to-skin and breastfeeding, through the release of oxytocin, lowers cortisol levels and the “fight or flight” response in both mothers and babies, making for calmer more confident mothers.^4,5 Early initiation of breastfeeding is shown to be associated with both higher breastfeeding rates upon leaving the hospital and higher rates of continued breastfeeding in the months that follow.^6,7 Other maternal benefits of skin-to-skin contact include less postpartum bleeding and anemia and quicker expulsion of the placenta.^8,9

The most recent Cochrane Review on the subject acknowledged these multiple benefits of skin-to-skin contact without finding any evidence of negative associations with the practice.¹⁰ The World Health Organization (WHO) and the United Nations Children’s Fund created the Baby Friendly Hospital Initiative in order to encourage breastfeeding friendly practices within hospitals and birthing centers worldwide. The organization offers the baby friendly designation to institutions that implement the “ten steps to successful breastfeeding,” one of which is helping mothers initiate breastfeeding within 1 hour and uninterrupted skin-to-skin contact is an essential part of that effort. These steps are promoted by all maternal and child health authorities including the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics, and the American College of Nurse-Midwives.¹¹

I decline post-delivery pitocin

During pregnancy, up to 40% of the maternal blood supply is directed to the uterus and the uterine vessels dilate in order to accommodate that increased blood flow. Immediately after delivery, the uterus suddenly has a lot of empty space and those enlarged vessels can quickly expel a great deal of blood unless the uterus rapidly contracts, thereby constricting the vessels and limiting vaginal bleeding. Post-delivery administration of pitocin is part of what is termed “active management” of the third stage of labor, which includes early cord clamping, traction on the umbilical cord to facilitate rapid placental delivery, and administration of pitocin to more efficiently and reliably contract the uterus. Postpartum hemorrhage is defined by the World Health Organization as a blood loss of more than 500 ml following delivery and complicates up to 4% of vaginal deliveries. Twenty percent of maternal deaths related to childbirth are a result of postpartum hemorrhage.^12,13 Postpartum hemorrhage is serious and can kill a woman within only a few hours.

A number of studies have been performed examining whether prophylactic pitocin administration, either immediately after delivery of the baby or delivery of the placenta, reduces the risk of a postpartum hemorrhage when compared to expectant management of the third stage of labor. Expectant management of the third stage is basically a hands-off approach where the cord is left uncut until it naturally ceases pulsating and the placenta spontaneously separates and is expressed from the uterus. While one aspect of expectant management of the third stage, delayed cord clamping, has not been shown to increase maternal blood loss, when it is compared to routine prophylactic pitocin augmentation, expectant management is associated with a greater risk of postpartum hemorrhage.¹⁴ In nine different trials, including over 9000 women, routine pitocin administration after delivery was shown to decrease overall blood loss and reduce the chance of a postpartum hemorrhage, including the risk of a severe postpartum hemorrhage of over 1 L.¹⁵ Pitocin was determined to be the most effective medication at reducing this risk and routine administration after delivery also decreased the need for any additional medications to contract the uterus.

While pitocin has a bad reputation, especially among mothers wishing to labor naturally, the objections to pitocin after delivery, when it no longer affects the labor process and cannot be transferred to the baby, are less numerous. Some mothers report anecdotally that their afterbirth cramping was worse with pitocin. Some worry that synthetic oxytocin will interfere with breastfeeding efforts, though no study to date has shown this and pitocin has such a short half-life that, in theory, this should not be a concern. Other women simply feel they would rather take a “wait and see” approach, especially if they have just gone through an entire labor without receiving medications. They often do not want medications after delivery unless truly needed. However, a “wait and see” approach is actually just treatment of uterine atony and bleeding if it occurs, which is associated with higher blood losses and greater incidences of true hemorrhage. Ultimately, given the high frequency of hemorrhage and the rapid pace at which it can become life threatening, this is a situation where the intervention is likely the lesser of the evils. Certainly, the evidence supports that conclusion. That said, women are entitled to take their chances if they are strongly opposed to this preventative measure, but they should understand the difference between intrapartum pitocin and postpartum pitocin and the potential benefits of the treatment. Women choosing to forego routine postpartum pitocin should also be aware of the conditions that may increase their risk of a postpartum hemorrhage and they may wish to reconsider their decision if they have any of the following¹⁶:

