The Sacred Hour

Uninterrupted Skin-to-Skin Contact Immediately After Birth

Raylene Phillips MD, IBCLC, FAAP


NAINR. 2013;13(2):67-72. 

In This Article

Skin-to-Skin Contact Increases Breastfeeding Rates and Duration

All mammals have a set sequence of behaviors at birth – all with a single purpose – to breastfeed. Baby mammals are born to breastfeed! Surprisingly, it is the newborn that initiates breastfeeding, not the mother. However, being warm, being fed and being protected are intricately and inseparably linked to being in the right place, and the "right place" is bodily contact with mother. When skin to skin, the newborn displays an impressive and purposeful motor activity, which, without maternal assistance, brings the baby to the mother's breast. All newborn mammals are born knowing how to breastfeed, but this is a place-dependent competence that requires skin-to-skin contact.

As early as the 1970s, Ann-Marie Widstrom, PhD, RN, MTD, a Swedish nurse-midwife, began to notice a pattern in the behaviors of babies that were placed skin to skin with their mothers immediately after birth and allowed to peacefully adjust to extra-uterine life with no interruptions. Being a researcher, she began to document what she saw and published her observations in 1990.[24] In 2011, a beautiful teaching film was created by Healthy Children Project documenting nine instinctive stages Dr. Widstrom had observed in the behaviors of healthy newborn infants when they are placed skin to skin with the mother immediately after birth and left uninterrupted until after the first breastfeeding. The DVD, entitled "Skin to Skin in the First Hour After Birth: Practical Advise for Staff after Vaginal and Cesarean Birth" is a very useful tool for anyone involved in caring for newborns to learn about normal infant behaviors when babies are placed skin to skin after birth.[25]

The nine instinctive stages include 1) the birth cry, 2) relaxation, 3) awakening, 4) activity, 5) resting, 6) crawling, 7) familiarization, 8) suckling, and 9) sleeping. The birth cry (1st stage) occurs immediately after birth as the baby's lungs expand but usually ends abruptly when the baby is placed onto the mother's chest. Relaxation (2nd stage) begins when the birth cry stops and usually lasts 2–3 minutes during which the baby is very quiet and still. Awakening (3rd stage) begins with small head movements, as the infant opens his eyes and shows some mouth activity. During activity (4th stage) the baby has more stable eye opening, increased mouthing, and suckling movements and often some rooting. Resting (5th stage) can occur at any time between the other stages. Many assume, when babies were resting, that they have given up trying to find the breast and seem to clearly need assistance to breastfeed successfully. With knowledge of the nine instinctive stages, we know this is simply a normal stage and babies will move on when they are ready.[25] Indeed, rushing a newborn to the breast during a resting stage is usually counterproductive. During crawling (6th stage) the baby makes short pushing exertions with his feet or slides his body towards one of the mother's breasts. The baby may lift the upper torso and bob his head in a clear effort to get near the breast. After reaching the breast, familiarization (7th stage) begins and may last up to 20 minutes while the baby becomes acquainted with the nipple by licking, touching and massaging. During all of these stages, the baby moves in a purposeful manner but without frustration or hurry. The challenge for those observing is to relax, leave the baby and the mother alone and marvel at the amazing drama unfolding as the baby finds the breast, latches and suckles without assistance or interference. After adequate familiarization with the new environment and mother's nipple, the newborn opens his mouth wide, cupping the tongue which is now low in the bottom of the mouth, grasps the nipple in a correct latch and begins to suckle (8th stage). This usually occurs about an hour after birth. Sleeping (9th stage) follows usually between 1.5 and 2 hours after birth.[25]

If all staff personnel are educated about this normal and instinctive process, they will be equipped to be supportive of baby's progress towards the first breastfeeding. Knowledge of the nine instinctive stages of newborn behaviors provides a roadmap to reassure staff that assistance is not necessary and often interferes rather than helps. Newborns should not be rushed to suckle when they have not had time to go through the previous seven stages, as they will not be ready. It has been noted, for example, that early in the familiarization stage, the newborn's tongue is flat and high in the roof of the mouth, whereas just prior to self-attaching, the baby cups the tongue and drops it while opening the mouth wide for a deep and effective latch. When babies are rushed to the breast before all their senses are awakened and before their tongues are familiar enough with the nipple, latching is often unsuccessful and everyone is frustrated.

A DVD entitled "The Magical Hour: Holding Your Baby Skin to Skin During the First Hour after Birth" is a wonderful resource for families that includes interviews with parents whose babies had been placed skin to skin immediately after birth. The DVD includes an explanation of the nine instinctive stages of newborn behaviors and beautifully filmed video recordings of babies experiencing each stage. A double-sided, one-page handout describing the nine instinctive stages of newborn behaviors is also available to be given to parents prenatally and/or just prior to delivery.[26]

If parents and family members are educated about what to expect after their baby is born, they will be less inclined to interrupt the process by wanting to hold the baby and be willing to leave the baby skin to skin with the mother until after the first breastfeeding. Fathers and other family members love knowing what to expect and watch in amazement as babies progress through the stages as described by staff, in the DVD and on the handout.