Kangaroo Mother Care Saves Lives

Read the full article here — premature babies on their mothers’ chests have better outcomes than those placed in incubators. This is particularly important in low-income countries who simply don’t have the resources to have all the “bells and whistles” that can help preemies survive and thrive.

Fantastic Kangaroo Care and Skin-to-Skin Contact Resources

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 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.

What’s the Rush?

Reality Rounds has been posting on different issues with her role as a NICU nurse, and a recent comment inspired this post. The post itself was on the realities of prematurity, and the struggles that the babies (and their parents, nurses, and doctors) face when they’re born too soon.

The comment was from a mother whose two children were both born early — at 30 and 31.5 weeks. She relates:

As a side note, one day when my second was still in the NICU, I was taking the elevator up to the NICU floor and another NICU mom was in there with me. There were a couple of pregnant women going to see their OBs on a higher floor and they were lamenting that they wished their babies would just come *now*. As the elevator doors opened at the NICU floor, the other NICU mom and I gave each other knowing looks and as we walked out the door, we simultaneously said “No, you don’t.”

Yes, indeed! I remember what it’s like to be “great with child,” getting anxious for the pregnancy to be done, to meet the baby, to no longer have him kicking you 24/7, to get your body back, to not have your back hurt any more, etc., etc. But you don’t really want your baby born too soon!

I think it may would probably cut down on the numbers of elective inductions (and requests for early inductions or C-sections that are not medically indicated), if women were to be given a tour of the NICU sometime in their second trimester (much like they might take a tour of the L&D unit prior to giving birth), so that they could see the realities of premature birth. And it doesn’t even have to be really preterm birth — even slightly preterm may have problems, as At Your Cervix attests:

A [fetal lung maturity] test was done and showed “mature” levels for a recent “near term” gestation infant. Baby was delivered. Guess what? Baby had respiratory distress shortly after birth and was sent to the NICU. Baby was NOT ready to be born. The lungs were NOT fully ready for life outside the confines of his former uterine home. One can only wonder how much brain growth and development was also lost, from not having the last few precious weeks in the womb.

[Make sure you read all the comments at AYC, especially “Lonely Midwife.”]

Plus, there is research to show that babies born by elective C-section at 37 weeks have double the risk of problems as those born at 38 weeks; and the 38-weekers have double the problems of those born at 39 weeks. So, what’s the rush?!?

I don’t know. Have we gotten so arrogant, that we are doing what Jeff Goldblum’s character said in Jurassic Park? — “Your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

Obviously, doctors will not induce before 36 weeks for no maternal or fetal indication. At least, I hope that would not be the case! So, it’s not like most preemies are intentional. Yet, if a baby is born before his due time, but is born just because “well, it’s term, and you’re tired of being pregnant, so why not?” he will likely have complications that he would not have had, had birth started naturally. While the worst and most difficult NICU stays are likely to be unavoidable, there are some that could be avoided — like the one AYC mentioned — by waiting on nature. What’s the rush?

Oral Hygiene, Preeclampsia, Preterm Birth

I’d previously read that gingivitis is associated with higher rates of preeclampsia, but that it was not known if it was a “cause and effect” or just an association. If gingivitis causes preeclampsia, then better oral hygiene might prevent some cases of preeclampsia; but if it’s just an association — that women who are predisposed to either gingivitis or preeclampsia, or just are in poorer health or have an underlying health condition — then combatting gingivitis would do nothing.

In that vein, I was intrigued when I read this article, which said that bacteria has been found in the amniotic fluid of women who have given birth prematurely. One possible pathway given was that a kind of bacteria normally found in the mouth (and harmless there) may make its way into the bloodstream, and from there through the placenta into the baby’s amniotic fluid. This might weaken the amniotic sac, or perhaps cause some sort of uterine infection or fetal infection, or something that would account for the preterm birth. This is a new discovery, because this bacteria does not respond to traditional culturing, but instead requires examining DNA.

I wonder if preeclampsia might also be a manifestation of some sort of infection, perhaps transmitted through the weakened areas of the mouth when gingivitis occurs — the puffy and bleeding gums just seem like wide-open places for bacteria to cross into the blood-stream.

As an aside, I had two heart surgeries as a young child, and am supposed to take antibiotics for life whenever I have dental work done. It’s to prevent this sort of thing from happening — nasty oral bacteria (that may do nothing worse than cause bad breath, plaque or cavities when kept in the mouth) upon entering the bloodstream move to the weakest point, which for heart patients would typically be the heart. Southern humorist Lewis Grizzard eventually lost his life because of this — after four heart surgeries. In a pregnant woman, the baby may be “the weakest point” which is attacked, or at least may be the area with the least defenses. Antibiotics are given with the hope and assumption that if the dental patient’s mouth is pricked or otherwise open and/or bleeding, and oral bacteria enter the bloodstream, that the prescription antibiotics will prevent these bacteria from setting up a heart infection.

