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      <h1 id="top">4.1 The first hours</h1>
      <div class="captionBox">
        <img width="405" height="568" src="images/UK_BF_poster.jpg" alt="Promotional poster - from Baby Friendly UK" />
        <p>Promotional poster - from Baby Friendly UK</p>
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      <blockquote>
    <div>
      <p> The benefits to the mother of immediate breastfeeding are innumerable, not the least of which, after the weariness of labour and birth, is the emotional gratification, the feeling of strength, composure, and the sense of fulfillment that comes with the handling and suckling of the baby.<sup><a href="#note1">1</a></sup> </p>
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  <p class="cite">Ashley Montague, 1978</p></blockquote>
      <div class="section" id="Baby_Friendly_Step_4"><h2>Baby Friendly Step 4</h2>
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      <div><span style="font-weight: bold;"> Step 4 </span> of the <span style="font-style: italic;"> Ten Steps to Successful Breastfeeding </span> states: <p> "Help mothers to initiate breastfeeding within a half-hour of birth." </p> <p> This step is now interpreted as: <strong style="font-weight: normal;"></strong> <br /> </p></div>
      <blockquote>
        <div>
          <strong style="font-weight: normal;">Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.</strong>
          <sup><a href="#note2">2</a></sup>
        </div>
      </blockquote>
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      <div class="section" id="Immediately_following_birth"><h2>Immediately following birth</h2>
    <div>
      <p> At the time of birth nearly 90% of newborns are vigorous, term babies with no risk factors, who do not need to be separated from their mother in order to receive the initial steps of resuscitation.<sup><a href="#note3">3</a></sup> </p>
      <ul>
        <li>Immediately move newborn onto mother's abdomen with skin-to-skin contact.</li>
        <li>In this position: Upper airway can be cleared by wiping the mouth and nose, baby can be dried, assigned Apgar scores, visually assessed and vital signs recorded.</li>
        <li>Cover both mother and baby with dry linen.</li>
      </ul>
    </div>
  </div>
      <div class="section" id="The_first_breastfeed"><h2>The first breastfeed</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/Klaus_Pediatrics1998.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/Klaus_Pediatrics1998.pdf" target="_blank">Read this great article!</a></h3>
      <div>
        <p>
				What happens now is truly a miracle to watch! Click on the icon on the left to read this paper, then file it in your Workbook. If you are in contact with colleagues who are with birthing mothers, share it with them too.
			</p>
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    <div>
      <p> Several researchers have described this species-specific set of innate behaviors when baby is placed in skin-to-skin contact with the mother immediately following birth. It is clear that newborn babies are born with the instinct to breastfeed.<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup> </p>
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    <div class="captionBox"><img width="495" height="307" src="images/skin-to-skin_500_RC.png" alt="" /><p> <br />&copy; R.Cantrill, IBCLC</p></div>
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      <div>
        <ul>
          <li>Newborn, full-term babies who spent more than 50 minutes in skin-to-skin care are 8 times more likely to breastfeed spontaneously than infants not in skin-to-skin care.<sup><a href="#note8">8</a></sup></li>
          <li>Newborn preterm infants in skin-to-skin care achieve thermo-cardio-respiratory stability within 6 hours, compared to babies in traditional incubator care who mostly do not.<sup><a href="#note9">9</a></sup><br /></li>
        </ul>
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      <div class="section" id="The_role_of_the_birth_attendants"><h2>The role of the birth attendants</h2>
    <div>
      <p> This critical period in the relationship between mother and baby is, in some birthing units, a high-intervention time when it should be exactly the opposite. Recall that the AAP Neonatal Resuscitation Program<sup><a href="#note3">3</a></sup> states that all observations can take place with infant in skin-to-skin contact with his mother. The role of the birth attendants at this time is to support the mother to provide the ideal environment for her baby to adapt to extrauterine life, orientate to the breast and coordinate suckling. </p>
      <p> Appropriate support is given by discussing with the mother, and others present, the importance of uninterrupted skin-to-skin contact. Some birth attendants tell of the mother and her support people being enthralled as they watch the baby move through this sequential pre-feeding behavior, not wishing to interrupt it. A little education can go a long way! </p>
