The benefits and effects of skin to skin contact and the initial breastfeeding latch, immediately after birth, are widely known: increased rate and duration of breast feeding, maintenance of the neonate’s blood glucose and temperature, cardio-respiratory stability in preterm neonates, improved maternal attachment behavior and reduced crying [
8,
11,
15,
17,
19]. Furthermore, it is a practice recommended by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the Center for Disease Control and Prevention, the Academy of Breastfeeding Medicine as well as being promoted by Unicef and its Baby Friendly Initiative [
1‐
3,
6,
22]. Yet, at present, skin-to-skin contact is not widely adopted in delivery wards, the main reason being a lack of knowledge and education about contact at birth, and the absence of standardized guidelines for skin-to-skin contact [
15‐
17]. Moreover, the association between early skin-to-skin contact and what is known as Sudden Unexpected Postnatal Collapse has been frequently reported and clearly described in literature on the subject [
5,
11,
12,
16,
17,
19,
20]. Sudden Unexpected Postnatal Collapse (SUPC) of presumably healthy infants, within a few hours or days from birth, is a rare but recognized event. It includes any condition resulting in cardio-respiratory failure or permanent cessation of breathing [
4,
5,
7,
10,
11]. The definition of SUPC varies, depending on the population studied and the authors of the publication [
9]. According to the British Association of Perinatal Medicine, SUPC includes any apparently healthy neonate at, or near term (> 35 weeks gestation), who is well at birth (with a normal 5 min Apgar score and deemed able to support routine postnatal care) or considered well enough for skin-to-skin contact and routine postnatal care, suddenly collapses, i.e. is discovered in a state of cardio-respiratory extremis, such that resuscitation with intermittent positive pressure ventilation is required; or the newborn collapses within the first 7 days of life and either dies, or requires intensive care, or develops encephalopathy [
21]. Although rare, SUPC can have serious consequences: in Herlenius and Kuhn’s review, both neurologic sequelae in survivors, as well as mortality, are reported as high as 50% [
14]. The estimated incidence of SUPC in the first hours to days of life also varies greatly, due to differing definitions, the inclusion and exclusion of criteria, and the lack of standardized reporting; however it is considered to be 2.6–133 cases per 100,000 newborns [
10,
14]. Many risk factors have already been identified and thoroughly discussed in literature, among them are primiparity; unattended skin-to-skin contact and initial breastfeeding; mother distracted by avoidable circumstances (i.e. messaging, phoning); prone and side position of the neonate; mother’s lack or little experience in breastfeeding; and inability to identify changes in the neonate’s appearance and behavior [
5,
7‐
9,
13,
14,
18]. All of these, in different ways, influence the outcome of skin-to-skin contact and may be responsible, wholly or in part, for SUPC. In particular, early skin-to-skin contact in the first 2 hours of life coincides with the first two periods of the transitional phase from fetal to extra uterine life: the first period of reactivity, which covers the first 30 minutes of life, and the period of decreased responsiveness to stimuli, which lasts an hour and a half, followed by a second period of reactivity [
14]. It is during these 90 min of decreased responsiveness that the risk factors for SUPC occurring during early skin-to-skin contact are at their highest and most dangerous. Diagnosis of SUPC requires ruling out other potential medical conditions, e.g. sepsis, cardiac disease and metabolic disease [
9]. Our study clearly describes the organizational aspects of the delivery wards when a birth takes place and highlights the following: a lack of standardization of the timing and duration of early skin-to-skin contact and of the way it is performed; a lack of organization of the single delivery wards (no standard timing of routine newborn care, and recording the monitoring of vital signs during early skin-to-skin contact on the clinical chart in only 9/28 wards in 2012, increased to 13/26 in 2016, but still not a significant practice); codified and written procedures of skin-to-skin contact (present only in 12/28 delivery wards in 2012 and in 10/26 in 2016); a lack of counseling on the potential risks of unsafe positions of both mother and baby during early skin-to-skin contact; a lack of continuous observation of mother-baby dyad during early skin-to-skin contact (in nearly half of the delivery wards); and a potential safety issue concerning weak lighting (in 13/28 wards in 2012 and in 6/26 in 2016, while only just sufficient to see the neonate’s vital signs in the remaining wards, a very slight improvement). Yet what also emerges from this survey is the strong effort made to promote and implement early skin-to-skin contact: in all the delivery wards after a natural birth, in 11 out of 28 wards after caesarean sections in 2012, 11/26 in 2016; and suggested to mothers who have given birth under sedation in 12/28 