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MO-07-0036 BFP

Nurses, certified nurse midwives, and physicians should encourage new mothers to hold their newborns skin to skin during the first two hours following birth and as much as possible thereafter, unless contraindicated.




5.1 Assuming baby and mother are stable, the mother and baby should be skin-to-skin during the first several hours following birth. This includes the post-cesarean mother and baby, when alert and stable.

5.1.1 Babies are usually most ready to breastfeed during the first hour following birth. For the normal newborn this should occur prior to such interventions as: the newborn bath, glucose sticks, foot printing, and eye treatments.

5.1.2 During the first day of life, skin-to-skin time and breastfeeding should take priority over other routine events such as infant bathing, pictures, and visitors.






5.1 Mothers should be permitted to engage in this normal physiological process, regardless of birth method, as long as medically stable. Post-cesarean mothers can still engage in breastfeeding. Temperature stabilization will almost always occur best with the baby in skin-to-skin contact on the mother’s chest, with a blanket covering the infant and mother. 1,2,4,5,8,9

5.1.1 The normal infant has a strong suck reflex during the first 20-30 minutes post-birth. Disturbing the mother and infant during this time can make it difficult for the infant to learn the suckling process. 7,11,12

5.1.2 Separation of mother and baby for routine procedures may be distracting and interfere with breastfeeding initiation unnecessarily. Organizing nursing care to focus on keeping the mother and newborn together will increase the opportunities for the newborn to demonstrate feeding readiness. 3,10,13


Sample Policies:

  • Academy of Breastfeeding Medicine: Clinical Protocol #5: Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term; Revision, June 2008 (PDF) EnglishOpens a new browser window.
  • Childbirth Center Policy (PDF)Opens a new browser window.

“Golden Hour” Sample Patient Information

Ferber SG, Makhoul R; The Effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn: A Randomized, Controlled Trial PEDIATRICS Vol. 113 No. 4 April 2004, pp. 858-865 (Full Text)

Christensson K, Siles C, Moreno L, et al. Temperature, metabolic adaptation and crying in healthy, full-term newborns cared for skinto-skin or in a cot. Acta Paediatr. 1992;81:488–493 (Abstract)


5.1.3 If breastfeeding is delayed due to medical condition(s) of mother or baby, the baby should be put skin-to-skin and allowed to approach the breast as soon as possible after they are stable.

5.1.4 The baby should be encouraged to breastfeed without restriction.

5.1.5 Nursing policies and practices should support care of the mother and infant together and should be documented in nursing charting.

(Refer to Policy #9 for safety considerations)


5.1.3 Early suckling allows the infant to receive the immunologic benefits of colostrum. Colostrum also stimulates digestive peristalsis of the infant. Suckling stimulates uterine involution and inhibits bleeding for the mother. 6,7

5.1.4 Restricting breastfeeding may increase the degree of physiological breast engorgement that occurs during the transitional milk phase.


Resources on Medications and Breastfeeding (LInk):

Example of a program Evaluation Tool:

Policy #5 References:

1. American Academy of Pediatrics Policy Statement (2005). Breastfeeding and the use of Human Milk, Pediatrics, 115, 496-506. (2005 Version)
2. American College of Obstetrics and Gynecology Educational Bulletin. (July 2000). Breastfeeding: Maternal and infant aspects, No. 258, p.5. 
3. DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. (2001). Maternity care practices: Implications for breastfeeding. Birth, 28(2), 1523-1536. [Abstract]
4. Durand, R., Hodges, S., LaRock, S., Lund, L., Schmid, S., Swick, D., et al. (1997, March/April). The effect of skin-to-skin breastfeeding in the immediate recovery period on newborn thermoregulation and blood glucose. Neonatal Intensive Care, 23-29. [Abstract]
5. Kennell, J. & Klaus, M. (1998). Bonding: Recent observations that alter perinatal care. Pediatrics in Review. 19(1), 4-12.
6. Lawrence, R. (1987). The management of lactation as a physiologic process. Clinics in Perinatology, 14(1), 1-10.
7. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical professional (6th ed.). St. Louis, MO: Mosby (pp. 217, 272, 80, 275)
8. Mikiel-Kostyra, K., Mazur, J., & Boltruszko, I. (2002). Effect of early skin-to-skin contact after delivery on duration of breastfeeding: A prospective cohort study. Acta Paediatrica, 91(12), 1288-1289. (Abstract)
9. Rapley, G. (2002). Keeping mothers and babies together—breastfeeding and bonding. Royal College of Midwives, 5(10), 332-224. (Abstract)
10.Righard, L. & Alade, M. (1990). Effect of delivery room routines on success of first breast-feed. The Lancet, 336, 1105-1107.
11. Salariya, E. M., Easton, P. M., Cater, J. I. (1978, November 25). Duration of breastfeeding after early initiation and frequent feeding. The Lancet, 1141-1143.
12. Taylor, P. M., Maloni, J. A., & Brown, D. R. (1986). Early suckling and prolonged breast-feeding. American Journal of Diseases of Children, 140, 151-154.
13. Winikoff, B., Laukaran, V. H., Myers, D., & Stone, R. (1986). Dynamics of infant feeding: Mothers, professionals, and the institutional context in a large urban hospital. Pediatrics, 77(3), 357-365.

Additional References:

ACOG Update: Committee Opinion #361, "Breastfeeding: Maternal and Infant Aspects," Obstetrics & Gynecology, February 2007.More detailed information on breastfeeding can be found in ACOG Clinical Review (Vol. 12, Issue 1 (supplement), Jan-Feb 2007) "Special Report from ACOG, Breastfeeding: Maternal and Infant Aspects" available to Fellows online at www.acog.org and to nonmembers by emailing jbrenner@acog.org.

Anderson, G. C., Moore, E., Hepworth, J., & Bergman, N. (2003). “Early skin-to-skin contact for mothers and their healthy newborn infants”. Cochrane Database Syst Rev(2), CD003519. [Abstract]

Bergman, N. J., Linley, L. L., & Fawcus, S. R. (2004). “Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns”. Acta Paediatr, 93(6), 779-785. [Full Text (PDF)Opens a new browser window.]

Bier JA, Ferguson AE, Morales Y, Liebling JA, Archer D, Oh W et al. Comparison of skin-to-skin contact with standard contact in low-birth-weight infants who are breast-fed. Arch.Pediatr.Adolesc.Med. 1996;150(12):1265-9. [Abstract]

Bramson L, Lee JW, Moore E, Montgomery S, Neish C, Bahjri K, Lopez-Melcher C; Effect of Skin-to-Skin Mother-Infant Contact During the First 3 Hours Following Birth on Exclusive Breastfeeding During the Maternity Hospital Stay, Journal of Human Lactation, Vol. 26, No. 2, 130-137 (2010) [Abstract]
     Prospective cohort study of 19 hospitals in hospitals in San Bernardino and Riverside Counties. N=21,842 mothers who delivered a singleton infant between 7/05 and 6/06. Maternal infant-feeding method intention (measured prior to birth), sociodemographic characteristics, intrapartum variables, and early skin-to-skin mother-infant contact during the first 3 hours following birth were correlated with exclusive breastfeeding during the maternity hospitalization.
     The results of the study demonstrate a dose-response relationship between early skin-to-skin contact and breastfeeding exclusivity.

Bystrova, K., Widstrom, A. M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Welles-Nystrom, B., Wassberg, C., et al. (2003). “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, 92(3), 320-326. [Abstract]

Castral, T. C., Warnock, F., Leite, A. M., Haas, V. J., & Scochi, C. G. (2008). “The effects of skin-to-skin contact during acute pain in preterm newborns”. Eur J Pain, 12(4), 464-471. [Full Text (PDF)Opens a new browser window.]

