Early Human Development 132 (2019) 30–36

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

The effect of labor medications on normal newborn behavior in the first T

hour after birth: A prospective cohort study
⁎
Kajsa Brimdyra, , Karin Cadwellb, Ann-Marie Widströmb, Kristin Svenssonb,d, Rayle Phillipsc
a
Healthy Children Project, 327 Quaker Meeting House Road, East Sandwich, MA 02537, USA
b
Karolinska Institutet, Tomtebodavägen 23a, 171 65 Solna, Sweden
c
Loma Linda University, School of Medicine, 11234 Anderson St, Loma Linda, CA 92354, USA
d
Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Sweden

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Skin-to-skin contact after birth between mother and baby has immediate and long-term advantages.
Newborn behavior Widström's 9 Stages of Newborn Behavior offer an opportunity to evaluate a baby in the natural, expected and
Skin-to-skin optimal habitat. Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin
Labor medications (synOT), have been studied in relation to neonatal outcomes with conflicting results.
Epidural
Aims: Determine the effects of common intrapartum medications on the instinctive behavior of healthy new-
Synthetic oxytocin
Widström's 9 stages
borns during the first hour after birth through a prospective cohort study.
Study design: Video record newly-born term infants during the first hour after birth while in skin-to-skin contact
with mother. Code and analyze videos using Widström's 9 Stages; compare with the labor medications mothers
received.
Subjects: Convenience sample of sixty-three low-income mothers self-selected to labor with or without in-
trapartum analgesia.
Outcome measures: Duration of time infants spend in each of Widström's 9 Stages for four cohorts: 1) exposed to
no synOT or epidural fentanyl during labor, 2) exposed to fentanyl (but not synOT), 3) exposed synOT (but not
fentanyl), 4) exposed to both fentanyl and synOT.
Results: A strong inverse correlation was found between intrapartum exposure to fentanyl and synOT and the
normal behavior of an infant, as measured by time in each Stage.
Conclusions: Intrapartum exposure to the drugs fentanyl and synOT is associated with altered newborn infant
behavior, including suckling, while in skin-to-skin contact with mother during the first hour after birth.
Widström's 9 Stages offer an opportunity to analyze newborn behavior whilst in the optimal habitat of the infant.

1. Introduction continuous, uninterrupted skin-to-skin contact after birth include in-

Worldwide, only 45% of newborns experience any skin-to-skin
contact with their mother soon after birth [1]. Infants who have been
allowed to have the experience of early skin-to-skin contact with mo-
thers for the first 1–2 h after birth are reported to have immediate
health advantages including more optimal blood glucose levels, better
respirations, more optimal temperatures, and less crying [1,2]. Failure
to experience skin-to-skin contact and early initiation of breastfeeding
has been linked to increased infant mortality, with the risk of dying in
the first 28 days after birth increasing 41% for newborns who initiated
breastfeeding at 2–23 h and increasing 79% for those who initiated
breastfeeding > 24 h after birth. Long-term advantages of immediate,
creased self-regulatory behaviors at 1 year of age [3] as well as possible
epigenetic gene regulation [4] and the establishment of the newborn's
microbiome [5,6].
Research shows that when healthy newborns are placed in skin-to-
skin contact on their mothers' chests immediately after birth, they will
demonstrate instinctive behaviors and, if undisturbed, will crawl to-
wards their mothers' breasts and begin to suckle within the first 1–2 h
after birth [7,8]. More specifically, when in skin-to-skin contact with
mother in the first hour after birth, healthy babies go through 9 distinct
and measurable stages (Widström) (Table 1, Fig. 1). Knowledge of these
stages provides an opportunity to observe the newborn's complex, in-
stinctive behavior in its natural setting. The neonate must coordinate

⁎
Corresponding author.
E-mail addresses: kajsa@centerforbreastfeeding.org (K. Brimdyr), karin@centerforbreastfeeding.org (K. Cadwell), Ann-Marie.Widstrom@ki.se (A.-M. Widström),
Kristin.Svensson@ki.se (K. Svensson), RPhillips@llu.edu (R. Phillips).

