NR451 RN Capstone Course
Term and Year
Skin-to-Skin Contact for Neonates
The separation of mother and neonate for non-urgent medical reasons is a growing trend in nursing practice. However, research has indicated that the practice can have a deleterious long term effect on the healthy infant and mother with regard to breast feeding, cardio-respiratory stability, and blood glucose levels (Moore, Anderson, Bergman, & Dowswell, (2014). The solution to the problem is to initiate skin-to-skin contact at birth (Moore, et al., 2014). The nursing focused plan is to introduce the practice of skin-to-skin contact following birth, which entails placing the naked infant prone on the mother’s bare chest and covering the infant’s back with a warm blanket (Moore, et al., 2014).
Change Model Overview
The Johns Hopkins Nursing evidence-based practice model is a framework that guides the synthesizing of evidence and the translating of the evidence into nursing practice (Newhouse, Dearholt, Poe, Pugh, White, 2007). The conceptual model is based on three pillars of nursing practice: practice, research and education. The central idea is that clinical decision making is informed by evidence that is both research based and non-research based. The Johns Hopkins Nursing evidence-based practice model consists of three stages. The first stage consists of identifying the question. The question must be answerable. The second stage consists of the systematic data gathering of the research based and non-research based evidence and the synthesis of both types of evidence. The final stage involves translating the evidence into practice. An evidence-based practice team is formed in order to decide if the implementing of the recommended plan of action is feasible. The team needs to consider the internal and external factors as part of the feasibility issue. The translation stage includes the implementation of a pilot study of the practice change, measuring the outcomes, and disseminating the results.
As to why nurses should endorse the Johns Hopkins Nursing evidence-based practice model, Newhouse, et al. (2007) suggested that evidence-based practice results in better patient care and greater nursing autonomy. Further, evidence-based practice is a necessary component in professional nursing.
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Practice Question
Step 1: Recruit Interprofessional Team
The interprofessional team will be composed of members of the neonatal team and other individuals involved in the care of the mother and neonate. The neonatal team is obstetricians, anesthesiologists, and pediatricians. Also included in the team are a breast feeding consultant, and the charge nurse and nurse in the maternity ward. Key stakeholders will also have to be identified and that would consist of decision-making administrators on both the hospital level and maternity ward level.
Step 2: Develop and Refine the EBP Question
The PICO elements are problem, intervention, comparison and outcome. The evidence-based practice problem/question is whether skin-to-skin contact between mother and infant for 25 to 120 minutes after birth has an impact on infant self-regulation, co-regulation with the mother and early breast feeding. The intervention group will be healthy infants placed skin-to-skin with the mother following birth for 25 to 120 minutes in the Operating Room and during recovery with rooming-in during the hospital stay. The infant is placed ventrally on the mother’s bare chest and covered with a warm blanket. The control group of healthy infants will receive non urgent care as usual with rooming in during the hospital stay. Both groups should have infants rooming in to control for later mother child direct contact. The two variables to be measured in the two groups of infants include are evidence of the infants’ first breastfeeding and infants’ and mothers’ salivary cortisol level.
Step 3: Define the Scope of the EBP
Previous study indicate that immediate skin-to-skin contact between mother and infant constitutes a “sensitive period” psychophysiologically and programs the baby’s system for future behavior and physiology, specifically, the baby’s ability to self-regulate. Further, painful or disruptive procedures conducted on infants causes stress (Neu, Hazel, Robinson, Schmiege, & Laudenslager, 2014). The stress causes an activation of the hypothalamic-pituitary-adrenocortical axis that initiates a feedback loop interaction among the adrenal glands, pituitary, and hypothalamus. The result is a secretion of the glucocorticoid cortisol. If the infant’s system is well-regulated, the rise in cortisol level reduces further stimulation and thus the feedback loop ceases. Early developmental experiences can have an influence on the long term responsiveness of the hypothalamic-pituitary-adrenocortical axis to stress (Törnhage, 2009). Therefore, stressful procedures can be responsible for a less resilient hypothalamic-pituitary-adrenocortical system throughout the infant’s development (Neu, et al., 2014). A less than optimal hypothalamic-pituitary-adrenocortical system can lead to longer hospital stays and thus a possible disruption in the infant mother bond. A dysregulated system can result in infant mortality, particularly among infants who are preterm or have a low birth.
Steps 4 and 5: Determine Responsibility of Team Members
The interprofessional team is composed of members of the neonatal team (obstetricians, anesthesiologists, and pediatricians). These individuals are included on the evidence-based practice team because they have direct contact with the mother and infant. Also included in the team is a breast feeding consultant as breast feeding is an outcome factor of the proposed pilot. Additional team members are a nurse and a charge nurse in the maternity ward as they both have direct contact with the mother and infant. All members of the team will function as data gatherers as they are all in contact with the infant and mother. A nurse in the maternity ward will collect salivary samples from the infant and mother.
