Evidence Based Practice Synthesis Paper
Evidence Based Practice Synthesis Paper
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Abstract
Breastfeeding is remarkably beneficial for both mother and baby. However, according to the
Center for Disease Control and Prevention (2014) only 18.8% of our nations infants are
breastfed under the current recommendations. Skin to skin contact has shown to be effective in
increasing the rate of breastfeeding. This project was conducted in order to increase the incidence
of skin to skin contact immediately after birth. Search engines used were CINAHL, Pubmed, and
National Guideline Clearinghouse. Based on randomized controlled trials, recommendations, and
discussion with stakeholders at Florida Hospital Tampa, the intervention of skin to skin contact
will be implemented and the probability of this intervention of increasing breastfeeding initiation
is very high.
Keywords: breastfeed, breastfed, initiation, and skin to skin
communication, February 16, 2015). Skin to skin has improved initiation of breastfeeding and
maternal confidence can help women overcome barriers and continue to breast feed their infants.
Therefore, skin to skin contact can ultimately improve infants nutrition and outcomes and help
meet our national guidelines for breastfeeding. The PICOT question is as follows: In new
mothers how does the implementation of skin-to-skin contact immediately after birth compared
to standard practice affect the breastfeeding initiation within 48 hours of birth? The infrastructure
of Florida Hospital Tampa will allow this project to be successful. The infrastructure is
composed of nurses and physicians that will implement skin to skin contact. Nurses play a
crucial role in not only documenting skin to skin, but also educating mother and baby on how to
properly breast feed and implement skin to skin. Florida Hospital Tampa has already begun
utilizing skin to skin; therefore this intervention should be implemented successfully. This
project will help ensure everyone involved in mothers and infants care utilizes skin to skin
when possible.
Literature Search
Search engines that were used to find randomized controlled trials were CINAHL,
PubMed, and National Guideline Clearinghouse. Keywords used were breastfeeding, breastfed,
skin to skin, and initiation.
Literature Review
Three randomized controlled trials and one guideline were used to demonstrate the
effectiveness of skin to skin on breastfeeding initiation rates (refer to Literature Review table).
Aghas, Talat, & Sepideh (2014) conducted a randomized controlled trial to measure
breastfeeding success rates and self-efficacy in new mothers in regards to breastfeeding. The
SSC (skin-to-skin contact) group had the bare newborn lay on the mother's chest immediately
after the umbilical cord was cut. Weights, measurements, and vitamin K shots (routine care) were
postponed for at least two hours. The control group had weights, measurements, vitamin K shots,
and were placed under a radiant heater immediately after the cord was cut. Fifty-seven motherinfant pairs were randomly assigned to the control group, while 57 mother-infant pairs were
randomly assigned to the SSC group. The primary measurement of this study was maternal
breastfeeding self-efficacy at 28 days post-partum. The second measurement measured success
in first time breastfeeding and mean time of first breastfeeding initiation. Success in first time
breast feeding in the SSC group was 56.6% versus 35.6% in the routine care group (p=0.02).
Mean time of first breastfeeding initiation was significant between the two groups (p <0.0001).
This study concluded infants with skin to skin contact immediately after birth had more rates of
success with first breastfeeding and took less time to initiate breastfeeding. A weakness of this
study is follow ups did not occur after one month. It would be beneficial to see the longer lasting
effects of this study. Also, the sample size was small with 114 healthy, full-term mothers who
intended to breastfeed. This study will be a good resource because of the discussion of the
benefits of immediate skin-to-skin contact.
Dumas et al. (2012) looked at mother-infant interactions at post-partum day four. The
sample consisted of 176 mother-infant dyads. The women were randomly separated into one of
eight groups. The groups were skin to skin contact with swaddling or clothing in the maternity
ward; mothers arms group, separated by swaddling or clothing; the nursery group, separated by
swaddling or clothing; and the reunited group, again separated by swaddling or clothing. The
interventions in this study were skin to skin contact and rooming-in versus mother and infants
who were separated immediately after birth, then reunited two hours after birth. This study also
looked at skin to skin contact (infants being naked against the mothers skin) versus infants who
were clothed or swaddled. Infants who experienced skin to skin contact for the first two hours
after birth showed more successful breastfeeding results. At day four postpartum, skin to skin
contact pairs showed more successful attempts at latching (p=0.01) and less stimulation needed
by the mother (p=0.04). This study is helpful because it shows infants have more successful
breastfeeding outcomes when skin to skin contact occurs in the first two hours after birth. A
limitation of this study was a small sample group. Also, having eight separate groups made the
study confusing and hard to differentiate results.
