DURING THE postpartum period, close physical contact between newborns and mothers, fathers, and/or family members facilitates attachment, breastfeeding, and relationship building. Supporting physical contact via skin-to-skin contact (kangaroo care) while ensuring infant safety can present a challenge during this time.1 Parent and staff perceptions related to safety between parents and newborns should be incorporated into best practices.
The literature contains limited information on parent and nurse understandings surrounding the potential for newborn falls associated with skin-to-skin contact. This article explores perceptions of the safety of skin-to-skin contact among nurses and parents based on a descriptive and exploratory study conducted in the authors' facility and makes recommendations for preventing newborn falls and drops.
According to The Joint Commission and the National Database for Nursing Quality Indicators, newborn falls are defined as a “sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor, on or against another surface, on another person or object.”2 Newborn drops are described as “a fall in which a baby being held or carried by a healthcare professional, parent, family member, or visitor falls or slips from that person's hands, arms, lap, etc. This can occur when a child is transferred from one person to another. The fall is counted regardless of the surface on which the child lands and regardless of whether or not the fall resulted in injury.”2 These two terms are considered synonymous by The Joint Commission and subsequently require the same safety precautions.2 For the purposes of this article “newborn falls” will serve as an umbrella term.
Newborn falls are underreported in the US, but they are estimated to occur at a rate of 3.94 per 10,000 patients and result in approximately 600 to 1,600 in-hospital falls annually.2,3 The most common maternal risk factors associated with newborn falls include a cesarean section birth, the use of pain medication within 4 hours, breastfeeding, and times during the second or third postpartum night, specifically around midnight to the early morning hours.2
Skin-to-skin contact involves positioning infants prone on a parent's chest, with their legs flexed and head turned to one side. It facilitates infant self-regulation and coregulation with parents, allowing the baby to engage in more quiet sleep time.4 Although it is considered safe, nurses and therapists may need to transfer the infant from the isolette to the parent and back again, especially if invasive devices such as endotracheal tubes are involved. These transfers may increase the risk of a fall. Parents must be educated on safe skin-to-skin contact with continuous reinforcement.
Safe practices involve assessing the parent for sleepiness and following a process to aid in preventing potential newborn falls (see Newborn safety).2 Unfortunately, some interventions limit skin-to-skin contact between parents and newborns. Holding devices that consist of soft, breathable, stretchy, and strapless tops that wrap around the torso can be used to promote patient safety while maximizing skin-to-skin contact.
This exploratory and descriptive study consisted of a survey and interviews intended to fill the gap in research evidence and explore common concerns. Following Institutional Review Board approval, 300 nurses in both the level II and level III neonatal ICUs were invited to participate in an electronic survey focused on the facilitation and limitations of skin-to-skin contact between newborns and parents. The survey included the following questions:
- How many newborn falls or near-falls have you observed during physical contact such as kangaroo care?
- What facilitates physical contact, including kangaroo care (ease, interest, best for parent and baby)?
- What are the barriers to physical contact between newborns and parents or family members?
- What do you do that makes physical contact such as kangaroo care safe and successful?
- What are your concerns when parents and newborns are engaging in physical contact such as kangaroo care (baby and/or parent)?
Information was not collected on some specific nursing units (only the levels II and III neonatal ICUs), and demographic data were not collected on the nurses. In a convenience sample, two nurses in the level II neonatal ICU and four nurses in the level III neonatal ICU were interviewed for additional insights. One-on-one interviews regarding nurse experiences and concerns with parents holding newborns during skin-to-skin contact took place privately on the unit.
Additionally, 30 English-speaking parents who received care in one level III neonatal ICU were approached for study and survey participation. Only parents in level III ICUs were approached due to convenience, and all parents who were approached participated. Five survey questions were based on clinical experience and the literature, which addressed parental concern about dropping their infant, falling asleep while holding their infant, nurses waking them up if they were falling asleep while holding their infant, and additional comments on fears surrounding newborn falls.
Of 300 total nurses, 66 (22%) responded to the survey. Of those, 61 participants (92%) reported no history of observing a newborn fall or near-fall. Approximately 30 of the surveyed nurses (46%) acknowledged that best practices are the main driver for skin-to-skin contact, as it is considered beneficial for both parents and infants. To ensure safe and meaningful physical contact, 24 nurses (36%) cited parental education as key, along with reassurance and support.
Additionally, 22 nurses (33%) stated that frequent assessment or monitoring is necessary to ensure safe practices, especially during skin-to-skin contact. For infants with invasive catheters or tubes, consultation with a respiratory therapist was recommended by 17 nurses (25%).
Discussing barriers to physical contact, 24 nurses (36%) cited the critical nature of infants, 19 (29%) noted a lack of parental availability, and 9 (14%) pointed to a lack of time. Parental fears or unwillingness to participate were each cited by six participants (9%).
