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
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