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              <img src="design/books.png" class="icon" alt="" />
              <h3>Workbook Activity 4.2</h3>
              <p>Complete Activity 4.2 in your workbook.</p>
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      <div class="section" id="Addressing_barriers_to_skin-to-skin"><h2>Addressing barriers to skin-to-skin</h2>
    <div>
      <p class="listTitle"> Concern that the baby will get cold. </p>
      <ul>
        <li><strong>Dry</strong> the baby and place in skin-to-skin contact on mother's chest. </li>
        <li> Put a dry cloth or blanket over both the mother and the baby. </li>
        <li> If the room is cold cover the baby's head with a bonnet to reduce heat loss. </li>
        <li> Babies in skin-to-skin contact have higher temperature than those dressed  and better temperature regulation than those under a heater or in incubator care. <sup><a href="#note10">10</a></sup> <sup><a href="#note11">11</a></sup> </li>
      </ul>
      <p class="listTitle"> Baby needs to be examined. </p>
      <ul>
        <li> Most examinations can be conducted with baby on mother's chest. </li>
        <li> There is no need to move the baby to monitor vital signs. </li>
        <li> Weighing can be delayed. </li>
      </ul>
      <p class="listTitle"> Mother needs to be stitched. </p>
      <ul>
        <li> Baby can stay on mother's abdomen while stitching an episiotomy. </li>
        <li> Baby can stay on mother's chest while stitching a caesarean section. </li>
      </ul>
      <p class="listTitle"> Baby needs to be bathed. </p>
      <ul>
        <li> Delaying the first bath provides better thermoregulation and allows the vernix to remain on the skin. <br /> <ul><li> Gently wipe the baby dry after birth, preserving the vernix. </li><li> Vernix retention is associated with significantly higher skin hydration, a lower skin pH and significantly less erythema. <sup><a href="#note12">12</a></sup> </li><li> Early bathing is associated with a significant fall in temperature. <sup><a href="#note13">13</a></sup> </li></ul> </li>
      </ul>
      <p class="listTitle"> Delivery room is busy. </p>
      <ul>
        <li> Mother and baby can be transferred to the postnatal ward while in skin-to-skin contact. </li>
      </ul>
      <p class="listTitle"> Insufficient staff to remain with the mother. </p>
      <ul>
        <li> A family member can stay with the mother and baby. </li>
        <li> Discuss routine precautions with the family member to ensure their safety. </li>
      </ul>
      <p class="listTitle"> Baby is not alert. </p>
      <ul>
        <li> If a baby is sleepy due to maternal medications it is even more important that the baby has contact as he/she needs extra support to bond and feed. </li>
      </ul>
      <p class="listTitle"> Mother is tired. </p>
      <ul>
        <li> A mother is rarely so tired that she does not want to hold her baby. </li>
        <li> Contact with her baby can help the mother to relax. </li>
        <li> Review labor practices such as withholding fluid and foods, and practices that may increase the length of labor. </li>
        <li> Skin-to-skin care and breastfeeding is best when the mother is in a reclined or semi-reclined position; a good position for resting. <br /> </li>
      </ul>
      <p class="listTitle"> Lack of knowledge of health professional wishing to move the baby </p>
      <ul>
        <li> This first step following birthing has far-reaching effects on mother, baby and breastfeeding. </li>
        <li> Train all birthing room staff in the effects of immediate and undisturbed skin-to-skin contact. </li>
        <li> Refer all staff to the hospital policy which they must follow. Hospital breastfeeding policies will reflect the 10 Steps to Successful Breastfeeding, including Step 4. </li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Just the thing for busy staff!</h3>
      <div>Supporting the mother to care for her baby with skin-to-skin contact will significantly reduce the workload of the health care staff looking after her.<br /><ul><li>The infant will adapt to extrauterine life more quickly, reducing any risk of hypothermia or cardio-respiratory instability.<br /></li><li>Breastfeeding will be initiated early and successfully, with minimal input from others.</li><li>Breastfeeding will stimulate the release of oxytocin, reducing the risk of maternal hemorrhage.<br /></li><li>Skin-to-skin care will colonize the baby with the mother's normal flora, which, when combined with breastfeeding, significantly reduces the risk of nosocomial infections.</li><li>Maternal self-confidence and independence will rise.</li></ul></div>
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      <div class="section" id="Maternal-infant_bonding"><h2>Maternal-infant bonding</h2>
    <div>
