There has been an amazing set of observations about the first few minutes of life that really forces us to completely re-evaluate our care of a mother, baby and father in the perinatal period.
Immediately after delivery, if the infant is pink, breathing, moving and looking good, with no grunting or retractions or any difficulty, the baby should be thoroughly dried. In the past, we've placed the baby on the mother's chest while the baby is wet and this is probably not ideal. It would be good to dry the baby thoroughly, dry it with several towels and then if the mother so desires, place the baby in one of three positions, either on the abdomen or on the chest or lower down and next to her if she'd rather not have it on her body. Most women prefer after birth to have the baby on their chest or with the head just at the sternum, the lower portion of the sternum.
If the baby is placed on the abdomen or with the head on the lower portion of the sternum, the baby will rest for a period of about 30 minutes and will tend to look up at its mother on and off. In this period, the baby is in what is called the quiet-alert state. In this state, the baby is unusually exciting. It's very interested in faces. It will look directly at the father's and mother's eyes. It's important that the mother and the obstetrical group, midwives, nurse and obstetrician not disturb the baby, not bathe the baby or give Vitamin K or eye ointment, but delay these for an hour until the time for the mother and baby is over with. The baby will have a whole set of behaviors that are very exciting and very valuable for the mother and father to view and to understand. At the end of about 30 minutes, the baby begins lip-smacking movements. After a short period of time, the baby begins to move forward, mainly by pushing with its back legs. As it starts towards the mother's chest, the baby will often move its head from side to side, sometimes extending its chin all the way to the shoulder. As the baby moves forward, if the right breast is washed, the baby will go to the left breast. If the left breast is washed, the baby will go to the right breast. If both breasts are washed and amniotic fluid is placed on the right breast, the baby will go to where the mother's amniotic fluid is placed. As the baby moves forward, you'll often see the baby bouncing its face on the mother's chest and it's very, very active at bouncing. It's quite surprising and then as the baby approaches the breast and approaches the nipple, the baby opens its mouth very, very widely, so that it places its lips on the areola and not on the nipple itself, protecting the nipple. It makes a perfect placement all on its own.
Another alternative is to place the baby in the middle of the chest. In this case, the baby again will wait about 30-40 minutes after birth. If the room is somewhat darkened and everybody is quiet, the baby will move a little bit to one side or the other and it does this by pulling its body up with a little pushup and then landing down, not in the middle, but either to the right or towards the left breast. If the baby is let alone, using its back legs and the little pushups, it will maneuver to the breast all on its own. It's quite remarkable; the mother and father will appreciate how well equipped this infant is, not only to begin to suck, but to actually literally find a breast all on its own. Again, the baby moves towards the nipple and when it gets to the nipple, it will open its mouth again widely and protect the nipple itself and go right onto the areola. When it starts to suckle, it will look, not uncommonly, up at the mother and this is a wonderful thing to see and this occurs at somewhere between 40 minutes and an hour.
All this hinges on the baby being fine at birth and the mother wanting to have this arrangement. It is important that the baby not be washed and not have eye ointment or Vitamin K until this moving to the breast, beginning to suckle and this period of suckling is over with. This is usually an hour or an hour and 15 minutes. This is a delightful introduction for the father, mother and baby and it's hopeful that the couple will be left alone for this period once the placenta is delivered.
It is interesting that the baby has a built-in sense (almost with a computer chip in its brain) to do this and it shows some of the capacities that the baby comes with. At the same time, the mother is built to take part in this.
A Swedish group at Karolinska, Wittsgrome and her colleagues, have beautifully shown that if you place a baby on the mother's chest after it's dried, that the baby will warm up faster than if it's wrapped up in blankets and placed in a bassinet: there's a wonderful heating device on the mother. They also demonstrated, Kelki Christianson did, that when the baby is placed there, there will be only a small amount of crying so that the baby appears to be very happy, probably because he smells his mother. It's nice and warm and he's used to the mother's voice.
I think all mothers should know the different ways of getting to know the baby in the first hour. The obstetrical group with the midwife should manage this for all of the mothers.
The third way, if the mother doesn't want the baby on her body, she could have it next to her. She may need a small heat panel, because there won't be enough heat transmitted from the mother's chest if the baby is next to her.
The surgical repair of an episiotomy could interfere with this important mother/infant process. At present, episiotomies are still almost routine in many practices. However, the Cochran database shows that episiotomies are necessary less than 5 to 8 percent of the time. Hopefully, as the frequency of episiotomies decreases, the importance of focusing on the mother/infant connection will increase.