Srivastava, Gupta, Bhatnagar, & Dutta (2014) compared the intervention of early skin to
skin contact for at least the first two hours after birth versus the control group of standard care
(infant is clothed, wrapped in a sheet, and placed next to the mother). The sample size consisted
of 298 mother-infant dyads who were randomly assigned to either the intervention or control
group. This study concluded that skin to skin contact led to better suckling competence based on
their IBFAT (infant breastfeeding assessment tool) score compared to the control group (mean of
9.55 vs. 6.77, respectively; p<0.0001). Results of successful breastfeeding were measured by
using the IBFAT and maternal satisfaction was measured in terms of breastfeeding at discharge.
Strengths of this study were better suckling competence in the skin to skin contact group and
retention of breastfeeding in the skin to skin contact group. A weakness of this study was not
describing or displaying their IBFAT more thoroughly. This study is helpful in showing positive
results of breastfeeding with early skin to skin contact.
The Academy of Breastfeeding Medicine recommendations include: all pregnant women
with be educated about benefits of breastfeeding and will be encouraged to exclusively
breastfeed unless contraindicated, skin to skin will be implemented immediately after birth if
mother and baby are stable, the baby will be dried off on the mother, the administration of
vitamin K and prophylactic antibiotics will be delayed until after the first hour, the baby and
mother will be given the opportunity to breastfeed within the first hour, mother and infant will
remain together, using skin to skin whenever possible, including rooming in at night, and
mothers being properly educated on how to breastfeed (Philipp, 2010). Randomized controlled
studies included had many similarities to current guidelines. Aghas et al. (2014) instruct skin to
skin start as soon as the umbilical cord is cut and be continued for two hours. Dumas et al.
(2012) intervention group had newborns and mothers do skin to skin for the first two hours and
rooming in whenever possible. Srivastava et al. (2014) also had the intervention group do skin to
skin for two hours rather than one. All three randomized controlled trials also withheld
antibiotics, vitamins, and weights until after mother and baby did skin to skin for at least two
hours.
Synthesis
The implementation of skin to skin contact initiates higher rates of breastfeeding. All
three randomized controlled trials utilize skin to skin as the intervention compared to the control
group that does not utilize skin to skin. Aghas et al. (2014) measured success and mean time of
first breastfeed which yielded significant results, p=0.02 and p <0.0001, respectively. Dumas et
al. (2012) measured how many attempts at latch and how many times the mother had to stimulate
the baby at post-partum day four yielding results of p=0.010 and p=0.044, respectively.
Srivastava et al. (2014) measured suckling competence and how many infants were still
breastfeeding at day four postpartum and six weeks postpartum. At day four, the skin to skin
group displayed better suckling competence: p<0.0001. Also, at day four and six weeks
postpartum infants in the skin to skin group exclusively breast fed more than the control group,
86.1% vs. 66.9% and 85.2% vs. 63.6%, respectively.
Therefore, all three randomized controlled trials demonstrate that skin to skin contact has
positive effects on breastfeeding initiation rates. Also, the Srivastava et al. study measured a
significant retention in breastfeeding in the skin to skin group (2014). These studies demonstrate
that this project should also yield positive results with the intervention of skin to skin contact.
More research should be conducted on barriers that mothers encounter when breastfeeding.
While a few of these studies researched maternal confidence, which may help women overcome
barriers, it is still not clear if this confidence can help overcome pain, latching problems, low
milk supply, etc.
Proposed Practice Change
According to Srivasta et al. (2014) skin to skin contact involves placing the naked infant
on the mothers bare chest immediately, or as soon as mother and baby are stable. This results in
improved breastfeeding initiation rates due to the infant being most awake immediately after
birth. Since infants are most awake, this is the optimal time to initiate breastfeeding. After about
two hours after birth newborns tend to fall asleep and opportunities for breastfeeding can be
missed (Srivasta et al., 2014). Therefore, Philips (2010) recommendation of the initiation of skin
to skin contact immediately after birth, continuing for one hour, and postponing medications and
weights should be employed.
Change Strategy
Promoting Staff Engagement
In order to promote involvement in this project, members of the team will be educated on
the positive impact skin to skin contact can have on patient outcomes. Further, meetings will be
held on a regular basis in order to educate the team on skin to skin and how to implement all
aspects of this project, address any concerns, and discuss progress.