      <p> This is the beginning of a loving relationship between the parents and their newborn. The infant appears to play his part in the establishment of these bonds by actively interacting with his parents. Following an initial cry at birth the infant becomes quietly alert and seeks visual contact, massages the mother's chest and breasts and latches and breastfeeds. The high blood levels of beta endorphins, oxytocin and prolactin in both mother and infant facilitate falling in love.<sup><a href="#note14">14</a></sup> </p>
      <p class="listTitle">For this to occur the following factors have to be in place and considered. These are all influenced by the birth attendants.</p>
      <ul>
        <li>the availability of the infant to his/her parents,</li>
        <li>an environment conducive to parent and child interaction, and</li>
        <li>the attitude of those present at the delivery to the appearance of the infant<sup><a href="#note14">14</a></sup></li>
      </ul>
    </div>
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            <td class="body"><h3>What about a baby to be artificially fed?</h3>
    <div>Skin-to-skin time with mother is equally important for EVERY baby. In Topic 4.3 Postnatal interventions, you will read the effects of separating mothers and newborns - facilitating breastfeeding is only one of many, many benefits of skin-to-skin contact.<br /></div>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
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      <div>
        <ul>
          <li>the interpretation of Step 4 of the Ten Steps</li>
          <li>the immediate care of the newborn following birth AND where it should take place</li>
          <li>the many important functions that skin-to-skin contact on the mother's chest has for both her and her infant</li>
          <li>how you could address the barriers to skin-to-skin care should your colleagues be concerned<br /></li>
        </ul>
      </div>
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      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
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      <div></div><div class="activity" id="activity_g">
<script type="text/javascript">
/* <![CDATA[ */
var gqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('What is the FIRST action that should be taken after a baby is born?', [{text:'dry the baby thoroughly then move the baby onto the mother\'s abdomen for her to hold',feedback:'No. You\'ve got the order wrong.',score:0},{text:'assign Apgar scores, then if baby does not require resuscitation move the baby onto the mother\'s abdomen for her to hold',feedback:'The first Apgar score isn\'t assigned until 1 minute. You\'ll do something with the baby before then.',score:0},{text:'move the baby onto the mother\'s abdomen for her to hold, then dry the baby',feedback:'Yes, that\'s right. All routine resuscitation, care and observations can occur with baby in skin-to-skin contact on mother\'s abdomen.',score:1},{text:'assist the mother to latch the baby to the breast for his first breastfeed',feedback:'No. The baby won\'t require assistance if you just place baby and mother in skin-to-skin contact.',score:0}]),
	new MCQ('How will thermal stability be achieved most efficiently?', [{text:'dry, dress and wrap the baby in a warm blanket',feedback:'This is not the most efficient way to achieve thermal stability.',score:0},{text:'dry and dress infant, then place under a radiant heater',feedback:'This is not a very efficient method.',score:0},{text:'dry infant and place naked in a temperature-controlled isolette',feedback:'No, this is quite inefficient compared to the most efficient method.',score:0},{text:'dry the infant, then place him naked in skin-to-skin contact on the mother\'s chest, covering both with dry linen.',feedback:'This is the most efficient way to stabilise the baby\'s temperature.',score:1}]),
	new MCQ('The baby in skin-to-skin contact with his mother uses his knees and feet to move towards the breast. Apart from moving the baby, what function does this serve?', [{text:'it strengthens the baby\'s back muscles',feedback:'No. Baby isn\'t really in need of strengthening exercises at this stage of his life.',score:0},{text:'it causes the release of oxytocin in the mother',feedback:'Yes. This will cause her uterus to contract expelling the placenta and reducing bleeding, and the colostrum in the breast to move down towards the nipple.',score:1},{text:'it causes the mother to bring her baby to her breast',feedback:'No. Most mothers are happy to rest, allowing the baby to move as he wishes.',score:0},{text:'it stimulates the release of prolactin in the mother',feedback:'No, not from this action.',score:0}]),