Evidence
Steps 6 and 7: Conduct Internal/ External Search for Evidence and Appraisal of Evidence
Most of the types of evidence found for the skin-to-skin practice were research articles, primarily quantitative (Bystrova, 2009; Moore, et al., 2014; Neu, et al., 2014). There was one description of the implementation of evidence-based practice improvement project for skin-to-skin contact following Caesarian delivery and several observations of babies’ feeding behaviors within the one hour skin-to-skin contact period following birth (Brady, Bulpitt & Chiarelli, 2014; Cantrill, Creedy, Cooke, & Dykes, 2014; Hung & Berg, 2011; Koopman, Callaghan-Koru, Alaofin, Argani, & Farzin, 2016). The World Health Organization and Baby-Friendly USA both produced position papers associating skin-to-skin contact and the benefits of breast feeding (Baby-Friendly USA, 2011; World Health Organization, 2013). Two systematic literature reviews on skin-to-skin contact were located (Moore, et al., 2014; Stevens, Schmied, Burns, & Dahlen, 2014). Overall, the literature provides solid evidence for the efficacy of skin-to-skin contact, notably with respect to successful breast feeding initiation.
Steps 8 and 9: Summarize the Evidence
Compared to the routine separation of mother and neonate, immediate skin-to-skin contact for 25 to 120 minutes led to improved mother-infant interactions one year later (Bystrova, 2009). Implementation of immediate skin-to-skin successfully improves early breastfeeding after both vaginal and Caesarian births and promotes infant self-regulation (Hung & Berg, 2011; Koopman, et., al., 2016; Moore, et al., 2014; Neu, et al., 2014; Svensson, et al., 2013). Further, an evidence-based practice model was successfully applied to skin-to-skin practice (Brady, et al., 2014).
Step 10: Develop Recommendations for Change Based on Evidence
Based on the literature review, an evidence-based practice improvement project for a pilot study on skin-to-skin contact is warranted. The pilot study will conduct a pilot study on the implementation of skin-to-skin contact in the maternity ward.
Translation
Steps 11, 12, and 13, 14: Action Plan
A table summarizing the time line for the pilot study is attached. The pilot study will take six months to complete. In the first month, the team will be assembled and stakeholders will be identified. A meeting will take place between the stakeholders and the team members. The purpose of the meeting is to inform the stakeholders about the advantages of skin-to-skin contact and to foster their support. Mothers will be recruited by their obstetricians during their prenatal visits. Recruiting will continue from month 1 to month 5. Data will be gathered from month two to month five. Data analysis and report preparation will take place in the fourth and fifth month of the study. The report will follow the format of a written research paper: description of the problem, literature review, methods and analysis, results and recommendations. A meeting with the stakeholders will take place again at the end of the sixth month in order to discuss the results, to distribute the report, and to foster further support for a full study.
Steps 16 and 16: Evaluating Outcomes and Reporting Outcomes
The study groups and the procedures have been discussed under Step 2. The first outcome of the study is the time of first breastfeeding. The hypothesis is that infants in the intervention group will begin breastfeeding earlier than the infants in the control group. Timing of breast feeding will be operationalized by noting the time of the infants’ first breastfeeding in the OR, recovery room, or the maternity ward.
The second hypothesis is that the intervention group will demonstrate less stress and will obtain a greater level of co-regulation with the mother. Following Neu, et al. (2014), stress and co-regulation will be measured by level of salivary cortisol. For each mother and child dyad, data collection takes place between 10am and 2pm. Salivary cortisol levels are taken during a period when the mothers hold the infants. Salivary cortisol levels are measured three times: before the infant is picked up, half an hour after the infant has been picked up, and one hour after the infant was picked up. Absolute cortisol levels are expected to be lower in the intervention infants than the control infants. Within each dyad, the difference in cortisol levels between mother and infant will become progressively less during the holding period in the intervention group, but not in the control group. Salivary cortisol will be measured by placing a filter paper on the infant’s and the mothers’ tongues until one inch of the papers are thoroughly wet (from 30 seconds to 2 minutes). The results will be presented in a report to the stakeholders at a meeting at the end of the six-month study period
Steps 17: Identify Next Steps
The study results are presented to the key stakeholders, who are also decision-making administrators. If the results of the pilot study are successful, the next step will be to recommend to the stakeholders that another study be conducted in order to determine barriers and facilitators to the implementation of immediate skin-to-skin contact following birth. Once the barriers and facilitators are identified and dealt with, the new practice will have a greater chance of a smooth implementation and sustainability. The skin-to-skin contact practice has applicability to preterm or low weight infants, and infants in intensive care units.
