Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Randomized controlled trial of early skin-to-skin contact: effects on the

mother and the newborn
MA Marín Gabriel (pedmgma@gmail.com; mangel.maringa@salud.madrid.org)1,2, I Llana Martín1, A López Escobar1, E Fernández Villalba1,
I Romero Blanco1, P Touza Pol1
1.Pediatrics, Hospital Madrid-Torrelodones, Madrid, Spain
2.Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain

Keywords Abstract
Breastfeeding, Episiotomy, Maternal mood,
Objective: To estimate the influence of skin-to-skin care on the thermal regulation of the infant
Newborn temperature, Skin-to-skin contact
and the rate of breastfeeding at different points of time. We also aim to establish whether skin-to-skin
Correspondence
contact reduces maternal pain during episiotomy repair and decreases the time to expel the placenta.
MÁ Marı́n Gabriel, Hospital Madrid-Torrelodones,
Avda Castillo de Olivares s ⁄ n. CP 28250, Madrid, Methods: A randomized control study was performed with 137 patients in each branch of the
Spain. study. Differences between the study groups were analysed with the unpaired t-test, Fisher test or chi-
Tel: +34 91 267 50 00 | square test as appropriate.
Fax: +34 91 257 00 00 |
Results: Greater thermal stability in the skin-to-skin care group was found where an average tem-
Email: pedmgma@gmail.com;
mangel.maringa@salud.madrid.org perature rise of 0.07C was observed. Mothers in the skin-to-skin care group exclusively breastfed
Received
more frequently at discharge. Mean time to expel the placenta was lesser in the skin-to-skin care
23 July 2009; revised 6 October 2009; group.
accepted 15 October 2009.
Conclusion: This study shows that skin-to-skin care implies better thermal regulation and a better proportion of
DOI:10.1111/j.1651-2227.2009.01597.x
exclusive breastfeeding at hospital discharge.

INTRODUCTION
Skin-to-skin contact (SSC) is defined as holding the baby
naked against the mother’s or father’s skin near the chest.
Some authors have performed different studies demonstrat-
ing the benefits of SSC on the initiation and duration of
breastfeeding, body temperature control, analgesic effect
during painful procedures, physiological stabilization of the
newborn or feeling of competence in parents (1–6). It also
decreased the incidence of postpartum depression in moth-
ers of preterm infants (7), but these data are only supported
by a few published studies (8,9).
SSC increases oxytocin levels in the maternal blood. The
importance of this hormone for its role in uterine contrac-
tions and ejection of breast milk during infant suckling is
well known, in addition to the emotional process that takes
place between the mother and the infant during childbirth
(10).
Recently, several investigators have studied ways to
reduce the pain during episiotomy repair, such as previous
care before the intrapartum period, different ways to suture
or by special care during the postpartum period (11–14).
No previous study has assessed the effect of SSC on mater-
nal pain during episotomy repair.
Abbreviations
CG, control group; HADS, Hospital Anxiety and Depression
Scale; NICU, neonatal intensive care unit; SSC, skin-to-skin con-
tact; VAS, Visual Analogue Scale.
The principal aim of the study was to estimate the influ-
ence of SSC on thermal regulation in term and nearly term
infants. Secondary aims were to: 1) establish whether SSC
has any influence on neonatal recovery from hypothermia;
2) estimate the rates of breastfeeding upon hospital dis-
charge and at infant’s 1 month of age; 3) determine the
influence of SSC on the frequency of infants admitted to a
neonatal intensive care unit (NICU); 4) establish whether
SSC reduces maternal pain during suturing episiotomy and
decreases the time to expel the placenta; and 5) determine
whether the SSC policy has any influence on maternal
mood.
PATIENTS AND METHODS
Design
A randomized controlled study was performed during
4 months in the Madrid-Torrelodones Hospital. The
research protocol was fully approved by the institutional
ethics committee and the investigation local area com-
mittee. Patients were informed prenatally and asked to
sign a letter of consent before their participation in the
project.