Step 2
Steps Defined by
Model
Assess the need for
change in practice
Steps Defined by
Time Frame
Project
The lack of infants
January 2015
being consistently
breastfed was
discovered by the
team. Internal
evidence was
collected by lactation
specialist at FHT. This
information was
compared with
external evidence.
CINAHL, PubMed,
January 2015and National
February 2015
Guideline
Clearinghouse was
used to locate
randomized controlled
trials and current
recommendations to
support the
intervention of skin to
Step 3
Step 4
Design practice
change
Step 5
Implement and
evaluate change in
practice
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skin contact.
Multiple studies were
read and compared.
Studies that most
closely matched this
projects intervention
were chosen. The
evidence was
synthesized.
Feasibility, benefits,
and risks were
considered. The
intervention is
deemed feasible,
beneficial, and of
little to no known
risk.
The proposed practice
change is to initiate
skin to skin
immediately, having
mother and baby
attempt breastfeeding
within the first hour,
withholding
medications and
weights until after this
first hour.
Based on appraisal of
randomized controlled
trials, the probability
of this projects
intervention of skin to
skin increasing the
initiation of
breastfeeding is high.
There would not be
any additional costs
by changing the
intervention to skin to
skin.
February 2015
March 2015
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Step 6
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25% increase in breastfeeding initiation compared to the routine care group. The labor and
delivery nurse can help ensure skin to skin is started immediately and the mother/baby nurse will
conduct the breastfeeding assessments.
Dissemination of EBP
Since Florida Hospital is a large organization with twenty-five hospitals, there is
opportunity to reach out with many other facilities. To begin, our team can send a mass email to
other Florida Hospitals and to other organizations to see if they utilize skin to skin contact. If
facilities state they do not, Florida Hospital Tampa can correspond with them by email and in
person to aid in the process. In order to disseminate nationally, presentations can be held at
national conventions. All organizations should be reminded of our current national guidelines,
which include skin to skin contact to be used to aid in breastfeeding.
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References
Aghdas, K., Talat, K., &Sepideh, B. (2014). Effect of immediate and continuous mother-infant
skin-to-skin contact on breastfeeding self-efficacy of primiparous women: A randomized
control trial. Women and Birth, 27,37-40. http://dx.doi.org/10.1016/j.wombi.2013.09.004
Centers for Disease Control and Prevention.(2014). Breastfeeding report card. Retrieved from
http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
Dumas, L., Lepage, M., Bystrova, K., Matthiesen, A., Welles-Nystrom, B., &Widstrom, A.
(2012). Influence of skin-to-skin contact and rooming-in on early mother-infant
interaction: A randomized controlled trial. Clinical Nursing Research, 22(3), 310-336.
doi: 10.1177/1054773812468316
Office on Womens Health, U.S. Department of Health and Human Services.(2014). Why
breastfeeding is important. Retrieved from
http://womenshealth.gov/breastfeeding/breastfeeding-benefits.html
Office on Womens Health, U.S. Department of Health and Human Services.(2012). Common
breastfeeding challenges. Retrieved from
http://www.womenshealth.gov/breastfeeding/common-challenges/
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Table 1
Literature Review
Reference
Aghdas, K., Talat, K.,
&Sepideh, B. (2014).
Effect of immediate and
continuous mother-infant
skin-to-skin contact on
breastfeeding selfefficacy of primiparous
women: A randomized
control trial. Women and
Birth, 27, 37-40.
http://dx.doi.org/10.1016/
j.wombi.2013.09.004
Aim
Design and
Measures
To measure
The intervention
breast
group utilized skin
feeding
to skin contact
success rates while the control
and selfgroup utilized
efficacy in
standard practice
new mothers. (receiving
medications,
weights, and being
placed under a
warmer
immediately after
birth.)
Sample
57 infantmother
dyads in the
intervention
group and
57 infantmother
dyads in the
control
group.
Outcomes/stati
stics
The primary
measurement of
maternal selfefficiency was
measured at 28
days postpartum. Mothers
showed
increased selfconfidence in
mothering
abilities in the
skin to skin
group. The
second
measurement
measured
success in first
time breast
feeding (p=0.02)
and mean time
of first breast
feeding
To observe
motherinfant
interactions
at postpartum day
four.
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298 motherinfant
dyads.
(p<0.0001).
At day four
post-partum,
skin to skin
contact pairs
showed more
successful
attempts at
latching
(p=0.010) and
less stimulation
needed by the
mother
(p=0.044).
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