One of my friends emailed this to a childbirth educators list I’m on, and I thought it was fantastic, so wanted to share with others.
First, is a Power-Point presentation (in pdf format) from Dr. Bergman on the importance of skin-to-skin contact for full-term newborns, and even greater importance of kangaroo care for preemies. Drawing on developmental curves of other mammals, Dr. Bergman points out that humans are basically born immature — dogs, cats, monkeys, etc., are all born more highly developed (as measured by percentage of brain growth, etc.); and preemies are born more on the “marsupial” level of immaturity and prematurity. Animals are born with brains that are 80% of the size of adult brains; humans are not. Based on brain development (as a percentage of the adult size, compared to newborn/adult brains of animals), humans don’t reach the 80% marker until about a year after full-term birth. When born premature, they are even less that. The presentation presents powerful and compelling arguments for attachment parenting concepts (such as, sleeping with the baby, carrying the baby in an infant carrier on the mother or father, breastfeeding on demand, skin-to-skin contact, not crying it out which can be harmful, etc.), and even stronger arguments for “kangaroo care” for preemies.
The second resource is the Kangaroo Mother Care website which has even more links, stories, research, etc., on kangaroo care and premature birth. Dr. Bergman draws a distinction between “Kangaroo Care” as practiced in U.S. hospitals (“This has been defined as “intra-hospital maternal-infant skin-to-skin contact”. KC is generally started later, and on stabilised prematures, and is used an adjunct to technological care”) and “Kangaroo Mother Care” which in part includes NEVER separating the mother and the baby — if the baby needs additional care, then technology is brought to him, rather than him taken away from the mother to go to the technology.
Dr Nils Bergman was the Doctor who introduced Kangaroo Mother Care (KMC) to South Africa. He has recently published the results of a strict scientific trial (in Acta Paediatrica) comparing skin to skin immediately after birth to incubator care . What he found was that skin to skin care was much better for the newborn than the incubator. Babies were warmer and calmer, breathed better and had a more stable heart rate with skin to skin care.
Surprisingly, the smaller the baby was-down to 1200grams- the more stable they were, and the more unstable in the incubator! This is opposite to what people think!
In fact there is other research suggesting that the incubator is harmful! Babies’ brain development requires skin to skin contact and being held and carried, and eye to eye contact to form the right brain pathways. Depriving babies of this skin to skin care makes alternative stress pathways which can lead to ADD, colic, sleep disorders etc.
Surprisingly incubators are still used for the very reason of stabilizing the baby when they in fact do the opposite!
There is a lot of information on the website, and I can’t do it justice, so just explore it for yourself, share with friends, and remember for future reference. Although the following story is anecdotal (although if a doctor wrote it, it would not be a mere “anecdote” but would be a “case study”), this woman saved her baby’s life by instinctively picking her up and putting her on her chest. The baby was born at 24 weeks gestation, weighing 20 oz (566 grams), and doctors didn’t believe she would live — her heart was beating only every 10 seconds and she wasn’t breathing.
She said: “I didn’t want her to die being cold. So I lifted her out of her blanket and put her against my skin to warm her up. Her feet were so cold.
“It was the only cuddle I was going to have with her, so I wanted to remember the moment.” Then something remarkable happened. The warmth of her mother’s skin kickstarted Rachael’s heart into beating properly, which allowed her to take little breaths of her own.
Miss Isbister said: “We couldn’t believe it – and neither could the doctors. She let out a tiny cry.“The doctors came in and said there was still no hope – but I wasn’t letting go of her. We had her blessed by the hospital chaplain, and waited for her to slip away.”But she still hung on. And then amazingly the pink colour began to return to her cheeks.
“She literally was turning from grey to pink before our eyes, and she began to warm up too.”
The baby was eventually taken and put on a respirator, but “Her heart rate and breathing would suddenly sometimes drop without warning” — which reminds me of one of the graphs in either the PDF or the website — that the baby’s heart rate and breathing and temperature were all more stable and regular when on the mother than in an incubator.