Participation criteria included healthy mothers with sin-
gle pregnancies and documented prenatal care who were
admitted at term or nearly term (35–42 weeks gestation) to
the hospital delivery room.
Exclusion criteria included mothers who showed signs of
foetal distress during labour, mothers who required

1630 ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1630–1634
Marı́n Gabriel et al.
caesarean section, and those infants that needed any type of
resuscitation such as positive pressure or intubation proce-
dures. Infants with meconial amniotic fluid and without
respiratory effort were also excluded.
Procedure
Paediatricians who assisted delivery were randomized
according to the first letter of his ⁄ her surname into two
groups at the beginning of the study: an SSC group
(n = 6) and a control group (CG) (n = 7). If a delivery
was assisted by a paediatrician of the SSC group, he ⁄ she
always performed skin-to-skin care, and if a delivery was
assisted by a paediatrician of the CG, he ⁄ she always
made resuscitation on the examination table. Mothers
were blinded to their paediatrician group (SSC or CG)
assignment.
In the SSC group, the umbilical cord was clamped 10–
15 sec after birth and all babies were immediately placed
over the mother’s abdomen. The infants were carefully dried
and only clothed in a diaper and a cap, and held upright
between the mother’s breasts. Finally, the baby and the
mother were covered with a warm blanket around the
infant’s back during SSC to ensure maintenance of infant
body temperature. The identification process was per-
formed during SSC. After 2 h of continuous SSC, the babies
were separated from the mother following hospital routines,
which included weighing, anthropometric measurements,
eye and vitamin K prophylaxis, and the administration of
hepatitis B vaccine. The babies were then dressed and given
back to their parents.
In the CG, the umbilical cord was clamped 10–15 sec
after birth and all babies were immediately placed on an
examination table with a heater above. The infants were
carefully dried and only dressed with a diaper and a cap.
The identification process was performed on the warming
table. Finally, babies were wrapped with a warm blanket
and then given back to their parents at an average of 10 min
of life. After 2 h without SSC, routine procedures were
made as in the SSC group.
A midwife measured newborn’s temperature with a digi-
tal thermometer in the axilla when the infant was 1-min, 5-
min, and 2-h old. Hypothermia in the first minute was
defined as an axillary temperature less than 36C. Recovery
from hypothermia at 5 min was considered when axillary
temperature was over 36C.
Time of placental delivery was considered as the interval
of time from childbirth to totally expelled placenta.
The Visual Analogue Scale (VAS) was used to measure
mother’s pain while suturing. This is a measurement instru-
ment that tries to measure a characteristic or attitude that is
believed to range across a continuum of values and cannot
easily be directly measured (e.g. pain). VAS in the study was
a horizontal line, 10 cm in length with score ranging from 0
(no pain) to 10 (very severe pain). The paediatrician col-
lected the VAS during suturing episiotomy. Women who
did not receive episiotomy and those who received perineal
laceration were excluded. Ninety-five percent of the moth-
ers received epidural anaesthesia.
ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1630–1634
Skin-to-skin contact: effects on the mother and the newborn
The Hospital Anxiety and Depression Scale (HADS) was
assessed upon hospital discharge during the last 3 months
of the study. This is a self-report rating scale of 14 items on a
4-point Likert scale (range 0–3). The scale is designed to
measure anxiety and depression (seven items for each sub-
scale). The total score is the sum of the 14 items, and for
each subscale, the score is the sum of the seven respective
items (range 0–21). The depression scale items are based on
the main symptoms of depression psychopathology. Anxiety
symptoms are based on the psychic manifestations of situa-
tional anxiety. The problem considered was not present if
the score was 7 or less, doubtful if it was from 8 to 10 and it
was considered that there was a problem if the score was
equal or more than 11 (15,16). If the infant was admitted to
the NICU, HADS was not passed.
