An implementation algorithm to improve skin‐to‐skin practice in the first hour after birth

Abstract Evidence supporting the practice of skin‐to‐skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin‐to‐skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin‐to‐skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self‐attachment and suckling. However, the most recent Cochrane review of early skin‐to‐skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin‐to‐skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin‐to‐skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.

Part of Obstetric Practice" suggests that SSC care should begin "early" (American Congress of Obstetricians & Gynecologists, 2016). The International Childbirth Education Association Position Paper on SSC directs that it begin "immediately after the birth of the baby" (Lowrie, 2015, p. 1), and the Lamaze Healthy Birth Practice #6 warns against interruption: "Disrupting or delaying skin-to-skin care may suppress a newborn's innate protective behaviors, lead to behavioral disorganization, and make self-attachment and breastfeeding more difficult" (Lamaze International,n.d.,p. 212). A collaborative document "Points to Bear in Mind in Regard to the Implementation of 'Early Mother-Infant Skin-to-Skin Contact'" was published by the major Japanese professional organizations involved with birth and contains implementation strategies that include starting as soon as possible after birth and continuing until breastfeeding is complete (Japan Society of Perinatal and Neonatal Medicine et al., 2012).
While in immediate, continuous uninterrupted SSC with mother in the first hour after birth, babies progress through nine instinctive, complex, distinct, and observable stages ( Table 1) that have been documented elsewhere (Widström et al., 2011). In Stage 7, the baby finds the nipple and licks, mouths, massages, and becomes familiar with the mother's breast; in Stage 8, the infant self-attaches and suckles.
Uncompromised term newborns go through these stages at varying rates and usually achieve suckling within 60 to 90 min after birth (Widström et al., 2011;Widström et al., 1987). Interruption, such as non-emergent newborn care, is a modifiable practice that has been linked to decreased achievement of suckling (Robiquet et al., 2016).
In spite of the supportive policies, professional statements, and the numerous advantages of SSC described in the literature, the most recent Cochrane review of early SSC for mothers and their healthy newborn infants (Moore, Bergman, Anderson, & Medley, 2016) cites inconsistencies in the practice. For example, only 47% of the 38 included trials selected for the systematic review reported that SSC began "early" or "immediately," meaning that after the birth, the baby had been carefully dried and placed, without delay, on the mother's abdomen (in the case of a vaginal birth) or on the mother's chest above the drape (in the case of a caesarean birth). In addition, 66 studies were assessed and excluded from the Cochrane review. The primary reason for exclusion was that "… the investigators did not state that the infants in the intervention group received immediate or early skin-to-skin contact" (Moore et al., 2016). In some published accounts of SSC, the duration has ranged from as few as 15 min (De Chateau & Wiberg, 1977;Vaidya, Sharma, & Dhungel, 2005) to a mean of more than 30 hr, Syfrett 1993 as cited in Moore et al. (2016). The Cochrane review concludes: Despite our concerns about the quality of the studies, and since we found no evidence of harm in any included studies, we conclude the evidence supports that early SSC should be normal practice for healthy newborns including those born by cesarean and babies born early at 35 weeks or more. (Moore et al., 2016, p. 3)

