Recent years have seen a significant trend towards increased family‐centred care (FCC), an approach that promotes mutually beneficial partnerships between parents and healthcare professionals in the care of babies in neonatal intensive care units (NICUs). 1 The approach can be extended to include the delivery room, expecting that optimal health outcomes will be achieved when the parents play an active role in supporting their extremely preterm babies right from birth. Facilitating a neonatologist‐supervised first cuddle between parents and their newborn in the delivery room is the ideal way to commence and promote the special partnership between parents and healthcare professionals in their baby's care.
While early physical contact including skin‐to‐skin care is well established for extremely preterm babies within neonatal units, it is not routinely commenced in the delivery room setting in most centres. A Swedish survey of first‐time events experienced by parents showed that only 30% of mothers (and 29% fathers) of 81 babies born 28–33 weeks’ gestation got to hold their baby in the delivery room 2 ; a UK survey of 32 mothers of babies born at 24–32 weeks’ gestation in 2011, showed that no parents held or touched their baby until in the NICU and the first cuddle often occurred weeks after birth. 3
Following initial resuscitation/stabilisation, our centre has offered mothers the opportunity to cuddle their swaddled newborns for several minutes before NICU admission, irrespective of birth gestation, 4 with ongoing intensive care provided throughout. The ‘delivery room cuddle’ (DRC) has been practised at preterm deliveries in our centre for ~15 years. In early years it was offered only sporadically, that is, by only a minority of attending consultants according to their personal practice, though in more recent years it is now offered routinely as senior doctor/nurse/advanced neonatal nurse practitioner teams have gained experience and enthusiasm in its practice. Our practice of the DRC involves only limited direct skin‐to‐skin contact, as baby has been placed in a polythene bag and swaddled in a towel beforehand.
In this paper we: i) review the safety of the DRC practice in extremely preterm babies born in our centre; ii) elicit parents’ perspectives and feedback on the practice; iii) discuss the rationale for DRC being routine delivery room practice; and iv) share our experience of practical and safety considerations for practising the DRC.
Eligible babies were inborn in our hospital at <27+0 weeks’ gestation, without major congenital abnormality, and admitted to our tertiary‐level NICU in the 12‐year period 2006–2017. We reviewed birth history notes recorded in electronic patient records. We identified those with a documented DRC prior to NICU admission (DRC group), and compared them with a closely contemporaneous group of inborn infants matched for birth gestation and multiplicity, then (as far as possible) sex and delivery mode, whose written delivery room record indicated that they had been only ‘shown to parents’ prior to NICU transfer (control group). Main short‐term safety outcome measures of interest were inadvertent extubation during DRC, admission time and temperature on arrival to NICU, and survival to discharge. Data were compared using the Mann–Whitney and chi‐square/Fisher's exact tests as appropriate. This review of routine service provision did not require formal ethics approval.
We surveyed parents of babies born <27+0 weeks’ gestation who had a DRC in the 13‐year period 2006–2018. Of 32 mothers identified, we excluded nine bereaved mothers whose infants had subsequently died, and one mother who died post‐partum. Between June and December 2018, we invited 22 mothers of still‐living babies to participate in a web‐based questionnaire. A single reminder email/letter was sent to non‐responders. The questionnaire (Appendix S1) was developed with the input of a mother (EA) with personal experience of a DRC with 23‐week twins. 4 This service evaluation did not require formal ethics approval.