The mother–infant dyads were followed up during the
infants’ stay in the hospital. In addition, follow-up tele-
phone calls were made 1 month after hospital discharge to
monitor the duration of breastfeeding. Exclusive breastfeed-
ing was considered when the baby was only breastfed. Par-
tial breastfeeding was considered when the baby received
breastfeeding at least once a day. Lack of information about
breastfeeding status at 1 month old was considered if no
answer was obtained after three phone calls (5.8% SSC
group vs 13.1% CG).
Statistical analysis
The size of the sample was calculated to permit a standard
deviation of 0.7, a power of 80% and an alpha error of 5%.
The estimated minimum sample size was 124 neonates in
each group. Data analysis was performed with the SPSS sta-
tistical software (SPSS Inc. Chicago, IL, USA). Mean values
were used as central measures. Standard deviation or
95% confidence interval was used to measure dispersion.
Differences between the two study groups were analysed
using the unpaired t-test, Fisher test or chi-square test as
appropriate.
RESULTS
A total of 430 patients were assessed for eligibility. Eighty
patients were excluded (77 patients did not meet inclusion
criteria and three patients refused to participate), thereby
resulting in 350 patients. In the SSC group, 16 patients did
not receive allocated intervention (positive pressure resusci-
tation or intubation (n = 12) and meconial amniotic fluid
without respiratory effort (n = 4)); eleven patients were lost
to follow-up (digital thermometer without battery (n = 7) or
thermometer absent in the delivery room (n = 4)); two
patients were excluded because positive pressure was used
after 1 min of life; and finally nine patients were excluded
from the analysis because data were incomplete, thus result-
ing in 137 patients. Eight mothers in this group were lost to
follow-up at the infant’s age of 1 month. In the CG, 13
patients did not receive allocated intervention (positive
pressure resuscitation or intubation (n = 10) and meconial
amniotic fluid without respiratory effort (n = 3)); 13
patients were lost to follow-up (digital thermometer without
1631
Skin-to-skin contact: effects on the mother and the newborn Marı́n Gabriel et al.

battery (n = 7) or thermometer absent in the delivery room Table 2 Frequency of breastfeeding at discharge and at 1 month of life
(n = 6)); one patient was excluded because positive pres- SSC group Control group
sure was used after 1 min of life; and finally 11 patients were
BF at discharge n = 118 n = 120
excluded from analysis because data were incomplete, thus
Exclusive BF 84.7% (78.3–91.2)* 70% (61.8–78.2)
resulting in 137 patients. Eighteen mothers in the CG were
Exclusive + Partial BF 99.2% (97.5–100) 95.8% (92.3–99.4)
lost to follow-up at the infant’s age of 1 month. The descrip-
BF at 1 month old n = 117 n = 113
tion of each branch of the study is summarized in Table 1. Exclusive BF 65% (56.3–73.6) 65.5% (56.7–74.3)
There were no significant differences except for infant Exclusive + Partial BF 91.5% (86.4–96.5) 90.3% (84.8–95.7)
weight, which was lower in the SSC group. Most of the
BF = Breastfeeding; SSC = Skin-to-skin contact.
infants did not require any type of resuscitation or only
Mothers without breastfeeding intention during pregnancy were excluded
required aspiration of secretions (96.3%). No differences in
(n = 12 SSC Group, n = 6 control group). Results expressed as mean (95%
marital status or ethnicity were observed (data not shown). CI).
The temperature difference registered at different time *p = 0.01.
points is reflected in the Figure 1. More thermal stability in
the first 5 min of life was found in the SSC group where an
average temperature rise of 0.07 ± 0.58C is observed vs (65.7% to 94.3%) in the former group and 54.5% (25.1% to
)0.22 ± 0.52C in the CG (p < 0.001). Mean temperature in 84%) recovered in the CG (p = 0.12).
the first minute of life was 36.6 ± 0.79C in the SSC group The proportion of mothers who breastfed their children is
vs 36.9 ± 0.58C in the CG (p < 0.01). There were no differ- given in Table 2. Mothers in the SSC group exclusively
ences in mean temperature between the groups at 5 min, breastfed more frequently upon discharge, but no differ-
nor at 2 h of life. ences were found at 1 month of life.