Chiu S-H, Anderson GC, Burkhammer MD; Newborn Temperature During Skin-to-Skin Breastfeeding in Couples Having Breastfeeding Difficulties, Birth, Volume 32, Number 2, June 2005, pp. 115-121(7) [Abstract]

Chiu SH, Anderson GC, Burkhammer MD; “Skin-to-skin contact for Culturally diverse Women Having Breastfeeding Difficulties during Early Postpartum”. Breastfeeding Medicine, 3(4), 231-37, 2008. [Abstract]
     N=48 healthy, culturally diverse dyads. Early BF cessation is more common in black women and women who experience BF difficulties during early postpartum. Skin-to-skin (SSC) contact during early postpartum promotes and sustains BF. The focus of this secondary analysis is on BF status and maternal race/ethnicity. Dyads were selected because they were experiencing BF difficulties mean 16.9 hours postpartum. Following informed consent, SSC intervention was given with four breastfeeds: the next three after enrollment plus one before hospital discharge. BF status (duration and exclusivity) was measured using a six-category instrument, the Index of Breastfeeding Status, at hospital discharge and by telephone interview 1 week and 1 month later.
     BF status was generally similar in this culturally diverse sample, except that at 1 month black mothers had lower exclusive BF (33%) and higher BF cessation (46.7%). These mothers were all high risk for poor BF outcomes, with black mothers at highest risk. Even so, BF outcomes exceeded those in studies that included all BF mothers whether or not they were having difficulties.
     Authors conclude that SSC BF intervention be provided in hospital in a time-sensitive manner by a warm perceptive person, to transcend the likelihood of early BF cessation for most mothers regardless of race and ethnicity.
Christensson, K. (1996). Fathers can effectively achieve heat conservation in healthy newborn infants. Acta Paediatr, 85(11), 1354-1360. [Abstract]

Christensson, K., Cabrera, T., Christensson, E., Uvnas-Moberg, K., & Winberg, J. (1995). Separation distress call in the human neonate in the absence of maternal body contact. Acta Paediatr, 84(5), 468-473. [Abstract]

Christensson K, Siles C, Moreno L, et al. Temperature, metabolic adaptation and crying in healthy, full-term newborns cared for skinto-skin or in a cot. Acta Paediatr. 1992;81:488–493 (Abstract)

Dabrowski, G. A. (2007). Skin-to-skin contact: giving birth back to mothers and babies. Nurs Womens Health, 11(1), 64-71. [Full Article (PDF)Opens a new browser window.]

Edmond, K. M., Zandoh, C., Quigley, M. A., Amenga-Etego, S., Owusu-Agyei, S., & Kirkwood, B. R. (2006). Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics, 117(3), e380-386. [Full Article]

Feldman, R., Grenbaum C.W., Yirmiya N., Mayes, L.C. (1996). Relations between cyclicity and regulation in mother-infant interaction at 3 and 9 months and cognition at 2 years. . Journal of Applied Developmental Psychology, 17(3), 347-365. [Abstract]

Feldman, R., & Eidelman, A. I. (2003). Skin-to-skin contact (Kangaroo Care) accelerates autonomic and neurobehavioural maturation in preterm infants. Dev Med Child Neurol, 45(4), 274-281 [Abstract]

Feldman, R., Eidelman, A. I., Sirota, L., & Weller, A. (2002). Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics, 110(1 Pt 1), 16-26. [Full Text]

Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2003). Testing a family intervention hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch. J Fam Psychol, 17(1), 94-107. [Abstract]

Feldman, R., Weller, A., Zagoory-Sharon, O., & Levine, A. (2007). Evidence for a neuroendocrinological foundation of human affiliation: plasma oxytocin levels across pregnancy and the postpartum period predict mother-infant bonding. Psychol Sci, 18(11), 965-970. [Abstract]

Ferber SG, Makhoul R; The Effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn: A Randomized, Controlled Trial. Pediatrics Vol. 113 No. 4 April 2004, pp. 858-865 [Full Text]

Galligan, M. (2006). Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN Am J Matern Child Nurs, 31(5), 298-304; quiz 305-296. [Article]
Goldstein-Ferber S, Makhoul I. The Effect of Skin- to- Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn:  A Randomized, Controlled Trial. Pediatrics, 2004. [Full text]
     N=47 healthy mother-infant pairs. During a 1-hour-long observation the KC infants slept longer, were mostly in a quiet sleep state, exhibited more flexor movements and postures, and showed less extensor movements. KC seems to influence state organization and motor system modulation of the newborn infant shortly after delivery. Medical and nursing staff may be well advised to provide this kind of care (KC) shortly after birth.

