Thursday, October 30, 2008

Evidence-Based Practices for the Fetal to Newborn Transition

I've been going through my files and came across this article that I haven't posted yet. Email me if you'd like the full text. I've included a few excerpts from the full text, as well as the article's abstract.

Evidence-Based Practices for the Fetal to Newborn Transition
Judith S. Mercer, CNM, DNSc, Debra A. Erickson-Owens, CNM, MS,
Barbara Graves, CNM, MN, MPH, and Mary Mumford Haley, CNM, MS
Journal of Midwifery and Womens Health 52 (2007): 262–272.

The transition from fetus to newborn is a normal physiologic and developmental process—one that has occurred since the beginning of the human race. Many hospital routines that are used to assess and manage newborns immediately after birth developed because of convenience, expediency, or habit, and have never been validated. Some practices are so ingrained that older traditional practices, such as providing skin-to-skin care or delaying cord clamping, must be considered “experimental” in current studies. However, recent research is beginning to identify some older practices that should not have been abandoned and some current practices that should be stopped. In order to achieve a gentle, physiologic birth and family-centered care of the newborn, practices that might interfere with maternal and newborn bonding need to be closely scrutinized. This article examines the evidence about practices related to the newborn transition, including the effects of various drugs used labor, umbilical cord clamping, thermoregulation, suctioning, and resuscitation of the newborn.

An important tenet of practice for all health care personnel is to first do no harm. This idea takes on additional importance when dealing with newborns, as there is almost no long-term data on the safety of many procedures. No clear conclusions can be drawn from studies on maternal analgesia effects on the newborn; thus, judicious use of medications in labor is recommended with further study of better biobehavioral assessment tools to differentiate outcomes. Delaying clamping of the umbilical cord appears to offer protection from anemia without harmful effects. The practice of immediate clamping, especially with a nuchal cord, should be discontinued. The evidence suggests that skin-to-skin care of the newborn after birth and during the first hour of life should be the mainstay of newborn thermoregulation and care. Routine suctioning of the infant at birth should be abandoned. Meconium-stained babies should not be suctioned on the perineum and vigorous infants should not be intubated and suctioned. There is no evidence that
amnioinfusion prevents meconium aspiration syndrome. The mounting evidence suggests that use of 100% oxygen at birth to resuscitate newborns may cause harmful effects. Room air is permissible for the first 90 seconds with oxygen available if there is not an appropriate response in that time.

Routine interventions, such as suctioning the airway or stomach or using 100% oxygen for resuscitation, or immediate clamping of the umbilical cord, have never based on any clear evidence that they improve newborn care or outcomes. Yet some of these practices are so firmly entrenched that it will take a large body of research to change the standard. We must continue to
build a body of knowledge that supports the evidence: more often than not, less intervention is better.

Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed
cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is recommended as the mainstay of newborn thermoregulation and care. Routine suctioning of infants at birth was not been found to be beneficial. Neither amnioinfusion, suctioning of meconium-stained babies after the birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more often than not, less intervention is better. The recommendations support a gentle, physiologic birth and family-centered care of the newborn.


  1. In other words, yet again, if medical personnel would just let everything happen as it's meant to and stay out of a normal, natural birth, there's nothing but benefits to be had.

    Why does this seem like such a difficult fact to express to everyone? Sigh.

  2. Well, it's not quite so simple as that (in the sense that "skin to skin" is something you still choose to do, not something that automatically happens by itself). And resuscitation is an intervention, so it's more a question of whether resuscitating with room air is better than 100% oxygen, rather than just "letting everything happen as it's meant to." Make sense? I do understand where you're coming from, though.

    These routines aren't done exclusively by medical personnel; depending on their training, some midwives in home and hospital also practice some or all of these non-evidence-based routines. Routine suctioning of healthy newborns is something that even a good number of home birth midwives continue to do (and even birth kits reflect that--look at how many home birth kits include bulb syringes!).

  3. Yeah, I'm not too surprised :) But I think it's interesting to ponder whether these findings on routine clamping and suctioning prove a more general point that Sandra makes. And exactly how general that point is, about not intervening in the process? There should be independent measures of whether a practice is beneficial or harmful. It's not a given that 'letting everything happen' to a healthy, well newborn is always the single most beneficial course of action. I think these studies should keep coming! I'll be glad whenever they exonerate midwifery practices. But if for example vitamin K turns out to be more important than not poking babies, then that's one area where we shouldn't necessarily default to non-intervention. (Just an example, I'm not up on vit. K.)

  4. I'd love a copy of the full text. thanks


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