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  Maternal age >40

  
  
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  Large baby

  
  
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  Prolonged labor and/or instrumental delivery

  
  
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  Labor induction or augmentation

  
  
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  High maternal BMI

  
  
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  Multiple gestation

  
  
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  Preeclampsia, hypertension

  
  
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  History of a previous postpartum hemorrhage

I decline eye ointment for my baby

In the United States, it is considered standard of care to apply erythromycin eye ointment to all newborns shortly after delivery, as prophylactic treatment for neonatal ophthalmia, conjunctivitis occurring within the first 30 days of life. Neonatal ophthalmia can be caused by a number of organisms, including Neisseria gonorrhoeae (<1% of US cases), Chlamydia trachomatis (2–40% of US cases), and other bacteria such as Staphylococcus, Streptococcus, Haemophilus, and other Gram-negative bacterial species (20–50% of US cases). It can also be caused by viral infections such as herpes simplex, adenovirus, and enterovirus.¹⁷ In the majority of cases, it is a mild illness, easily treated with either topical or oral antibiotics. However, N. gonorrhoeae conjunctivitis, which develops in up to 50% of neonates exposed to the bacteria during delivery, can quickly progress and lead to permanent vision damage or even blindness.

Prophylaxis against N. gonorrhoeae was initiated in the late 1800s by Dr. Carl Siegmund Franz Credé, who discovered that application of silver nitrate to infants’ eyes after birth decreased the incidence of conjunctivitis from 7% to 0.5%.¹⁸ Throughout the twentieth century, this practice was widely adopted, though the recommended prophylaxis was changed from silver nitrate to erythromycin, which was less irritating, not associated with chemical conjunctivitis, and more effective in preventing C. trachomatis conjunctivitis. Many states even adopted laws that mandated prophylaxis which are still in place and enforced in several states.¹⁹ In the last decade, however, the practice has been called into question by many within and outside the medical community. The primary reason for this is the unreliable efficacy of erythromycin. Up to 30% of N. gonorrhoeae is resistant to erythromycin and topical erythromycin has questionable ability to prevent C. trachomatis and does not prevent other, more serious, complications from the infection.²⁰ Routine prophylaxis has already been abandoned in several European countries without an increase in neonatal ophthalmia-related blindness.²¹ Critics of prophylaxis argue that a superior form of prevention would be routine screening of all pregnant women for both N. gonorrhoeae and C. trachomatis in the first trimester of pregnancy, treatment and test of cure for all infected patients, and third trimester rescreening and appropriate treatment for all at-risk patients. Alternative prevention strategies have also been suggested including colostrum administration to the eyes, which was shown to have potential efficacy in one small randomized control trial, and povidone-iodine administration, which has demonstrated efficacy but, like silver nitrate, is associated with significant rates of chemical conjunctivitis.^22,23

Despite the questionable effectiveness for prophylaxis, erythromycin ointment is not associated with significant side effects and supporters of prophylaxis argue that it also prevents other forms of bacterial conjunctivitis that, while less severe, are more common. This claim has not been studied, but given the current knowledge regarding bacterial sensitivities, it seems a reasonable assumption. The suggested side-effects and concerns regarding its use are mainly eye irritation, blurred vision that may impede bonding, and contribution to overall antibiotic resistance.²⁴ These seem to be relatively minor concerns which the benefits of prophylaxis may very well outweigh for most parents. However, the recommendation for prophylaxis is also not based on overwhelmingly strong evidence, given current antibiotic resistance, and parents should be able to weigh the benefits and side effects for themselves. Regardless of prophylaxis policies, improved screening of all women for the more serious infections appears prudent, particularly if parents are electing to forgo any prophylaxis.

I decline vitamin K injection for my baby

The growing trend of vitamin K refusal first made national headlines in 2013, when the CDC reported that five infants in Tennessee had developed vitamin K deficiency bleeding (VKDB) in an 8-month period, with four of the babies presenting with bleeding into the brain and one baby presenting with gastrointestinal bleeding.^25,26 An additional two babies were identified with vitamin K deficiency without bleeding. All of the infants survived; however, three had permanent neurological damage and two required emergency brain surgery. All of the parents of the affected children had refused for their babies to receive the standard vitamin K injection, which is typically administered shortly after birth.