delivery wards in 2012 and 13/26 in 2016 - not a significant improvement however. Moreover, the skin-to-skin operation in the operating room requires the presence of dedicated personnel to assist the mother-child dyad. The monitoring of the mother-infant dyad is therefore very close, and consequently also the prevention of SUPC. To date, research on SUPC has focused mainly on the definition, etiology, incidence and clinical aspects of SUPC. Our study focuses instead on the practical and organizational aspects of the delivery wards that may lie behind the occurrence SUPC, highlighting on one hand the importance of first carefully and thoroughly assessing all those aspects that must be addressed and modified to minimize, as much as possible, the risk of SUPC; on the other hand the necessity of then standardizing the timing and duration, and the methods and procedures of early skin-to-skin contact. Attempts to standardize methods and procedures aimed at providing safe post-partum transition, and safe, immediate and uninterrupted skin-to-skin contact with continued monitoring of mother and neonate have already been made. However, none of these have yet been proven to concretely reduce the risk of sentinel events and SUPC. The AAP has recently collected and organized all available suggestions supporting the safe implementation of skin-to-skin contact, together with rooming-in guidelines [
9]. Our longitudinal survey (2012 vs. 2016) reveals that although there are no certain indications for preventing SUPC, the individual delivery wards tend to spontaneously improve assistance, based on the international literature available, although not always in significant measures (for example, skin-to-skin contact in the operating theatre; the constant presence of hospital staff; sufficient illumination in the room for the correct observation of the newborn, etc.). Other aspects need to be specifically addressed and important modifications made (i.e. availability or posting of written procedures; suggesting safer positions to mothers, etc.). In light of all that emerged from our survey, we hereby offer the following recommendations, the efficacy of which we intend to evaluate after having been applied for a pre-determined period of time [
23‐
27]:
-
Complete, clear and detailed information on the advantages of skin-to-skin contact, as well as on the associated risks and safety concerns, should be always given, both orally and written, to mother and partner before birth takes place.
-
All efforts should be made to assure continuous monitoring of mother and neonate during early skin-to-skin contact, and even more so if the mother is primiparus, exhausted or has been sedated.
-
As soon as the mother is admitted, parents should be invited to temporarily give up the use of mobile phones, or any other electronic gadget which might cause distraction, leaving them with staff during birth and early skin-to-skin contact [
18].
-
Technical details such as room lighting or calling for help systems, should be assessed periodically and renewed or replaced when necessary.
-
Non-routine monitoring with pulse oximetry, if not in particular conditions such as absence of family member, language barrier, excessive workload, reduced personnel [
28].
In 2017, the Department of Health of the Piedmont Region in collaboration with that of the Valle d’Aosta Region organized an update day for all the directors and the heads of the birth points of the 2 regions in order to report the surveillance data carried out in the 2012 and 2016, to reaffirm the good practices related to the birth event and to share systematic improvement actions. In all 28 of the delivery wards surveyed in Piedmont and the Aosta Valley, a new protocol on the physiological approach to newborns is currently in progress: another survey will be carried out during the course of next year (2020) to assess changes after its application.
In all 28 of the delivery wards surveyed in Piedmont and the Aosta Valley, a new protocol on the physiological approach to newborns is currently in progress: another survey will be carried out during the course of next year (2020) to assess changes after its application.
The survey carried out has some methodological limits, in fact the answers regarding the timing of the start of skin-to-skin contact and the consequent duration, despite the survey asked to specify the average interval in minutes from the beginning of the contact and duration, offering three response options (at least 30 min, at least 1 h and at least 2 h), in the absence of objective data can only represent the general impression of the people who completed the questionnaire. Furthermore the causes of suspension indicated with “on obstetric indication” or “on pediatric indication”, were not specified by the participants in the survey. Unfortunately in Italy and in the Piedmont and Valle d’Aosta regions there is no register for SUPC reports, the cases identified have been reported as anecdotal cases. Furthermore, the description of practice in the delivery rooms is linked to the answers to a questionnaire and there has been no description by external observers who have capillaryly observed the habits of each birth point “live”.