Our NICU admitted 396 babies born <27+0 weeks’ gestation in the 12‐year study period; 233 (59%) were inborn. 27 (12%) received a DRC prior to NICU transfer. The DRC followed initial on‐resuscitaire stabilisation which included endotracheal intubation in all but one case, and surfactant administration (endotracheally) in 25/27 cases. Table 1 presents baseline demographic data and short‐term safety outcomes. No inadvertent extubation was recorded during any DRC episode. There were no significant differences in age at NICU admission, admission temperature or survival to discharge for the 27 DRC babies versus controls.
n = 27
n = 27
|Birth gestational age, weeks+days||24+6 (22+5–26+5)||24+4 (23+1–26+5)||0.89 a|
|Birth weight, grammes||728 (506–1170)||685 (545–1132)||0.50 a|
|Singleton:Twin, n:n||18:9||17:10||1.00 b|
|Male:Female, n:n||15:12||15:12||1.00 b|
|Delivery mode vaginal:caesarean, n:n||26:1||23:4||0.20 c|
|Apgar score at 1 min||5 (1 to 9)||5 (0 to 9)||0.29 a|
|Apgar score at 5 mins||8 (2 to 9)||7 (1 to 10)||0.14 a|
|Apgar score at 10 mins||8 (5 to 10)||7 (3 to 10)||0.29 a|
|Postnatal age at NICU admission, minutes||19 (11–41)||21 (11–37)||0.53 a|
|Admission temperature, °C||36.5 (34.0–38.5)||36.6 (33.1–38.2)||0.89 a|
|Survived to discharge, n (%)||18 (67)||17 (63)||1.00 b|
12/22 (55%) mothers responded. Their index birthing had occurred 0.25–12 years previously: ten vaginally and two emergency Caesarean. Two were mothers of 23‐week gestation twins, and two were mothers of 26‐week gestation twins. All remembered being given their newborn baby/babies to cuddle in arms in the delivery room before NICU admission (10 vividly, 2 vaguely) and associated feelings. On a Likert scale (0=not at all important, 10=extremely important) they rated the importance of this first cuddle with median score 10 (range 4–10, IQR 9.9–10). Six reported feeling relieved/reassured; six reported intense feelings of pride and love; three reported initially feeling scared at the prospect of holding their tiny baby with additional comments reflecting anxiety that their baby's intensive care may have been delayed (Appendix S2). Nine reported being able to have a photograph taken during that first DRC, often very appreciated (Appendix S2).
We asked how important it was ‘that neonatal doctors/nurses try to offer, as far as possible, mothers of newborn premature babies an initial cuddle in the delivery room…’. Rating on a Likert scale (0=not at all important, 10=extremely important), the 12 respondents gave median rating 10 (range 5–10, IQR 9.25–10).
Figure 1 shows a selection of comments from respondent mothers regarding what the first cuddle meant to them, and Appendix S2 provides all free‐text comments returned. A pertinent reflection is provided by a co‐author (EA) on her DRC (Appendix S3).
Following acute delivery room stabilisation of the extremely preterm baby, immediate NICU admission has traditionally been considered absolute priority. Parents have generally, therefore, only been allowed a brief cursory ‘showing’ of their baby before its urgent transfer to the NICU. Other reasons the DRC is not yet routine may include concerns regarding the lack of safety and outcome data in extremely preterm infants, and an absence of published practice guidance. Importantly, practitioners may not have considered the direct involvement and needs of parents in the immediate postnatal management of extremely preterm babies, their views and wishes regarding this first early cuddle, and potential mutual benefits of the DRC. Waiting until after NICU admission, when remote from their mothers, inevitably decreases the chance for very early infant‐maternal contact. Facilitating a first, early cuddle then becomes logistically far more challenging, when the constraints of incubator, lines, tubing, monitor wires and ongoing procedures pose real physical barriers – explaining why many weeks can thus pass before the first cuddle.
