Delivery room skin‐to‐skin contact for very preterm infants promotes mother–child interaction and bonding

The concept of zero separation of a mother and her preterm infant has gained increasing attention within the recent years. Early skin-to-skin contact (SSC), ideally starting from birth has positive effects on parenting and attachment. Recently, a review article summarised the existing evidence on the benefits of early SSC for all gestational ages and provided a pragmatic implementation guide.1 From 2012 to 2015, we conducted a randomised controlled delivery room skin-to-skin study2 including firstborn singletons between 25 and 32 weeks of gestation, with the purpose to evaluate a standardised SSC-intervention to improve the quality of the mother–child-Interaction and bonding and thereby to enhance the neurodevelopment of this preterm infants and to reduce possible behaviour problems. After initial stabilisation, the standard care infants were allotted 5 min of visual contact with their mothers. Infants randomised into the intervention group received 60 min uninterrupted, supervised SSC. The results of our studies on the effects of delivery room (DR)-SSC on parenting are summarised in Table 1. In detail, the intervention group benefitted from the DR-SSC regarding maternal depressive symptoms, mother child interaction (MCI) and bonding. In a second step, we compared the MCI results of both preterm groups with a group of healthy mother and term infant pairs with zero separation within the first hours after birth.3 We found that DR-SSC brought MCI of preterm infants close to normal. Since 2015, when the delivery room SSC study was completed, DR-SSC has been implemented in our delivery room protocol as standard of care for all infants regardless of gestational age and birthweight. The preferred mode of delivery for infants <30 weeks of gestation in our centre is Caesarean section. After delivery, the infants are transferred to the preheated resuscitation unit, covered with a transparent wrapping, and started on CPAP delivered via mask and Benveniste valve. After 5 min we should see a stable breathing pattern. A pharyngeal tube is inserted to continue CPAP. Of note, in our centre all infants born <28 weeks of gestation are treated with surfactant via less invasive surfactant application (LISA) in a quasi-prophylactical approach. More than 90% of premature infants with a gestational age >23 weeks who need surfactant are eligible and receive surfactant via LISA. DR-SSC is started approximately 45 min after birth and is continued for 60 min supervision by the neonatal team. For SSC, infants are placed naked on their mother's chest in comfort position (e.g. left or right lateral) and covered with a transparent polyethylene wrap and a blanket. Room temperature is set to 24°C by automatically controlled heating. Infants' heart rate, respiratory rate, FiO2 and oxygen saturation are recorded continuously. Temperature is measured by a skin sensor if the infant is placed on the delivery room unit but not during DR-SSC for technical reasons. Continuous supervision of both, mother and infant is guaranteed by the attending neonatal team. Fathers are encouraged to be present during the intervention, but DR-SSC is restricted to mothers. Potential disturbances (medical staff entering and leaving the room, frequent talking of the supervising neonatologist to staff or parents) are to be kept at a minimum to give the parents the opportunity to completely concentrate on their infant. Duration of DR-SSC is variable, but we aim for at least 30 min depending on maternal and infant stability, After DR-SSC infants are transferred to incubator care at the NICU. Early SSC can be performed safely even in extremely immature infants if the staff is trained accordingly, and continuous supervision is guaranteed.2 Although SSC in the form of intermittent Kangaroo mother care (KMC) at the NICU has become standard of care worldwide, early or delivery room SSC in immature infants directly after initial stabilisation is still limited to few centres. However, the concept of early SSC is intriguing for several reasons. First, unique neuroendocrine changes regularly take place in the mother around birth. Most important, maternal oxytocin, a hormone that facilitates maternal sensitivity, peaks during labour and after delivery. SSC after birth further activates oxytocin release and higher oxytocin levels positively affect parent infant interaction.4 A randomised controlled study including healthy term infants demonstrated that separation within the first hours after birth results in less optimal mother child interaction 1 year later.5 Secondly, it may take several days until the mother has recovered sufficiently to visit her infant at the NICU and start KMC sessions. Even in Swedish NICUs, where early and continuous SSC has strongly been promoted for decades, only 5% of infants with a gestational age <28 weeks had SSC on the first day of life.6 Although the concept of early SSC is attractive for all gestational ages a recent review article emphasised the lack of studies on the effect of SSC on parenting in very immature infants.7 For term or moderate/late preterm infants early SSC, defined as within 180 min after birth was associated with beneficial effects regarding parenting such as improved interaction and higher maternal satisfaction. For very immature infants, data is limited to our RCT2 and parental reports. A silver lining, several study protocols have been published aiming at the effects of DR-SSC on neurodevelopment and parenting in preterm infants, but results are pending. Our research demonstrated the safety and benefit of DR-SSC for infants >25 weeks of gestation. However, our results and our approach may not readily be transferable to different settings. In our centre, DR-SSC is embedded in a bundle of interventions aiming for a minimal stress transition to extrauterine life. DR-SSC is a team effort and successful implementation requires close collaboration of the experts caring for both, the neonate and the mother. Issues such as supervision and monitoring of both mother and infant, timing of surfactant application and temperature management need to be discussed and adjusted to the centre specific requirements and standards of care. Katrin Mehler: Conceptualization; writing – original draft; investigation; funding acquisition. Angela Kribs: Conceptualization; writing – review and editing; supervision. Ruth Klein: Investigation; writing – review and editing. Eva Heine: Investigation; writing – review and editing. Patricia Trautmann-Villalba: Writing – original draft; investigation; methodology; validation; data curation. No funding was received. Open Access funding enabled and organized by Projekt DEAL. None of the authors declare a conflict of interest.