I don’t think that this doctor is suggesting that the only thing a premature baby needs, no matter how early it is born, is to be put on his mother’s chest — after all, he pointedly says that technology needs to be brought to the mother-baby when needed. But what if the interventions that are currently being done on premature infants are actually harmful, or at least, would be more helpful if the baby is on his mother’s chest (unless that is totally impossible). Yes, I’m sure there is a ton of research showing that babies receiving the current standard of care do better than babies in a “control group” — but what if standard interventions done on the mother’s chest were vastly superior than standard interventions done in a plastic box?
As an example of what I’m angling at, consider a hypothetical research project: babies are born, and divided into two groups — the first group is put in an orphanage where their physical needs are met (they are fed, clothed, and given diaper changes) but are basically kept in cribs all the time. The second group is put in a different orphanage where their physical needs are met and they also receive some social interaction, playing with other orphans and also sometimes the caregivers who are not as overwhelmed and busy as in the first orphanage. Obviously, the second group is likely going to do much better. However, neither of these settings is natural or normal — consider that there is also the possibility of babies not taken from the mother at all, but are given the level of maternal care and attention that you and I take for granted — breastfed, lovingly held and cared for, played with on a one-to-one basis, read to, etc. (in addition to the basic physical needs being met). Don’t you think that this third group would greatly excel either of the first two groups? Of course! So, is it not possible that our current standard of care, while better than that of the 70s or 80s, still pales in comparison to what might be possible if the technology (breathing assistance, drugs, fluids, nourishment, etc.) were done in the context of kangaroo care, rather than KC being more or less an afterthought?
“First, do no harm.” If, as that newspaper article demonstrated, it could shown that a mother’s natural inclination is to hold her premature infant on her chest, and that it holds some benefit to the baby (in this case, warming her, starting her breathing, and regulating her heartbeat), then that should be promoted — not necessarily at the expense of technology that has also been proven beneficial, but in conjunction with that technology to attain even better outcomes.
Several months ago, Reality Rounds posted a couple of heart-wrenching posts. She got a lot of flak, too, for it — all of it undeserved. I’m linking to them so that you can get a better idea of what’s involved in extremely preterm birth care; but, as my mother always says, “If you don’t have something nice to say, don’t say it at all.” First, “For they know not what they do” — which describes the extreme fragility of tiny babies, and the great caution the NICU team must employ not to hurt the baby as they try to help and save the baby:
We do everything. Dry the infant with towels. Careful. Not too rough. Do not want the gelatinous, friable skin to break and bleed unto the blankets. Listen for heart sounds. Heart rate is barely 60 beats per minute. No need for chest compressions. We breathe air and oxygen into the tiny lungs. Careful. Too much air can blow a hole in the tiny lungs. Too much oxygen can cause lung damage and blindness. We walk the wire.
It must be so extremely difficult to do everything that can be done to save the babies, knowing that it is hurting them physically (needles hurt! and worse for preemies — not to mention everything else). I liken it to what nurses in burn units must go through, as they try to save people who are badly burned — knowing that what they are doing, while necessary, is torture. And that even in the best of circumstances, the patient will endure untold pain, and be scarred for life — perhaps even unrecognizably scarred, perhaps losing fingers or toes or arms or legs. And perhaps when all is said and done and the patient is released to go home, he may even wish himself dead. Yet some people beat the odds and their injuries are not as life-altering or as scarring as they might have been; and many people are glad to be alive. But some people die in burn units, in spite of all the care given; and nurses and doctors must occasionally feel guilty that they did not “let nature take its course,” because then the person’s pain would have been shorter — when people die despite the best care given them, and die in pain, we can say in retrospect that it “would have been better” for them to have had no care at all and died quickly, than to have had their pain dragged out over days and weeks. But until we have a crystal ball to know which ones will have good results and which will not, we have to take care of them all.