	new MCQ('A newborn baby in skin-to-skin contact on his mother\'s abdomen does not appear to be making the usual progress towards self-attaching to the breast. You could do any of the following to to assist the normal progress of the baby, EXCEPT..', [{text:'Suggest mother expresses a drop or two of colostrum from the breasts and wipe it over her nipples.',feedback:'This is something you would try. The baby uses his sense of smell to locate the nipple.',score:0},{text:'Move the baby to the breast and help him to latch.',feedback:'Correct. Please don\'t do this. It interferes with the baby\'s innate reflexes and ability to learn.',score:1},{text:'Wipe some of the amniotic fluid over the mother\'s breasts.',feedback:'An excellent idea! If there\'s none obviously around at this time you\'ll find some if you uncurl baby\'s hands - gently wipe baby\'s hands over the nipples.',score:0},{text:'Don\'t do anything. Allow the baby extra time.',feedback:'This could also be very helpful, particularly if the baby had received intrapartum drugs.',score:0}]),
	new MCQ('Physiologically the mother and baby are primed at the time of birth to fall in love with each other. What are the three physical factors identified by one researcher that could interfere with this?(Choose all three factors)', [{text:'the availability of the infant to his/her parents',feedback:'Yes, that\'s one of them. Don\'t separate them at this critical time.',score:1},{text:'the baby not reaching the breast to lick, nuzzle or latch',feedback:'No. While this will enhance the hormonal milieu, skin-to-skin is even more important for artificially feeding mothers',score:0},{text:'an environment conducive to parent and child interaction',feedback:'Yes that\'s one of the factors.',score:1},{text:'the attitude of those present at the birth to the appearance of the infant',feedback:'That\'s one of the factors.',score:1},{text:'the baby not being the desired sex',feedback:'No. The hormones are there anyway.',score:0}]),
	new MCQ('When routine skin-to-skin care on the mother\'s chest is fully implemented into a birthing unit, does it increase or decrease the staff workload?', [{text:'Increase',feedback:'No. Skin-to-skin is the ultimate labor-saving action for birthing unit and postnatal ward staff. It prevents problems and gives mothers a greater sense of independence.',score:0},{text:'Decrease',feedback:'That\'s right. It\'s the ultimate labor-saving action in a birthing unit or postnatal ward. It prevents many problems and mothers gain independence faster.',score:1}])
]};

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  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#mont78" title="See full details">#</a> Montague A (1978) Touching: The Human Significance of the Skin</li>
          <li id="note2"><a href="references.html#worl06" title="See full details">#</a> World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care</li>
          <li id="note3"><a href="references.html#amer00" title="See full details">#</a> American Academy of Pediatrics (2000) The Textbook of Neonatal Resuscitation</li>
          <li id="note4"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
          <li id="note5"><a href="references.html#wids90" title="See full details">#</a> Widstrom AM et al. (1990) Short-term effects of early suckling and touch of the nipple on maternal behaviour</li>
          <li id="note6"><a href="references.html#vare98" title="See full details">#</a> Varendi H et al. (1998) Soothing effect of amniotic fluid smell in newborns</li>
          <li id="note7"><a href="references.html#matt01" title="See full details">#</a> Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier</li>
          <li id="note8"><a href="references.html#gome98" title="See full details">#</a> Gomez Papi A et al. (1998) Kangaroo method in the delivery room for full-term babies</li>
          <li id="note9"><a href="references.html#berg04" title="See full details">#</a> Bergman NJ et al. (2004) Randomized controlled trial of  skin-to-skin contact from birth versus conventional incubator for  physiological stabilization in 1200- to 2199-gram newborns</li>
          <li id="note10"><a href="references.html#carf05" title="See full details">#</a> Carfoot S et al. (2005) A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding.</li>
          <li id="note11"><a href="references.html#fran05" title="See full details">#</a> Fransson AL et al. (2005) Temperature variation in newborn babies: importance of physical contact with the mother.</li>
          <li id="note12"><a href="references.html#viss05" title="See full details">#</a> Visscher MO et al. (2005) Vernix caseosa in neonatal adaptation.</li>
          <li id="note13"><a href="references.html#berg05" title="See full details">#</a> Bergstrom A et al. (2005) The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial.</li>
          <li id="note14"><a href="references.html#attr02" title="See full details">#</a> Attrill B (2002) The assumption of the maternal role: a developmental process</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li class="current">4.1 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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