Parental cuddling of extremely preterm infants is not a new intervention. A strong body of evidence already supports the safety and efficacy of ‘kangaroo‐care’ skin‐to‐skin contact in the NICU, even from the earliest days, in both short‐ and long‐term outcomes. 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 In meta‐analysis of low, middle and high resource settings, kangaroo care was associated with lower mortality, lower incidence of neonatal sepsis, and improved head growth in low and very low birth weight infants. 6 During skin‐to‐skin contact, infants demonstrate enhanced physiological stability in respiratory rate and regularity, glucose homeostasis, reduced incidence of apnoea and cyanosis, increased oxygenation, improved thermoregulation and better pain measures. 5 , 6 , 9 In addition, infants receiving skin‐to‐skin care have enhanced sleep–wake cycling with longer sleep cycles, and electroencephalographic evidence of accelerated brain maturation, 11 , 12 with potential for enduring neurobehavioural, neurodevelopmental and social benefits. 8 During cuddles, parental stress reduces, feelings of parental competence increase, 6 , 7 and increased rates of successful lactation and sustained breastfeeding are observed. 5 , 6 , 9 The European Foundation for the Care of Newborn Infants, a parent‐led organisation, considers early skin‐to‐skin care to be of ‘particular importance’ for very preterm infants and recommends skin‐to‐skin contact be initiated as early as possible as standard care. 14
Nevertheless, the literature describing parent–infant cuddling within the delivery room, or very early (first‐hour) following very preterm birth, is sparse and recent. It includes a first case report in a 23+1 ‐week twin, 4 a small case series of 10 preterm babies (28–32 weeks’ gestation) 15 and two small randomised controlled trials (RCTs): Linnér et al. reported 55 babies (gestational age range 28+0–33+6) randomised to immediate stabilisation on maternal chest after birth with skin‐to‐skin contact for the first postnatal hour, or immediate stabilisation on a resuscitaire. Infants in the immediate skin‐to‐skin group were marginally cooler at 1 hour (mean: 36.3°C vs. 36.6°C, p = 0.03) 13 ; Mehler et al. reported 88 babies (mean gestation 29 weeks, range 25–32) randomised to either 60 mins of delivery room maternal skin‐to‐skin contact or 5 minutes visual contact only. Intubated babies and those needing >40% oxygen were excluded. Quality of mother–child interaction responses (primary outcome) at 6 months corrected age was better (p = 0.04) in those who received direct early skin‐to‐skin contact. NICU admission temperature was higher in the early skin‐to‐skin contact group (median: 36.6°C vs. 36.1°C, p < 0.001). The authors concluded that delivery room skin–skin contact promotes maternal‐child interaction, decreases maternal depression and bonding problems, and may benefit preterm development. 16
In our experience, mothers invariably want to cuddle their extremely preterm newborns. Cuddling the newborn baby in arms after birth is instinctive for parents, irrespective of gestation. Abrupt separation and removal of the baby to NICU are traumatic. A calm, supervised initial cuddle gives an opportunity for neonatologist and neonatal nurse to provide initial reassurance to parents, for parents to meet and form an initial physical and psychological bond with their baby, touch, kiss, smell, and perhaps hear them, and for baby to feel their first embrace. The DRC provides a brief moment of calm that can be enjoyed by both in anticipation of potential storms that may lie ahead after NICU admission and may help parents transition to their new ‘parental role’. 3 Parents can whisper their first words and – assisted by attendant staff – get their first family photographs/video together. Appendix S4 provides a short video clip illustrating one mother's DRC with her 22‐week gestation newborn; Figure 2 presents typical delivery room timings illustrated by this case.
The first minutes and hours after birth are now recognised as crucial for the formation of a tight bond between mother and infant. This ‘early sensitive period’ is a time of heightened maternal sensitivity and responsiveness, thought to be oxytocin mediated. 17 Facilitating contact in this period may improve quality of mother‐preterm baby interactions and increase chances for long‐term secure attachment. 17 This may be especially the case for the mothers of extremely preterm infants where abrupt separation at birth and often no direct maternal contact for weeks has hitherto been the accepted norm and expectation.
A further compelling justification for the DRC is that extremely preterm infants remain a very high‐risk group for mortality. One cannot easily predict at birth which babies are destined to deteriorate rapidly in the first hours, days or weeks thereafter. If a first cuddle is offered to parents only when a baby is dying or terminally ill, 4 some parents out of utter grief feel unable to hold their baby in such circumstances and may live with consequent guilt.