The second post is NICU is a war zone — stressful for the parents, stressful for the baby, stressful for the workers. Finally, “Is letting a 21-week baby die health care rationing?” which includes the following paragraph on “Benevolent Injustice”:
I have cared for many infants at the edge of viability. It is always emotionally draining. There is no justice to it. The extreme measures involved to keep a 22-23 week infant alive is staggering, and it is ugly. I once had a patient who had an IV placed on the side of her knee due to such poor IV access. When that IV infiltrated, I gently pulled the catheter out, and her entire skin and musculature surrounding the knee came with it, leaving the patella bone exposed. I have seen micro-preemies lose their entire ear due to scalp vein IV’s. I have watched 500 gram infants suffer from pulmonary hemorrhages, literally drowning in their own blood. I have seen their tiny bellies become severely distended and turn black before my very eyes, as their intestines necrose and die off. I have seen their fontanelles bulge and their vital signs plummet as the ventricles surrounding their brains fill with blood. I have seen their skin fall off. I have seen them become overwhelmingly septic as we pump them with high powered antibiotics that threatened to shut down their kidneys, while fighting the infection. I have seen many more extremely premature infants die painful deaths in the NICU, then live.
I do not claim any knowledge much less prowess in the field of premature birth. I do not blame anyone for allowing their extremely preterm baby die a natural death, rather than be subjected to these procedures. Nor do I blame parents who request that “everything” be done to save their babies. But care for premature babies is heart-wrenching either way, and painful. But what if there is a better way? I don’t know if this Kangaroo Mother Care extends to the micro-preemies, or there is some sort of cut-off point where it no longer helps — previously, I quoted that “babies down to 1200 grams” did better with KMC — which is about 2.5 pounds, and probably all late-second or early-third-trimester, much bigger than 20-23 week babies, for the most part (which is primarily the focus of the above blog posts). But what if current care is like the hypothetical orphanage study above — better than nothing, but not as good as kangaroo care in conjunction with life-saving interventions.
Sr Agneta Jurisoo studied what little literature was available on KMC during 1987. The following year she and Dr Bergman arrived at a small mission hospital in Zimbabwe, where premature births were common. There were no incubators, poor transport over great distances, and overloaded referral centres: only one of ten premature babies survived.
In the absence of incubators, they started a care plan in which the mother became the incubator. Instead of waiting for the baby to “stabilise”, the mother was used to stabilise premature infants immediately after birth. It was immediately clear this was highly effective, no matter how small or how premature, stabilisation took a mere six hours. With this care, now five of ten very low birth weight babies survived.
One problem is that current care is so entrenched, that it is very scary (and may even seem to be malpractice) to make the huge paradigm shift from taking the baby away from the mother for care, to putting the baby on the mother for care. Obviously, doctors and nurses are trained to take care of the baby alone, in an incubator — much like doctors are trained to have the mother on her back with her legs in stirrups when she gives birth. It can be very disorienting to have the baby come out “the wrong way” when the mother is on hands-and-knees or is squatting or kneeling. In the same way (only much, much bigger), it will take someone with a lot of guts to bring the NICU to the mother-baby pair, instead of taking the baby to the NICU. Who am I kidding? — it is a big shift to have full-term healthy babies put directly on the mother’s chest and kept there, instead of being put almost immediately into the warmer. Technology is very deeply entrenched in normal births and normal postpartum, and much more so in premature births! But “first do no harm” — first make sure that what you’re doing that is not physiologically normal (taking the baby from the mother) is going to first be not harmful, and second be beneficial. Certainly, there are times when babies need immediate surgery or other care that is not feasible or practical to be done on the mother. But I think steps need to be taken to keep mothers and babies together, if possible.
Filed under: postpartum | Tagged: baby, birth, childbirth, extremely preterm birth, kangaroo care, kangaroo mother care, neonatal intensive care unit, nicu, preemie, premature, prematurity, premie, preterm, preterm birth, ptb, xptb |