Key messages
• Skin to skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby.
• The most recent Cochrane review of early skin to skin contact cites inconsistencies in the practice.
• A novel algorithm is able to analyze the practice of skin to skin in the first hour and suggest opportunities for practice improvement.
• The tool allows for the analysis of implementation of the practice of skin to skin care in the first hour and illuminate the successes, barriers, and opportunities for improvement in achieving the standard of care for babies.
However, the authors found "inadequate evidence with respect to details … such as timing of initiation and dose" relative to outcomes (Moore et al., 2016, p. 29).
Although giving birth via caesarean is a well-documented barrier to SSC in the first hour (Stevens, Schmied, Burns, & Dahlen, 2014), it is not known whether other obstetrical conditions affect the practice. Robson's criteria have been used most often prebirth to prospectively "compare CS rates in a consistent and actionoriented manner" (Betrán, Vindevoghel, Souza, Gülmezoglu, & Torloni, 2014, p. 1). The Robson 10-group classification system utilizes straightforward obstetric parameters such as parity, singleton or multiple pregnancies, gestational age, spontaneous or induced labour, prior caesarean section, breech fetus, and abnormal positioning, including transverse or oblique. The use of the Robson classification system decreases interpretation and allows comparison across hospital systems, states, and countries. The modified Robson criteria for Canada (Farine & Shepherd, 2012)    Babies progress through nine observable, instinctive stages during the first hour after birth when in immediate, continuous, and uninterrupted skin-to-skin contact with the mother. Stage 8 is suckling, the first experience of breastfeeding.
1. The birth cry is a distinct and specific cry as the baby's lungs expand for the first time.
2. Relaxation is a time immediately after the birth cry ends, when the baby becomes still and has no visible movements.
3. Awakening begins as the baby opens the eyes for the first time, blinks, has small mouth movements, and limited hand and shoulder motions.
4. Activity involves larger body movements, including whole arm motions, specific finger movements, shoulder motion, head lifting, and stable open eyes.
5. Rest could happen at any point during the first hour, interspersed between stages or as a transition between stages.
6. Crawling involves the baby moving purposely towards the breast and nipple. It could be accomplished through sliding, leaping, bobbing, or pushing.
7. Familiarization is a stage at the mother's nipple where the baby licks, tastes, touches, and moves around the nipple and areola area.
8. Suckling involves the baby self-attaching to the nipple and initiating breastfeeding.
9. Sleeping is an involuntary activity of the baby around 1.5 to 2 hr after birth.

Healthy Children Project's Skin-to-Skin Implementation Algorithm
(HCP-S2S-IA; Figure 1), which considers the mothers' condition as she begins the birthing experience according to Robson criteria (Table 2) and then, using the tool, plots the experience of each dyad in regard to immediate, continuous, and uninterrupted SSC after birth.
We conducted iterative analyses of videotapes of immediate, uninterrupted, and continuous SSC in the first hour in two hospitals, one in Japan with mothers who gave birth vaginally and one in Australia with mothers who gave birth via caesarean.

| Data collection-Japan
For the purpose of examining the SSC implementation algorithm, we are analysing data from a Japanese study on newborn behaviour after vaginal birth from a Baby-Friendly designated hospital in Nishio, Japan.
A convenience sample of 14 clinically uncomplicated primipara and multipara mothers gave informed consent to participate into the study, which included videotaping infants during the first hour or so after birth while the babies were in SSC with their mother. The study's inclusion criteria included Japanese-speaking women ≥18 years of age who were healthy and non-smokers. Both primipara and multipara mothers were included if they planned a normal birth with no analgesia during labour. The infants were eligible if they were healthy and born at term and could continue in the study if they had an Apgar score of at least eight at 1 min after birth. Each dyad received a unique code within the study that was also associated with the video record of the first hour after birth. They were placed in SSC, as per hospital routine. The study did not change any hospital protocols or routines, with the exception of the addition of the video recording of the baby for the first hour after birth while in SSC with the mother.
Immediately after the birth, the newborn was placed in SSC ventrally on the mother's abdomen, dried, and covered with a warm blanket. Hospital protocol stated that the baby would remain in SSC continuously with the semireclined mother for at least the first hour after birth unless there was a medical reason to interrupt. The baby was monitored using Pulse Oximetry (Covidien-Nellcor and Puritan Bennett, Boulder, USA) following the Japanese guideline for early SSC (Wyllie et al., 2015). The baby was allowed to move, uninterrupted, through Widström's 9 Stages. The research protocol provided that if the baby was removed by the nurse or delivery ward staff for more than 60 min, the video recording would be stopped. The dyad would then be described as "removed for medical reasons." Demographics and labour medications were collected from the Electronic Medical Record System.
The study was approved by the Ethics Review Committee of the Nagoya University School of Medicine, Nagoya, Japan.
The infant's behaviour while in SSC with mother was video recorded for 1 hr. Subsequently, iterative analysis was performed by two research assistants who had been trained to identify each of

| Data collection-Australia
We also analysed data from an Australian study conducted at a metropolitan public hospital in Sydney, Australia, that has approximately 3,700 births a year. The Baby-Friendly Health Initiative in Australia recommends that for caesarean births, the "baby is placed skin-to-skin on the mother's chest whilst she is on the theatre