Potential risks include accidental extubation, medical gas disconnection, cold exposure, poor handling of baby and possibly hypoglycaemia. Mitigation of risks necessitates assiduous attention to cardiorespiratory and thermoregulatory monitoring throughout, and is achieved by having an experienced team lead, clear communication and a shared mental model of the DRC process. A pre‐cuddle briefing should identify an infant's eligibility/stability for a DRC and empower the team to abandon or curtail the process in case of physiological instability. Roles should be assigned for safeguarding the airway, and moving/handling of infant and equipment. Clear inter‐specialty communication is imperative. Anaesthetic/maternity teams will enable a clear path between infant and mother, but must first also confirm that there is no maternal contraindication or pending intervention which should delay or prohibit the DRC.
The process for achieving a safe DRC is outlined in Figure 3. Exact procedure will vary depending on available equipment, but no additional equipment is required beyond that commonly used for standard delivery room and NICU care (Figure 4).
The DRC takes place after initial on‐resuscitaire stabilisation, including surfactant administration if indicated. 18 The baby will remain ventilated as appropriate, in accordance with local protocols, either by non‐invasive support (eg nasal continuous positive airways pressure (CPAP) or high flow) or via endotracheal tube with secured airway. If lacking facility to provide definitive non‐invasive respiratory support during the DRC, CPAP may alternatively be delivered manually using facemask and T‐Piece with adjustable positive end‐expiratory pressure valve. 15 This method, however, requires a skilled practitioner to assure adequate airway positioning. If available, heated‐humidified gases may help maintain normothermia and enhance lung compliance. 19 , 20 Respiratory stability and normothermia should be confirmed prior to moving baby from resuscitaire to maternal chest.
Monitoring during DRC should be continuous and include oxygen saturations, heart rate, capnography (if intubated) and temperature. We routinely site an axillary skin temperature probe shortly after birth. The cuddle lasts for 5–10 minutes in our current practice.
Naturally, parents may feel scared and anxious immediately following birth. It is imperative they are emotionally supported and involved in the decision to have a DRC. If not already discussed ante‐partum, an experienced member of the neonatal team should update parents on baby's condition, describe the DRC process and offer the one‐off DRC opportunity.
In our practice, we specifically seek to reassure and encourage parents that their baby:
The DRC can be facilitated for most extremely preterm babies. We do not impose any lower gestational age cut off and have successfully practised the DRC for the benefit of both mothers and babies even at 22–23 weeks’ gestation 4 (Table 1; Figure 2; Appendices S3 and S4). In some situations, the DRC is impossible, unfeasible or inappropriate, for example acutely unwell mothers requiring medical stabilisation post‐delivery, or Caesarean delivery under maternal general anaesthesia. Fathers should not be overlooked in such circumstances and welcome the chance to hold their babies. The DRC will be contraindicated in babies requiring urgent ongoing stabilisation (eg prolonged respiratory or cardiovascular instability) or interventions which cannot be supported within the delivery room during a cuddle, and with certain congenital malformations.
It is essential to have the whole team on board. A written unit guideline helps 15 ; regular simulation training sessions will increase team confidence, awareness and consistency 21 ; medical, nursing and midwifery champions can help troubleshoot and enthuse. While we routinely support DRC periods of up to 10 minutes, practising for shorter durations may initially feel more comfortable until confidence and experience is gained. Even a brief DRC is preferable to no contact. Prospective audit of DRC practice, including NICU admission time, temperature, blood glucose and parental feedback is recommended. Changes we have implemented include improved communication with parents before and during DRCs, and protocolised continuous skin temperature monitoring to assure admission normothermia. Routine early continuous temperature assessment has reduced rates of admission hypothermia in our centre compared with these historical cases. 22
Evidence to date suggests that the risk of perinatal transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) is low. 23 , 24 , 25 , 26 , 27 For asymptomatic parents and/or those confirmed SARS‐CoV‐2 PCR negative, continued facilitation of the DRC should be safe, with adherence to appropriate personal protective equipment and local infection control guidelines. 26 , 28 For parents symptomatic or confirmed as SARS‐CoV‐2 positive, it would seem prudent to avoid routine early skin‐to‐skin contact until more is known about the risks of SARS‐CoV‐2 transmission to extremely preterm infants.