Vitamin K deficiency bleeding, formerly known as hemorrhagic disease of the newborn, is a rare but potentially lethal condition which can develop in infants that do not have a sufficient amount of vitamin K to support the development of blood clotting factors. Placental transfer of vitamin K is limited and vitamin K does not enter breast milk to any large degree. Exclusively breast-fed infants are at significantly higher risk of deficiency. VKDB has three distinct presentations²⁷:

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  Early-onset VKDB: occurs within the first 24 hours after birth and is associated with cephalohematoma, bleeding between the skin and the skull, gastrointestinal bleeding, or intracranial bleeding into the brain.

  
  
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  Classic VKDB: the most common (0.25–1.7% of neonates), occurs within the first 2 to 7 days of life, and usually consists of milder bleeding from the umbilicus site, gastrointestinal tract, circumcision site, or puncture sites.

  
  
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  Late VKDB: occurs after the second week of life up to 6 months of age, with an incidence of 4.4 to 7.2 per 100,000 live births; however, it can occur as commonly as 1 in 15,000 to 1 in 20,000 infants who are exclusively breast-fed. Fifty percent of cases present with intracranial bleeding, with a 20% mortality.

In 1961, as a result of a large Swedish study demonstrating a fivefold reduction in the risk of newborn bleeding with administration of either oral or injected vitamin K, the American Academy of Pediatrics recommended that all infants receive a vitamin K injection at birth.²⁸ This practice significantly reduced the incidence of VKDB in the United States and continued unchallenged until the 1990s, when a small study (800 patients) out of the United Kingdom demonstrated an association between vitamin K injections and childhood leukemia.²⁹ Consequently, vitamin K injections were substituted with oral vitamin K supplementation throughout the United Kingdom and a number of follow-up studies were performed, both examining the concern about a possible association of vitamin K injections with leukemia and comparing the efficacy of oral vitamin K regimens to injectable vitamin K regimens.

The follow-up studies on the issue of a possible cancer link were extremely reassuring. Less than 2 years after the initial study of concern was published, two large trials, one involving 1.4 million children and a second involving 50,000 children, found no association between vitamin K injections and childhood cancer or any other adverse outcome, aside from mild swelling or bruising at the injection site.^30,31 Ten additional, high-quality case-controlled studies were also performed in the following years and no link between childhood cancer and injectable vitamin K was identified.³² To date, there is simply no evidence that vitamin K has any association with childhood cancers, yet when parents who refused the vitamin K injection were asked why they declined it, this was a common explanation they offered, in addition to concerns about other “toxins” in the injection or the injection containing too much, synthetic vitamin K.³³ Why do parents believe this? Unfortunately, similar to vaccines, there are a number of “health-promoting” websites specifically encouraging parents to forgo the vitamin K injection and spreading misinformation.^34–36 Several of these sites incorrectly reassure parents that increasing the amount of maternal dietary vitamin K in the later weeks of pregnancy and during breastfeeding will provide adequate vitamin K for the newborn. They also describe and provide links to the study demonstrating an association with cancer without discussing all the evidence that disproved it. It is no wonder that parents are afraid and it is always easier to just not do something, as opposed to taking an active action. Often, when health decisions are being made, people feel less responsibility for an act of omission. If something bad happens, it is nature’s fault, not their own.

Many who are opposed to or simply nervous about injectable vitamin K suggest oral vitamin K may be used as an alternative and this method of VKDB prevention is actually utilized in several countries. Oral vitamin K has been shown to be equally effective as injectable vitamin K in preventing VKDB in the first 2 weeks of life. However, in countries that rely on oral vitamin K, higher rates of late VKDB, the more serious form of the disease, are observed. In a review of data from four different countries, failure of oral vitamin K regimens occurred in 1.2 to 1.9 per 100,000 live births, as opposed to no failures observed with the injectable form. Failure rates were higher in babies that did not complete the recommended additional four doses in the weeks following birth (2–4 per 100,000) and noncompliance with oral regimens has been shown to be around 7%.³⁷ Furthermore, there is no approved oral formulation in the United States, so multiple doses of the parenteral formula must be used, which infants are likely to spit out, making for inconsistent administration even when all the proper follow-up doses are given. While the overall risk of failure is low and oral supplementation certainly is superior to no vitamin K supplementation at all, given the lack of any adverse associations with the injectable form, oral supplementation seems like more trouble for less benefit.