| Results-Japanese data set
Analysis of the Japanese dyads is presented in Figure 2. Fourteen mothers consented to participate in the study. They are categorized in Table 3, column "Consenting, prebirth" according to Robson's criteria.
All mothers had a vaginal birth. Five mothers are included in Group 1, nulliparas with spontaneous labour; eight are multiparas with a spontaneous labour, and one is a multipara who was induced.
All 14 babies were immediately placed in SSC with their mother.
None were removed due to hospital policy or emergent care. Thirteen of the 14 babies received continuous SSC with their mother. One baby was removed at 50 min. Seven of the 13 remaining newborns were interrupted by staff who "helped" the newborn to breastfeed during the first hour. Six newborns were uninterrupted. One of the newborns who had immediate, continuous, uninterrupted SSC progressed through Widstrom's 9 Stages and achieved the standard of self-attachment and suckling. The other five newborns did not progress past the Activity Stage (Stage 4).

| Results-Australian study
Analysis of the Australian study is presented in Figure 3. Twenty-one mothers consented to participate in the study. Table 4 categorizes the 21 mothers according to Robson's criteria. All mothers had a repeat, elective caesarean section and were consented before surgery (Robson's category 4B).
One baby was immediately placed in SSC with mother. Seven were placed in SSC with mother within 5 min of birth. Twelve received SSC later than 5 min after the birth (between 5.01 and 65.05 min), and one did not receive any SSC within the first 2 hr after birth. Seven of the mothers who received immediate SSC, or SSC within 5 min of birth, did not experience continuous SSC because they received less than 45 min of initial SSC with mother. The newborns were removed from the mother for routine care. One baby was not removed for routine care. One mother requested the baby to be removed, and it was recorded as "interrupted" on the algorithm. A review of the algorithm (Figure 1) representing the data from the Japanese study indicates that the hospital practice succeeded with immediate SSC for mothers who gave birth vaginally. All newborns in the study were placed in SSC with mother within the first minutes after birth. Short delays (less than 5 min) were observed when the mother needed to move into a position that was more conducive to SSC, for example, after a mother gave birth on her hands and knees (ID-YJ11), she manoeuvred carefully, with the assistance of the midwife, to lay on her back, in a slight incline. This took 3:14 min.
Hospital practices were also successful at supporting the continuous aspect of SSC. Only one infant was removed and that was for routine care at 50 min. Hospital practices could be reviewed to determine whether staffing issues or staff education would help to ensure continuous SSC for at least 60 min, or until the newborn falls asleep (around 90 min after birth), for all mothers.
More than half of the mothers in the Japanese data set were subject to interruption by staff during the first hour after birth. Two of the newborns were moved by the staff. The other five were moved and then latched by the staff to the mother's nipple. We speculate that this may be a result of the historic understanding Step 4 of the BFHI,    Only one of the newborns who received immediate, continuous, uninterrupted SSC in the Japanese data set progressed through Widstrom's 9 Stages, self-attached, and achieved the standard of suckling within the first hour as a continuum of instinctive behaviour.
If babies do not achieve suckling, the hospital might closely examine practices and review elements that could be interfering with a newborn's instinctive behaviour. For example, synthetic oxytocin as well as epidurals containing fentanyl can change a newborn's behaviour during the first hour, resulting in the newborn not progressing to suckling . Robson's criteria applied to the Japanese data set mothers indicates that, of the five mothers in this category, three are primiparas who were not induced and did not have exposure to epidural, one is a multipara who was not induced and did not have exposure to epidural, and one was a multipara who was induced but did not have exposure to epidural. Yet none of the five newborns in this category progressed past the Activity Stage (Stage 4). What else could be inhibiting the newborn's innate behaviour? The algorithm highlighted an area of research that could be proving a barrier to the otherwise implemented advantages of immediate, continuous, uninterrupted SSC. For example, infants who had naso-oropharyngeal suctioning at birth were six times less likely to suckle effectively during the first hour after birth (Cantrill, Creedy, Cooke, & Dykes, 2014). One speculation is that the use of iodine during the birthing process, which has a strong and distinct odour, may be interfering with the instinctive behaviour of the newborn to smell the amniotic fluid and the colostrum/Montgomery gland scents as a directive to the breast (Porter, 2004;Porter & Winberg, 1999). Iodine has an intensifying impact on olfactory cells as well as a negative effect on eyesight. More exploration is needed to clarify the findings.