Step 18: Disseminate Findings
As it involves a finite number of individuals, communicating the information in maternity wards and intensive care units for infants can be accomplished through a meeting and throughout the rest of the organization by email newsletters. Outside the organization, the study results can be communicated at national nursing research conventions.
Conclusion
The positive influence of skin-to-skin contact on the health of infants is clear in the literature and has been endorsed by the World Health Organization (2013) and Baby-Friendly USA (2011). Therefore, the first two stages of the Johns Hopkins Evidence-Based Practice change model (identification of the problem and data gathering) are straight forward. However, the third stage, translating the evidence into practice, is more difficult because the current trend is to separate the mother and infant in order to conduct non urgent procedures. Long term infant health has cost saving implications for health care delivery systems and this is a convincing argument for changing procedure. To effect a permanent and wide-spread change, it will be helpful to establish solid evidence as to how much and where and the savings can be achieved. This will involve a national level health economics study.
References
Baby-Friendly USA. (2011). The guidelines & evaluation criteria for facilities. Retrieved from https://www.babyfriendlyusa.org/getstarted/the-guidelines-evaluation-criteria
Bergh, A-M., de Graft-Johnson, J., Khadka, N., Om’Iniabohs. A., Udani, R., Pratomo, H., & de Leon-Mendoza. S. (2016). The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia. BMC International Health and Human Rights, 16(4), 1-13. DOI 10.1186/s12914-016-0080-4
Brady, K., Bulpitt, D. & Chiarelli, C. (2014). An interprofessional quality improvement project to implement maternal/infant skin-to-skin contact during Cesarean delivery. Journal of Obstetric, Gynecologic, & Neonatal Nursing 43, 488-496; 2014. DOI: 10.1111/1552-6909.12469
Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A. S., Ransjö-Arvidson, A. B., Mukhamedrakhimov, R,, Uvnäs-Moberg, K., & Widström, A. M. (2009). Early contact versus separation: effects on mother-infant interaction one year later. Birth, 36(2), 97-109. doi: 10.1111/j.1523-536X.2009.00307.x.
Cantrill, R. M., Creedy, D. K., Cooke, M., & Dykes, F. (2014). Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study. BMC Pregnancy and Childbirth, 14, 20. http://www.biomedcentral.com/1471-2393/14/20
Hung, K. J. & Berg, O. (2011). Early skin-to-skin after cesarean to improve breastfeeding. MCN American Journal of Maternal and Child Nursing, 36(5), 318-324. doi: 10.1097/NMC.0b013e3182266314.
Koopman, I., Callaghan-Koru, J. A., Alaofin, O, Argani, C. H. & Farzin, A. (2016). Early skin-to-skin contact for healthy full-term infants after vaginal and caesarean delivery: a qualitative study on clinician perspectives. Journal of Clinical Nursing, 25(9-10),1367-76. doi: 10.1111/jocn.13227
Moore, E. R., Anderson, G. C., Bergman, N., & Dowswell, T. (2014). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Systematic Review, 5, CD003519. doi:10.1002/14651858.CD003519.pub3.
Neu, M., Hazel, N. A., Robinson, J., Schmiege, S. J., & Laudenslager, M. (2014). Effect of holding on co-regulation in preterm infants: A randomized controlled trial. Early Human Development, 90(3), 141–147. doi:10.1016/j.earlhumdev.2014.01.008.
Newhouse, R. P., Dearholt, S., Poe, S., Pugh, L. C., & White, K. M. (2007). Organizational Change Strategies for Evidence-Based Practice. Journal of Nursing Administration, 37(12), 552-557.
Stevens, J., Schmied, V., Burns, E., & Dahlen, H. (2014). Immediate or early skin-to-skin contact after a Caesarean section: A review of the literature. Maternal and Child Nutrition, 10(4), 456-73. doi: 10.1111/mcn.12128.
Svensson, K. E., Velandia, M. I., Matthiesen, A-S, T., Welles-Nyström, B. L., & Widström, A-M. E. (2013). Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: A randomized trial. International Breastfeeding Journal, 2013, 8, 1. http://www.internationalbreastfeedingjournal.com/content/8/1/1
Törnhage, C. J. (2009). Salivary cortisol for assessment of hypothalamic-pituitary-adrenal axis function. Neuroimmunomodulation, 16(5), 284–289.
World Health Organization. (2013). Implementation of the baby-friendlyhospital initiative. Retrieved from http://www.who.int/elena/bbc/implementation_bfhi/en/
Time Table for Pilot Study