Thirty infants (21.8%) from the SSC group and 11 infants During the study period, 17 patients were admitted to the
(8%) in the CG had hypothermia during the first minute of NICU, five (3.6%) from the SSC group and 12 (8.8%) from
life. Eighty percent recovered when they were 5 min old the CG (p = 0.13).
Mean time to expel the placenta was 408.7 ± 244.8 sec in
the SSC group vs 475.2 ± 276.6 sec in the CG (p = 0.05).
The VAS score during episiotomy suture was 1.4 ± 2.6 in
Table 1 Sample description and potentially affecting variables the SSC group and 1.3 ± 1.8 in the CG (p = 0.78).
SSC group (n = 137) Control group (n = 137) p
There were no differences in the mean anxiety score
(4.7 ± 2.8 SSC vs 5.2 ± 3.3 in the CG; p = 0.23) as well as
GA (w) 38.9 (1.3) 39.1 (1.2) 0.22 in the depression score (2.1 ± 2.2 SSC vs 2.2 ± 2.4 in the
Weight (g) 3,166.2 (389.2) 3,300.1 (414.1) 0.007 CG; p = 0.75).
LBW 3.7% (0.5–6.9) 6.1% (2–10.2) 0.12
Male 45.3% (36.9–53.6) 55.5% (47.2–63.8) 0.11
1 min Apgar >7 100% 98.5% 0.49
No resuscitation 67.9% 58.4% 0.13
DISCUSSION
The results of this study show that SSC may imply better
GA = Gestational age; LBW = Low birth weight; SSC = Skin-to-skin contact. thermal regulation in term and nearly term infants. Infants
Results expressed as mean (95% CI).
in the SSC group presented a temperature increase in the
first few minutes of life with almost no changes in the first
2 h of life, whereas those with standard care showed a pro-
gressive reduction in temperature during the same period.
1
Nevertheless, results may not have clinical significance.
SSC group
SSC group Control Several studies have demonstrated the beneficial effect of
0.5
Control SSC on the thermal control of infants. In a study involving
term infants, Christensson et al. (17) obtained an axillary
0 average temperature of 37.1C at 90 min of life in SSC com-
pared with 36.7C in the control group. Bystrova et al. (2)
observed that infants exposed to SSC presented an increase
–0.5
in axillary temperature of 1.6 ± 1.5C between 30 min and
p < 0.001 p = 0.49 120 min after delivery. In our study, the increase in temper-
–1 ature was found only in the first few minutes of life; in addi-
tion, this was lower (0.07 ± 0.58C) than that obtained by
–1.5 Bystrova et al., although in this study, the average axillary
Dif Ta5'-Ta1' Dif Ta2h'-Ta5'
temperature in the group of SSC patients was lower (mean
Figure 1 Temperature Difference at Different Time Points in the SSC Group temperature 34.5C) than in our study (mean temperature
and Control Group. In the left, difference between mean temperature at 5 min at 1 min of life 36.5C).
and 1 min are shown. In the right, difference between mean temperature at We observed that the temperature registered in the SSC
2 h and 5 min are shown. group in the first minute of life is significantly lower than

1632 ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1630–1634
Marı́n Gabriel et al.
that in the control group. The differences between the deliv-
ery room temperature and the heater temperature may be
the reason for this temperature difference. In the same way,
this thermal difference may explain the higher number of
patients with hypothermia at 1 min in the SSC group. How-
ever, a tendency towards greater recovery from hypother-
mia at 5 min in this group was found, which enables the
inference that infants with hypothermia may benefit from
SSC.
