key: cord-0996086-cy87tjqw authors: Clarke, Paul; Allen, Emma; Atuona, Sheila; Cawley, Paul title: Delivery room cuddles for extremely preterm babies and parents: concept, practice, safety, parental feedback date: 2021-01-04 journal: Acta Paediatr DOI: 10.1111/apa.15716 sha: 5735f81802f8d82cece1f9e4428d86936c9fa339 doc_id: 996086 cord_uid: cy87tjqw AIM: Following extreme preterm birth, there has traditionally been felt an imperative to rush baby to the neonatal unit for ongoing intensive care. Immediate needs of parents to bond with their babies through direct early physical contact have often been overlooked; many weeks can pass before parents get to hold their babies for the first time. Recognition of the importance of early contact is growing. We aimed to review the safety and value of routinely practising delivery room cuddles for extremely preterm babies. METHODS: We reviewed delivery room cuddles in babies born <27 weeks’ gestation in our centre between 2006 and 2017 via case‐control. We also conducted a questionnaire survey of mothers who experienced a delivery room cuddle to gain their feedback and perspectives. RESULTS: We found no difference in age or temperatures on neonatal unit admission. There was no case of inadvertent extubation associated with cuddles. Parental feedback was very positive. CONCLUSION: With appropriate safeguards, delivery room cuddles are feasible and achievable for extremely preterm babies irrespective of birth gestation. Facilitation of the cuddle is an early and very important family‐centred care practice which seems much appreciated by parents and which may improve bonding, lactation, and maternal mental health. 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. 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 • Safety and benefits of kangaroo-care cuddles for extremely preterm infants are well established, yet many mothers get first cuddles only weeks after birth. • We show that delivery room cuddles before neonatal unit admission are feasible for extremely preterm babies, irrespective of gestation, and describe key safety considerations. • Delivery room cuddles were greatly appreciated by parents, may improve bonding and breastfeeding, and may reduce maternal stress and guilt associated with preterm delivery. 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). Following acute delivery room stabilisation of the extremely preterm baby, immediate NICU admission has traditionally been con- 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 skinto-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 TA B L E 1 Baseline characteristics and short-term outcomes in babies who had a delivery room cuddle compared with matched controls F I G U R E 1 Selected free-text comments received from mothers relating to their delivery room cuddle. One mother of a baby not <27 +0 was inadvertently invited to participate in the survey, her response is nevertheless included 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 can- Potential risks include accidental extubation, medical gas discon- 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 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 antepartum, 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: • is stabilised, receiving optimum care and ready to receive their cuddle • will receive all medical support needed and be continuously monitored during the cuddle • will be comfortable and safe, as we will be present with them throughout • may derive benefit from this early physical contact The DRC can be facilitated for most extremely preterm babies. We do not impose any lower gestational age cut off and have successfully 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 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, 9 th 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. 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. 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. Not applicable. Written parental consents were provided for publication of the photograph and video clip (Appendices S3 and S4). 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