A Menu of Change
Dyad Care in the
Immediately after she gives birth, a woman and her infant are physically separate, but their physiology, physical safety, and emotional well-being remain deeply interconnected. Dyad care includes care to the mother and infant while they are in close physical proximity (optimally skin-to-skin) with the understanding that appropriate care of one must address the needs and interests of the other.
Physiologic changes in the minutes after birth modulate newborn warmth, respiratory and cardiac stability, breastfeeding, maternal-infant attachment, and postpartum blood loss. These normal physiologic changes include
physiologic closure of the umbilical arteries and veins,1
placental transfusion of approximately 35 ml of blood per kilogram of infant weight, which combined with decreased pressure in the lungs, assists with initiation of newborn respiration and effective gas exchange,1
vasodilation of the maternal superficial blood vessels in the chest to exchange heat with the infant,2
newborn reflexes including “the breast crawl” and self-attachment at the breast,3
expulsion of the placenta and involution of the uterus, and
interconnected hormonal shifts, including elevated oxytocin levels for mother and infant, increased oxytocin receptors in the mother’s brain, decreased beta-endorphin levels, rapid decrease in stress hormones (especially epinephrine), peak levels of prolactin, and increased prolactin receptors.4
Table 1. Practices That Promote Optimal Outcomes
for Mothers and Newborns in the First Hour After Birth
Provide a comfortable, non-threatening environment (ie, warm, dimly lit, free of noise, strangers and unnecessary activity).
↓ maternal stress hormones that inhibit oxytocin function; plausible related ↓ maternal blood loss.6
Avoid early cord clamping before pulsations stop.
↑ iron stores for infancy; ↑ transfusion of placental blood, including pluripotent stem cells to infant.7
Avoid routine oropharyngeal suctioning.
↓ vagal nerve stimulation (which can cause bradycardia, apnea), ↓ time from birth to optimal oxygen saturation.8,9
Provide immediate skin-to-skin contact that continues until breastfeeding is established or through the first hour.
↑ breastfeeding at 1-4 months; ↑ breastfeeding duration; ↑ cardio-respiratory stability in late preterm infants; ↑ blood glucose; ↓ crying; ↑ maternal-infant attachment for as long as 1 year.10
Whenever safely possible, the care provided should foster and support these physiologic changes rather than disrupt them. Assessment of vital signs, Apgar scores, and maternal bleeding should be conducted without separating mother and infant. Routine procedures such as weighing, bathing, and administration of prophylactic medications should be delayed until after breastfeeding has been established.5 This conflicts with the practice typical in some settings of “doing everything” first, bundling the infant, and bringing it to the mother to initiate breastfeeding.
Practices to Reduce Risk of Hemorrhage
Prevention of postpartum hemorrhage (PPH) is a critical goal in all maternity care settings. Since 2003, offering active management of the third stage of labor (AMTSL) for prevention of PPH has been a recommended international standard of care,11 and ensuring that resources and capabilities for active management are available in all birth settings has been prioritized in maternal safety efforts. In AMTSL, an uterotonic agent is given followed by controlled cord traction and massage of the uterine fundus. Other than the use of uterotonics, other components of AMTSL have not been well-described or well-studied; however in mixed-risk populations, AMTSL has been found to reduce the incidence of postpartum blood loss for women in the categories of >500 ml and >1000 ml, and reduce in incidence of postpartum hemoglobin < 9, and need for transfusion when compared with expectant management of third stage labor.12 In contrast, depending on the uterotonic agent, AMSTL can increase postpartum pain, need for analgesia, vomiting, and potential for return to the hospital for bleeding later post partum in international investigations. In women at low-risk of hemorrhage, AMTSL reduced the incidence of postpartum blood loss >500 ml but had no significant effect on blood loss >1000 ml or on the need for blood transfusion (however those studies may be underpowered).12 For those women who are at risk, the uterotonic with the least side effects is Pitocin;13 administration can be at the time of birth or following the placenta, in intramuscular or intravenous (diluted) routes, and does not require special storage. The routine use of Pitocin given intravenously in many institutions after the placenta delivers, is not consistent with the evidence base for active management of third stage labor and instead should be used with caution based on risk factors and or clinical evidence of ongoing risk for increased blood loss post partum.12-14
Interventions in labor and birth, including induction or augmentation of labor, episiotomy, instrumental vaginal delivery, and cesarean may predispose women to excess postpartum bleeding due to disruption of hormonal physiology, trauma to tissues, or both. Low rates of postpartum hemorrhage in home and birth center settings suggest that healthy, low-risk women who have not been subjected to medical or surgical interventions may safely be offered physiologic care in the third stage of labor as an alternative to active management.15,16
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Mercer JS, Skovgaard RL. Neonatal transitional physiology: a new paradigm. J Perinat Neonatal Nurs. 2002;15(4):56-75.
Bystrova K, Widstrom AM, Matthiesen AS, et al. Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatr. 2003;92(3):320-326.
Henderson A. Understanding the breast crawl: implications for nursing practice. Nurs Womens Health. 2011;15(4):296-307.
Buckley SJ. The Hormonal Physiology of Childbirth. New York: Childbirth Connection; in press.
Sobel HL, Silvestre MA, Mantaring JB 3rd, Oliveros YE, Nyunt U. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatr. 2011;100(8):1127-1233.
Hastie C, Fahy KM. Optimising psychophysiology in third stage of labour: theory applied to practice. Women Birth. 2009;22(3):89-96.
Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007;297(11):1241-1252.
Gungor S, Teksoz E, Ceyhan T, Kurt E, Goktolga U, Baser I. Oronasopharyngeal suction versus no suction in normal, term and vaginally born infants: a prospective randomised controlled trial. Aust N Z J Obstet Gynaecol. 2005;45(5):453-456.
Waltman PA, Brewer JM, Rogers BP, May WL. Building evidence for practice: a pilot study of newborn bulb suctioning at birth. J Midwifery Womens Health. 2004;49(1):32-38.
Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:CD003519.
International Confederation of Midwives, International Federation of Gynaecologists and Obstetricians. Joint statement: management of the third stage of labour to prevent post-partum haemorrhage. J Midwifery Womens Health. 2004;49(1):76-77.
Begley CM, Gyte GM, Devane D, McGuire W, Weeks A.. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011;11:CD007412.
Gizzo et al. Which uterotonic is better to prevent the PPH? Latest news in terms of clinical efficacy, side effects, and contraindications: a systematic review. 2013. Reprod Sci Sep;20(9):1011-9.
Gimpl, G., & Fahrenholz, F. (2001). The oxytocin receptor system: Structure, function, and regulation. Physiological Reviews, 81, 629–683.
Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A. Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study. Women Birth. 2010;23(4):146-152.
Nove A, Berrington A, Matthews Z. Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth: results of an observational study of over 500,000 maternities in the UK. BMC Pregnancy Childbirth. 2012;12:130.