Overall, 25 nurses (38%) expressed concern about tired parents or the possibility of falling asleep during skin-to-skin contact. Four of the six nurses interviewed in the convenience sample confirmed this concern. Similarly, 13 nurses (20%) identified the manner in which infants are held by parents as an area of concern. Potential dislodgment of tubes or catheters and the oxygenation status of infants also concerned seven nurses (11%), with one interviewee from the convenience sample wondering whether parents remembered how to hold their infant so as not to displace an endotracheal tube.
Interestingly, six nurses (9%) expressed concerns about parents using cell phones. Two explicitly stated, “Do not let parents use their cell phone.” This was also supported by three of the six nurses interviewed in the convenience sample.
Of the 30 parents from the level III neonatal ICU who completed the survey, 27 (90%) were not worried about newborn falls; however, 20 (67%) reported having fallen asleep or almost fallen asleep while holding their baby. When asked, “If nurses see you falling asleep while holding your baby, do they wake you up?,” 13 parents responded. Of those, 11 (85%) acknowledged being woken up. Of 26 parents who responded to a related question, only 5 (19%) felt that being woken up contributed to feeling tired.
Skin-to-skin contact is important for both parents and their newborns, and the role of nurses focuses on education, support, and reassurance. Although many nurses working in neonatal ICUs have not witnessed a newborn fall or near-fall from the parent's arms, they are concerned about the possibility due to tired or distracted parents. Monitoring the parent-infant dyad during skin-to-skin contact is important for safety and to ensure that any tubes and catheters remain secured and intact.
Parents were not concerned about newborn falls but they acknowledged the risk of falling asleep with a newborn in their arms. Nurses waking them up if they start to fall asleep was perceived as a “safety net” by parents, but they did not necessarily view it as contributing to increased tiredness.
Implications for practice and research
Safety is major component of quality care. Nurses must educate and support parents to promote safe practices during skin-to-skin contact, especially when the infant requires an endotracheal tube and other invasive tubes or catheters. Distractions should be limited and discussed with parents, as nurses perceive distractions as having a negative impact on safety in physical contact. Parent education may involve demonstrating the proper way to hold a newborn and validating parental understanding through observation. Any fears from parents or reluctance to engage in skin-to-skin contact should be recognized and addressed as well.
The delivery and postpartum period is tiring for parents, especially mothers. Nurses should assess maternal fatigue using clinical judgment and best practices for physical contact between newborns and mothers during hospitalization.5 Parents and nurses must collaborate to promote appropriate timing and length of skin-to-skin contact.
Nurses may consult with other team members, including respiratory therapists, to assist with transferring newborns to parents and monitoring the parent-infant dyad to ensure safety during physical contact. Devices such as I.V. catheters and endotracheal tubes require the availability of multiple healthcare professionals to ensure patient safety.
The use of hugging devices to secure the infant to the parent's chest may be explored in further studies in collaboration with supply chain staff, parents, and patient safety specialists. Hugging devices may hold newborns in place next to parents, especially in situations in which the parent is at risk for falling asleep. Others have suggested a pledge for patient safety throughout hospitalization in the form of a contract regarding expectations for both parents and the nursing staff.5
The study findings were limited to small and convenience samples of parents and nurses. It is also possible that only nurses interested in the subject responded to the survey. Additionally, it is not known how many times parents held their infant in the hospital before completing the survey.
The results confirm nursing and parental concerns from the neonatal ICU regarding safety during skin-to-skin contact. These include tired parents and the potential dislodgment of tubes and catheters. Parent education and collaboration with the nursing staff are key to safe practices during the postpartum period.
Understanding the risk of newborn falls and drops represents a challenge in healthcare. Facilities should consider processes to prevent newborn falls and drops, including:
- developing an assessment tool to indicate those at increased risk. This tool promotes common language and a shared mental model among healthcare professionals, and it acts as a cognitive aid to ensure uniform assessments.
- educating parents and counseling those at increased risk on newborn falls and drops and the need to call for help when tired. All parents should be cautioned against co-sleeping or falling asleep with their newborn in the bed.
- hourly staff rounding to assist potentially drowsy parents or caregivers with placing their newborn in a bassinet.
- promoting maternal rest.
- developing signage for the patient room or crib cards to reinforce the risk of newborn falls and the importance of placing infants in a bassinet when parents are sleepy or after the mother receives pain medication.
- developing a standardized reporting and debriefing tool in the event of a newborn fall. This will help capture important data to better understand the risk and environment in which the event occurred, resulting in consistent postfall care.
- providing emotional support to the family as second victims in the event of a fall.
Source: © The Joint Commission, 2019. Reprinted with permission. Adapted from: The Joint Commission. Preventing newborn falls and drops. Quick Safety. 2018. www.jointcommission.org/assets/1/23/Quick_Safety_Issue_40_2018_Newborn_falls_drops.pdf.