When I was pregnant the first time, I didn’t know about the gingivitis-preeclampsia risk, much less this newly released bacteria-preterm birth link. But I did know about the possibility that always exists (no matter how small) for oral bacteria to enter the bloodstream through an open sore in the mouth. I assume the risk is much greater when, say, the pick that cleans your teeth and may have untold numbers of bacteria on it jabs into the gum and more or less “injects” the bacteria below the surface. However, when my gums bled during pregnancy — which is not uncommon — I was concerned and wondered what to do about it. Sometime in the past, I had read that gingivitis might be caused by a lack of vitamin C, or at least, that taking vitamin C would stop it. You’re not supposed to take large amounts of vitamin C while pregnant because the baby might develop scurvy (although I think this is mostly talking about large doses around the time of birth, causing the baby to develop scurvy after birth when he’s withdrawn from the maternal vitamin C; and I’ve read one doctor who prescribes large doses of vitamin C, and his protocol for dealing with this is to give the baby vitamin C as well, and then gradually wean him off of it), so do your own research before doing anything! So I took a couple of grams of vitamin C for a few days, in addition to whatever was in my prenatal vitamin, whenever my gums started bleeding, and usually within a day it would stop. I only had to do this a few times during pregnancy.

Elective C-sections and the Risk to the Baby

Many women have a C-section for no medical reason, which is considered an “elective” C-section. Some of these include the “too posh to push” women; those who are afraid of labor and birth; those who want to schedule a “no-muss, no-fuss” C-section rather than go through the unpredictable and sometimes messy labor (which, by the way, I gotta question why these women even get pregnant in the first place — are not babies by their very natures unpredictable and sometimes messy? Perhaps the unpredictability and mess associated with labor somehow helps these women come to grips with the reality of life with a new baby, but I digress…); women who are not allowed to have a VBAC, women whose first birth was a C-section so go with what they know rather than attempt a vaginal birth, etc.

My husband’s cousin was sort of in this last group — her first baby was born preterm by C-section due to some health issue (I think pre-eclampsia, but can’t remember for sure right now), and her doctor told her she could have a VBAC IF she got all her work done and IF she could find something suitable to wear. No, wait a second, that was Cinderella’s wicked stepmother. No, her OB required that she go into labor naturally after she reached term but before the date of her already-scheduled C-section, which was at 38 weeks. Oh, yeah, just conjure up labor sometime in that week, and you’re good to go; if not, we’ll slice you open! Is it any wonder so many Cinderellas out there end up in rags instead of going to the ball?

But, a recent study (hopefully I’ll be able to find the article somewhere, but until then, I’ll make do with this) has looked at elective C-sections — that is, surgery for no medical reason — and found that babies who are born by C-section prior to 39 weeks have a much higher risk of complications, including respiratory distress, low blood sugar, infection or need for a respirator or intensive care. It also found that a full 36% of these elective C-sections were performed prior to 39 full weeks of gestation, which is the minimum age or cut-off point recommended by ACOG.

While “term” is considered to begin at 37 weeks, ostensibly, babies who are born after that time by C-section should not have any more problems than those born vaginally. However, in speaking of the difference between babies born at 37 weeks after the spontaneous onset of labor and those born at the same time with no labor but by elective C-section, one of the authors of this study says,

“We would not worry about a 37 1/2-week baby born vaginally with the onset of labor,” Thorp says. In that case, “there is some signal from a baby to his mother that says, ‘I’m ready …’ “

Hmm, maybe a baby should still be considered “premature” until the onset of labor. After all, while the exact mechanism may be unknown, it is accepted that, normally, the baby sends a “readiness” signal to his mother signifying to her body that he is ready to be born — he is mature enough to leave the womb and survive on the outside without the need of respirators and all the other gadgets I’m so glad exist to save the lives of premies.

Those born at 37 weeks were twice as likely

and those born at 38 weeks 50% more likely

to have a problem than those at 39 [weeks].

Wow, so nature knows best, huh? Who’d’a thunk it?

h/t to Dr. Jen for bringing the article to my attention

Early preterm birth by C-section

Here was an interesting article about the rise in late preterm births (34-36 weeks) in the United States. Here is an excerpt:

The Centers for Disease Control and Prevention have tracked an increase in preterm births for decades, with the percentage of births delivered before 37 weeks of gestation rising 21 percent between 1990 and 2006. That increase is the main reason the nation’s infant mortality rate has stubbornly refused to decline, remaining higher than most other developed nations.

Some preterm births were linked to mothers’ smoking, and others to the mothers’ lacking insurance. But more than 90 percent of the increase in preterm, nonmultiple births is attributable to an increase in babies being delivered by C-section at 34 to 36 weeks gestation, according to the March of Dimes.

“It comes from a general change in obstetric practice in our society,” said Dr. Alan Fleischman, medical director of the March of Dimes Foundation. “The doctors and the women are intervening in a much more aggressive style toward the end of pregnancy.”

Fleischman and other medical experts say there are a number of reasons doctors and mothers are choosing C-section delivery – and not all of them stem from medical necessity, the health of the mother or infant.

Miscellaneous “birth junkie” info

Pregnant in America (a book)

Understanding the Dangers of Cesarean Birth (a book)

Petition for Premies (March of Dimes)

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