The current issue of Midwifery Matters summarizes a study of the effects of having the baby skin-to-skin after birth and breastfeeding initiation soon after birth on postpartum blood loss of 500 ml or more. Turning to the study itself, investigators analyzed the birth records of 7548 women giving birth either at one of three Baby-Friendly hospitals at which skin-to-skin contact and breastfeeding within 30 minutes was standard practice, including at elective cesarean deliveries, or at a freestanding birth center where this was the norm. They evaluated the effect of the practices together vs. skin-to-skin but not early breastfeeding (early breastfeeding but not skin-to-skin was rare) vs. neither. Ninety-five percent of the women also had “active management of third stage,” a package of routine practices (oxytocin injection, immediate cord clamping [now established as harmful], and pulling on the umbilical cord to facilitate delivery of the placenta) that reduce blood loss at the birth.
In the overall population, 10% of women who had both practices experienced blood loss of 500 ml or more compared with 17% of women who had skin-to-skin contact but not early breastfeeding and 30% of women who had neither. After taking factors correlated with increased blood loss into account such as cesarean or instrumental delivery, induction or augmentation of labor, episiotomy, and blood clotting abnormality, women who had both practices were half as likely to experience excessive blood loss compared with women who had neither.
Investigators divided the population into women with no predisposing factors for excessive blood loss and women with one or more factors. Among the 2318 women in the higher-risk group, excessive blood loss rates were 13% in women who had both practices, 20% in women who had skin-to-skin only, and 29% in women who had neither. After taking correlating factors into account, again, women who had both practices were half as likely to lose 500 ml of blood or more compared with women who had neither. The effect was more pronounced in lower-risk women. Excessive blood-loss rates were 9%, 16%, and 28%, respectively, and after taking correlating factors into account, having both practices reduced likelihood of excessive blood loss by 75% compared with neither.
Study authors address the possibility of reverse causation for their findings, that is, the need to treat postpartum hemorrhage preventing putting the baby skin-to-skin or early breastfeeding. They offer three counterarguments: First, severe bleeding is rare whereas 15% of women overall had excessive blood loss. Second, the usual practice was to place the baby on the woman’s chest immediately. This would be before placental detachment and therefore the potential for heavy bleeding, and third, 95% of women had skin-to-skin contact within 30 minutes of birth.
The Take Away: Write the authors:
There are now three reasons that [skin-to-skin and early breastfeeding] should be integrated into standard maternity care: firstly as [an excessive postpartum bleeding] reduction strategy; secondly because of the known short- and long-term health benefits of breast feeding . . . and thirdly because of the way that bonding is facilitated . . . . The only exceptions . . . should be where the woman gives informed refusal or where the baby or mother is so ill that they need intensive resuscitation and/or immediate transfer.