Gray, L., Miller, L. W., Philipp, B. L., & Blass, E. M. (2002). Breastfeeding is analgesic in healthy newborns. Pediatrics, 109(4), 590-593. [Full Article]

Handlin L, Jonas W, Petersson M, Ejdebäck M, Ransjö-Arvidson A-B, Nissen E, Uvnäs-Moberg K. Effects of Sucking and Skin-to-Skin Contact on Maternal ACTH and Cortisol Levels During the Second Day Postpartum—Influence of Epidural Analgesia and Oxytocin in the Perinatal Period Breastfeeding Medicine. December 2009, 4(4): 207-220. doi:10.1089/bfm.2009.0001. [Abstract]

Hanson,L; Immunobiology of Human Milk: How Breastfeeding Protects Infants, 2004, Hale Publishing

Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. J.Perinatol. 1997;17(3):213-7. [Abstract]

Kennell, J., & McGrath, S. (2005). Starting the process of mother-infant bonding. Acta Paediatr, 94(6), 775-777.[Abstract]

Kennell, J. H. (2006). Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200 g to 2199 g newborns. Acta Paediatr, 95(1), 15-16. [Abstract]

Kennell, J. H., & McGrath, S. K. (2003). Beneficial effects of postnatal skin-to-skin contact. Acta Paediatr, 92(3), 272-273. [Abstract]

Klaus MH. Kennell JH, Klaus PH. Bonding: Building the Foundations of Secure Attachment and Independence. Reading, Mass: Addision-Wesley; 1995

Klaus MH. Klaus PH. The Amazing Newborn. Reading, Mass: Addison-Wesley/Lawrence :1985

Komara, C., Simpson, D., Teasdale, C., Whalen, G., Bell, S., & Giovanetto, L. (2007). Intervening to promote early initiation of breastfeeding in the LDR. MCN Am J Matern Child Nurs, 32(2), 117-121. [Abstract]

Ludington SM. Energy conservation during skin-to-skin contact between premature infants and their mothers. Heart Lung 1990;19(5 Pt 1):445-51. [Abstract]

Ludington-Hoe, S. M., Lewis, T., Morgan, K., Cong, X., Anderson, L., & Reese, S. (2006). Breast and infant temperatures with twins during shared Kangaroo Care. J Obstet Gynecol Neonatal Nurs, 35(2), 223-231. [Article]

Martinez, J. C. (2007). Skin-to-skin contact: A paramount contribution to the modern neonatal paradigm. NeoReviews, 8(2), e55. [Abstract]

McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S.  Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants (Review). The Cochrane Collaboration, 2009.[Abstract]
     The purpose of this study was to assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or LBW infants applied within ten minutes after birth in the delivery suite compared with routine thermal care.
     Concludes that plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to NICU and less hypothermia. Recommendations for clinical practice cannot be given.

Mooncey S, Giannakoulopoulos X, Glover V, Acolet D, Modi N. The effect of Mother-Infant skin-to-skin contact on plasma cortisol and beta-endorphin concentrations in Preterm Newborns. Infant Behaviour and Development 1997;20(4):553-7. [Abstract]

Moore, E. R., & Anderson, G. C. (2007). Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health, 52(2), 116-125. [Abstract]
     This study was done to evaluate effects of maternal-infant skin-to-skin contact during the first two hours post birth compared to standard care on breastfeeding outcomes through 1 month follow-up.
     Significantly more skin-to-skin held infants suckled competently during their first breastfeeding and established effective breastfeeding sooner. Infants who suckled competently did so regardless of skin-to-skin or swaddled provided that their mothers had erect nipples. Early skin-to-skin contact showed significant and better overall performance on breastfeeding status (exclusivity) and duration. Early skin-to-skin may not have significant positive effect on breastfeeding status in US because of multitude of other barriers in the environment that negatively influence long-term breastfeeding practices.