The higher temperature in the early postnatal period
has been attributed to the increase in metabolism that
takes place in the infant after birth. Studies have demon-
strated how those infants born by vaginal delivery pre-
sented higher plasma catecholamine levels, which causes
peripheral blood vessel constriction and elevated temper-
ature (18). Another implied mechanism is the conduction
of temperature from the mother to the infant. Some
investigators refer to the increase in axillary and chest
temperature in mothers during SSC (19); therefore, heat
is transferred from the body with higher temperature (the
mother) to the body with lower temperature (the infant).
There are only a few publications, which establish the
influence of SSC on breastfeeding at hospital discharge. In a
study with 30 healthy infants, Thomson et al. (20) found no
difference in this context. Nevertheless, Villalon and Alv-
arez (21) observed in 120 healthy infants that those in the
SSC group presented higher rates of breastfeeding when dis-
charged. Our results showed that SSC babies presented a
better proportion of exclusive breastfeeding at hospital dis-
charge (84.7%). However, a longer breastfeeding duration
in this group of patients was not observed, in contrast with
the available literature (20,22,23).
Some authors assessed different mechanisms that can
help in causing a less painful sensation during episiotomy
suture (12,13). However, according to reference documents,
we did not find any publication in which SSC was evaluated
as a possible analgesic procedure. Therefore, this is the first
article to do so. Nevertheless, according to the results
obtained, the application of SSC does not reduce the painful
sensation during episiotomy suturing. However, the low
VAS scores obtained in both groups enable postulating that
the pain caused during this procedure is minimal, which is
most probably because of the routine use of epidural anaes-
thesia. It would be interesting to assess the possible analge-
sic effect of SSC in those hospitals that do not apply routine
epidural anaesthesia.
Similarly, we did not find previous publications referring
to the possible influence of SSC on the time to expel the pla-
centa. In our study, a tendency towards shorter time for pla-
cental delivery was found in the SSC group. The movement
of the infant’s feet on the maternal abdomen (24) as well as
the liberation of oxytocin as a result of stimulation of the
nipples (25) may play a role in this context.
According to the literature reviewed, SSC confers a
greater sensation of competence on mothers, fortifies the
maternal-branch bond and leads to greater physical con-
tact between both (21,26–28). Nevertheless, in our study,
we did not observe that the application of SSC in the
ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1630–1634
Skin-to-skin contact: effects on the mother and the newborn
delivery room makes a difference to the outcome of
depression or anxiety state measured using the HADS
scale. It is possible that the demonstrated beneficial effect
in ill, premature infants in this sense will be reduced in
healthy, term infants (6).
Limitations
There is a possibility that the design of the study will not be
accurate; another double-blinded random study is recom-
mended. In addition, the necessary sample size was esti-
mated based on the principal aim of the study, for which
reason the conclusions inferred according to the results of
the secondary aims could be slightly modified. In the study,
the 13 doctors were randomized to the treatment groups. It
would have been better to randomize the mothers to treat-
ments for each doctor (a randomized block design with doc-
tor as block). Thus, each doctor should have been applying
both treatments. The room temperature of the SSC group
was around 24C, in contrast with the temperature in the
CG (around 30C); this difference in environmental temper-
ature based on the place of resuscitation may modify the
results. Maternal temperature prior to delivery was not
recorded and it is possible that this may have any influence
in the difference between groups. The temperature mea-
sured at 1 min was different between groups; it would be
desirable to see this intervention performed on two groups
where the initial temperature was not statistically different.
The degree of analgesia achieved with epidural anaesthesia
is variable. It would be desirable to quantify the painful sen-
sation prior to childbirth.
CONCLUSIONS
This study emphasizes the potential benefit of close skin
contact for the maintenance of temperature in term and
nearly term infants in the delivery room. It would be inter-
esting to test this intervention in developing countries or in
places where standard of care with radiant heat and con-
trolled delivery rooms is not available.
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