| Discussion-Australia
We examined the data of Australian mothers who gave birth via elective caesarean in relation to the standard of immediate, continuous, uninterrupted SSC with the goal of progressing to selfattached suckling followed by sleep. Only one newborn in the study was placed in SSC with a mother immediately after birth (Figure 3).
Short delays (less than 5 min) were observed in seven of the mothers before they received their newborn in SSC in the operating theatre. Hospital practices prevented 13 of the dyads from receiving immediate SSC.
A further review of the HCP-S2S-IA indicates that hospital practices also interfered with the continuous aspect of SSC. Seven of the eight newborns who were placed in SSC within 5 min of birth were removed within the first hour. In this example, hospital practices might be reviewed to examine whether or not staffing or staff education would help to ensure continuous SSC for at least 60 min, or until the newborn breastfeeds and falls asleep (around 90 min after birth).
Examination of uninterrupted SSC in the Australian data set indicates that the single mother who did not have her newborn removed for routine care by the staff asked for the newborn to be removed due to nausea. According to analysis, 20 of the 21 Australian newborns were unable to complete at least 60 min of SSC due to hospital policies or routine care. The tool provides feedback to the  The algorithm allows review and deeper understanding of the barriers to best practice of immediate, continuous SSC during the first hour after birth. The first question concerns immediate SSC between the mother and baby. Was the newborn placed immediately (within 5 min) on the mother's chest? What could be preventing this implementation of best practice? This could be the case if the hospital has a protocol, for example, that includes babies born by caesarean in the classification of those who should not be eligible for immediate SSC. This was the case for a number of mothers in the Australian study.
Other challenges could be a policy about births that occur in the Emergency Department or if certain anaesthesia was used. Perhaps the hospital has no policy about SSC as best practice, and implementation is based on staff preference or mother request. Does the facility not allow for staffing the required number of nurses to enable SSC?
Perhaps swaddling or washing or routinely assessing every baby while on a warming table was required by protocol, or conducted by staff choice, before SSC could be started. These would be included as No: Hospital Policy or Protocol on the algorithm. This categorization could highlight for the hospital the barriers to best practice.
None of the separation in our two example cases revealed prevention of immediate SSC due to emergent care for the mother or infant. This would have been the categorization if newborn did not have an initial birth cry or had a low 1-min Apgar requiring transfer to the NICU team, rather than to the mother's chest, or, the mother has haemorrhaged, requiring the newborn to be placed elsewhere. It is vital for a hospital to recognize if the lack of immediate SSC contact is due to hospital policy or a need for emergent care. Each reflects opportunities for more in depth review or quality improvement projects.
The next element of the model considers continuous SSC during the full first hour or so. Continuous SSC is vital for the warmth, respirations, and colonization of the newborn. Because the newborn will need to begin again the progression through Widström's 9 Stages after separation from the mother, any separation can be problematic because the newborn has limited time before falling asleep after birth.    including the timing of initial SSC, the duration, and the concept of continuous contact. A study of Australian midwives highlighted their understanding of the importance of SSC, but not of the importance of "continuous, uninterrupted" SSC (Cantrill, Creedy, & Cooke, 2004).
By highlighting the challenges of immediate, continuous, uninterrupted SSC, hospitals can illuminate where they are not yet meeting best practice, as well as understand a path forward towards best practice.
Although based on evidence, this algorithm is illustrated on only two sets of data. Implementation of the algorithm in different locations will strengthen the ability to compare and contrast strengths and barriers of different settings, allowing shared understanding of the challenges of implementing immediate, continuous, uninterrupted SSC. It is vital that the algorithm continues to focus on clinical practice, rather than the "result" of simply suckling, because that misunderstanding of the early interpretations of Step 4 of the BFHI resulted in helping the newborn to breastfeed, with unfortunate consequences.

| CONCLUSION
We

ACKNOWLEDGMENTS
The authors would like to acknowledge the generosity of the mothers, babies and hospital staff in our research studies.

CONFLICTS OF INTEREST
The authors declare that they have no conflicts of interest.

CONTRIBUTIONS
KB and KC substantially contributed to the creation of the algorithm.
JS substantially contributed to the data and analysis, with KB and KC, of the Australian caesarean data into the algorithm. YT substantially contributed to the data and analysis, with KB and KC, of the Japanese vaginal birth data into the algorithm. All authors contributed to the writing of the paper. All authors contributed to the interpretation of the data, drafting and revising the article, and final approval of the version to be published.