This is the first paper to describe the concept, rationale and practice of the DRC for extremely preterm infants (<27+0 weeks’ gestation) needing invasive or non‐invasive respiratory support, a sub‐group not yet described within the current literature. We provide preliminary safety data and parental feedback from service evaluation of our routine practice, supporting the DRC in this population. In our practice, the DRC did not delay NICU admission, nor lead to any difference in admission temperatures.
Limitations relate to the retrospective nature of our data from a relatively small cohort. While 12% of inborn infants had a DRC recorded in their birth history, other infants may have received a DRC and been excluded inadvertently due to lacking documentation. Additionally, the risk of selection bias with more stable infants receiving the DRC cannot be excluded. We are unable to report duration of the DRC, heart rate/oxygen saturation trends, admission blood glucose and pH as these items were often unrecorded in the historical records. Long‐term outcomes have not been assessed.
Our survey excluded bereaved parents. Nevertheless, our personal experience is that bereaved parents particularly cherish DRC memories. 4 One bereaved mother expressed deep regret she was never given the opportunity to cuddle her extremely preterm twins following birth elsewhere (Lottie King, personal communication via Twitter, 9th July 2018) (Figure 5).
Parents appreciate the DRC and would like it to be offered routinely. Effective communication and assiduous monitoring are vital throughout. Over the next few years, further evidence regarding the safety and benefits of the DRC will emerge from prospective studies presently underway in centres that have already adopted the practice as routine, and from currently recruiting trials. 29 , 30 With the inexorable move towards increased FCC, we predict that an early facilitated cuddle between mothers and their extremely preterm babies will in time become standard care for most babies before NICU admission and, furthermore, will become expected by parents.
For the future, we believe that the recent pioneering studies in very preterm infants 16 , 29 , 30 pave the way for trials that must include extremely preterm infants. We speculate that eventually their first hour(s) of intensive care will be spent at the maternal bosom, their natural incubator.
EA and SA have direct experience of the delivery room cuddle as mothers of extremely preterm‐born babies. There are no competing interests and no conflict of interests to declare in relation to this work.
This study was reviewed by the Research Services Manager of the Norfolk and Norwich University Hospitals NHS Foundation Trust. It was judged that the study met the definition of a service evaluation/audit and did not require formal ethical approval or NHS permissions.
Data from this study were previously presented in abstract form at the REASON Neonatal Meeting, Warwick, UK, July 2018, 7th Congress of the European Academy of Paediatric Societies (EAPS), Paris, November 2018, and at the 3rd jENS Congress of joint European Neonatal Societies (jENS), Maastricht, September 2019.
We thank Julie Dawson, Research Services Manager, for reviewing the study. The authors sincerely thank all parents who responded to the survey with their valuable comments, and Lottie King for encouragement and permission to publish her comments. The video clip illustrating the DRC in a 22‐week gestation newborn (Appendix S4) is shared with the kind permission and written consent of both parents. Dr Clarke wishes to sincerely thank all his medical, nursing, midwifery and obstetric colleagues in Norwich for their enthusiastic support of the DRC practice over many years. We are most grateful to Cathy Phillips and the REASON meeting organising committee for having first invited us to present our work, and to the three anonymous referees for positive and constructive comments on our earlier manuscript version.
Anonymised data collected for the safety review are available from the following online repository: http://dx.doi.org/10.17632/mc39c53xp2.1 The parental questionnaire pro‐forma is provided in Appendix S1.