I was totally inspired by Dr. Marshall Klaus' presentation on Bonding and Attachment and the ILCA Conference last July. Since that time, I have dedicated myself to providing all newborns with the opportunity to "make the crawl" for their first breastfeed. For those of you who did not attend this presentation, this means that the newborn is placed skin-to-skin on mom's chest immediately after delivery and allowed to remain undisturbed. I have been promoting skin-to-skin care as the norm for healthy newborn babies from birth-2 hours' age. Hopefully, that allows time for initial physiological stabilization, the first breastfeed and early bonding and attachment behaviors. There are some "required" tasks such as shots, prints, e-mycin eye ointment, weight, measurement, etc. I think that these can be safely done after the initial 2 hours. My question is this: do any of you know of a way to evaluate APGARs without interrupting the natural behaviors that are occuring during this time? This is an area where I'm having difficulty responding to my co-workers when they ask now they can accurately document APGAR scores on these babies. If they are delivered skin-to-skin to mom's chest and cord clamping is delayed, the color, respirations, tone, cry, etc may be very different from babies who are placed under a warmer in bright light and vigorously dried and stimulated! The Neonatal Resuscitation Procedure indicates: place under warmer, dry thoroughly, position, suction mouth & nose, stimulate and evaluate. Our Nurse Practice Committee feels that this is a standard of care which may not be met by skin-to-skin newborn evaluation. The feeling is that, in order to document that the Standard of Care for newborn infants was applied, resuscitative actions would have to occur in response to deviations from the currently-expected criteria. The "deviations" I'm referring to may be "normal" for skin-to-skin babies who are not vigorously stimulated. I do understand these concerns. I recall three births that I attended where the newborns' heart rate and respirations were within normal limits, yet they were, initially, pale, acrocyanotic and very quiet. They then became alert, their activity increased and they began licking and crawling and were soon breastfeeding; however the 1 and 5 minute APGAR scores would have indicated a need for resuscitative measures according to present guidelines. Of course, that would have disrupted the responses and behaviors we are trying to promote. I do believe that a large number of breastfeeding problems have their origins in early post-delivery interventions. I would really love to hear if anyone else is finding this to be a concern or can offer suggestions on how I might respond to this. Believe me, I was "sweating bricks" and watching these babies very closely and I KNEW they were OK, but the APGAR scores wouldn't have reflected that until well after the 5 (or even 10) minute time. Hopefully this will generate some discussion on how we can deliver care which both meets established standards and supports the initiation of breastfeeding within the first hour of birth. Amy Mueller, BSN, RN, IBCLC Traverse City [log in to unmask]