Moore, E. R., Anderson, G. C., & Bergman, N. (2007). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev(3), CD003519. [Abstract] [Full report]

Morelius, E., Theodorsson, E., & Nelson, N. (2005). Salivary cortisol and mood and pain profiles during skin-to-skin care for an unselected group of mothers and infants in neonatal intensive care. Pediatrics, 116(5), 1105-1113. [Full Text]

Perry, B. Attachment. On Six Core Strengths for Healthy Child Hood Development [Video]: Child Trauma Academy.

Perry, B. Self-Regulation. On Six Core Strengths for Healthy Childhood Development [Video]: Child Trauma Academy.

Righard, L. (1995). How do newborns find their mother's breast? Birth, 22(3), 174-175.

Righard, L. (1998). Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth, 25(1), 40-44. [Abstract]

Righard, L., & Alade, M. O. (1990). Effect of delivery room routines on success of first breast-feed. Lancet, 336(8723), 1105-1107. [Abstract]

Righard, L., & Alade, M. O. (1992). Sucking technique and its effect on success of breastfeeding. Birth, 19(4), 185-189. http://www.ncbi.nlm.nih.gov/pubmed/1472265

Righard, L., Flodmark, C. E., Lothe, L., & Jakobsson, I. (1993). Breastfeeding patterns: comparing the effects on infant behavior and maternal satisfaction of using one or two breasts. Birth, 20(4), 182-185. [Abstract]

Sobhy, S. I., & Mohame, N. A. (2004). The effect of early initiation of breast feeding on the amount of vaginal blood loss during the fourth stage of labor. J Egypt Public Health Assoc, 79(1-2), 1-12. [Abstract]

Uvnas-Mobert K. 2003. The oxytocin factor: Tapping the hormone of calm, love and healing. Cambridge, MA: Da Capa Press.

Uvnäs-Moberg K, Petersson M Oxytocin, a Mediator of Anti-stress, Well-being,Social Interaction, Growth and Healing (Article in German). Zeitschrift für Psychosomatische Medizin und Psychotherapie, Volume 51, Number 1, January 2005 , pp. 57-80(24), Publisher: Vandenhoeck & Ruprecht [Abstract]

Wahlberg V, Affonso D, Persson B. A retrospective, comparative study using the Kangaroo method as a complement to the Standard Incubator care. European Journal of Public Health 1992;2:34-7. [Abstract]

A listing of references related to Kangaroo Mother Care and Skin to Skin updated as of 11/04 by Dr. Susan Ludington is available. [Weblink (PDF)Opens a new browser window.]

Video or audio presentation of:

Melcher, CL; The Relational Teaching Model: A new approach to training resistant hospital staff - Presentation to the International Lactation Consultant Association, 2005: – Carol Lopez Melcher, RNC, MPH Perinatal Services Network Project Director Loma Linda University Medical Center/Children's Hospital, Loma Linda, CA

Conference Sessions that can be used for staff education: Go to ILCA for previous conference sessions. Some sessions that may be useful from the 2005 Conference:

Skin-to-skin Contact and Perinatal Neuroscience – Nils Bergman
Kangaroo Mother Care: Restoring the original paradigm for newborn care – Nils Bergman
Rational Use of Supplements: The journey towards best practice – Marina Green
The Almost Term Premature Baby: Caring for babies born between 25-39 weeks gestation – Molly Pessl
The Relational Teaching Model: A new approach to training resistant hospital staff – Carol Melcher

Conference Session in 2006

Celiac Disease: Importance Of Exclusive Breastfeeding For At-Risk Infants: by Ilana Chertok  Recorded 7/12/2006 at Interdisciplinary Breastfeeding Practice: Integration Through Innovation

ILCA Conference Session in 2010:

A closer look at Controversial Connection:Does exclusive breastfeeding reduce the risk for childhood obesity? by Jane Henig  Recorded 7/21/2010 at 2010 International Lactation Consultants

Hospital Self-Appraisal Questionnaire (Word)Opens a new browser window.

Back to Main Page of Breastfeeding Toolkit

Last modified on: 6/7/2011 12:24 PM