https://doi.org/10.1016/j.earlhumdev.2019.03.019
Received 13 February 2019; Received in revised form 28 March 2019; Accepted 29 March 2019
0378-3782/ © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
K. Brimdyr, et al.
Table 1
Widström's 9 Stages during skin-to-skin contact immediately after birth.
1. The birth cry is a distinct and specific cry as the baby's lungs expand for the first
time.
2. Relaxation is a time immediately after the birth cry ends, when the baby becomes
still and has no visible movements.
3. Awakening begins as the baby opens the eyes for the first time, blinks, has small
mouth movements and limited hand and shoulder motions.
4. Activity involves larger body movements, including whole arm motions, specific
finger movements, shoulder motion, head lifting, and stable open eyes.
5. Rest could happen at any point during the first hour, interspersed between stages or
as a transition between stages.
6. Crawling involves the baby moving purposely towards the breast and nipple. It
could be accomplished through sliding, leaping, bobbing, or pushing.
7. Familiarization is a stage at the mother's nipple where the baby licks, tastes, touches
and moves around the nipple and areola area.
8. Suckling involves the baby self attaching to the nipple and initiating breastfeeding.
9. Sleeping is an involuntary activity of the baby around 1.5 to 2 h after birth.
According to Widström et al., there are 9 stages that babies go through during
the first hour after birth that are innate and instinctive to the baby. Examining a
baby's natural and instinctive behavior during the first hour helps to eliminate
possible iatrogenic effects the testing itself may create.
many different state systems, including autonomic, sensory, motor and
behavioral states, in order to progress smoothly through these 9 Stages
within the first hour or so after birth. Many prenatal and perinatal
factors, including exposure to intrapartum medications, may affect the
newborn's ability to coordinate and integrate these state systems and
may affect neurobehavioral organization. Research has shown that at-
tenuated neonatal neurobehavioral organization (NNBO) when mea-
sured soon after birth could be related to the slow initiation of optimal
sucking behavior [9,10].
Although the cumulative effects of intrapartum analgesic medica-
tions on newborns is unknown, research shows that intrapartum an-
algesic medications have measurable negative outcomes, whether the
mother received the analgesic intravenously or via epidural space [11].
Studies indicate an association of intrapartum analgesia with an in-
creased need for neonatal resuscitation [12], raised temperature and
increased crying [13], higher rates of hypotonia and 1-min Apgar
scores < 7 [14], decreased neurobehavioral scores in the first hours
after birth and in the first month [15], and changes in the morphology
of the neonatal brain as measured by MRI [16]. Intrapartum analgesics
have also been implicated in the finding of less optimal breastfeeding
for both initiation and duration [17–23]. Infants of women who re-
ceived > 150 micrograms of epidural fentanyl during labor have been
found to have lower neurobehavioral scores after birth [15] and de-
creased breastfeeding duration at 6 weeks postpartum [24]. Other stu-
dies have not found an association between epidural anesthesia and
measurements of breastfeeding outcomes [25,26].
The purpose of this observational study was to evaluate the effects
of intrapartum medications on the instinctive behavior of a healthy
newborn during the first hour after birth. We hypothesized that in-
trapartum narcotic medications and synthetic oxytocin (synOT) would
affect newborn behavior, as described by Widström's 9 Stages.
2. Methods
Loma Linda University Children's Hospital (LLUCH) is designated as
a Baby-Friendly™ teaching hospital in Southern California with ap-
proximately 2500 births per year at the time of this study. The hospital
follows Step 4 of the Baby Friendly Hospital Initiative (BFHI) and
routinely provides uninterrupted skin-to-skin contact for all healthy
full-term newborns immediately after all vaginal and cesarean births for
at least one hour. This study protocol was limited to vaginal births only.
The hospital practice includes a consistent formulary for medications
used in epidurals, including fentanyl. The study protocol was approved
by the Institutional Review Board of LLUCH.
31
Early Human Development 132 (2019) 30–36
Researchers obtained informed consent from 96 clinically un-
complicated primipara and multipara mothers in 2013: one week each
in May, July, August and December. Inclusion criteria for the study
included women who were ≥ 18 years of age, healthy, English or
Spanish speaking as their primary language, 37 to 42 weeks pregnant,
and who had planned a vaginal birth. Infants were eligible if they were
full-term gestation, healthy, and had no known abnormalities. Informed
consent materials were available to prospective women in both English
and Spanish (with a translator for Spanish-only speaking participants).
Any identifying information was removed from the collected medical
records and given a unique code. This unique code was also linked to
the video of the baby that was recorded during the first hour after birth.
The observational study did not change any hospital care during
labor, birth or after birth; no hospital protocols or routines were
changed by the study except to unobtrusively video record the baby
during the first hour after birth while in skin-to-skin contact with the
mother.
Mothers determined, with their health care providers, if epidural
anesthesia and/or synOT was to be used during labor. A list of medi-
cations used during labor was collected from the medical records of
study participants after the first hour video was completed.
3. Data collection procedures
After birth, the full-term newborn was immediately placed in skin-
to-skin contact with the mother, who was semi-reclined on the hospital
bed; the baby was quickly dried and mother and baby were covered
with a warm blanket. The baby was to remain in skin-to-skin contact
with the mother for at least the first hour after birth unless separation
was medically indicated. The video researcher stood behind the mo-
ther's head and video recorded the behaviors of the newborn during the
first hour after birth. Babies who were removed for examination by the
nurse or by Neonatal Intensive Care Unit (NICU) staff for < 10 min but
then returned to the mother could remain in the study. Mother-baby
dyads were excluded from the study if the baby was removed by the
nurse or by NICU staff for more than10 min. Dyads were also removed
from the study if concerns for the fetus required emergency care by the
medical staff prior to birth or concerns for health of the mother at any
point.
Education was provided to staff using a professional video [27] and
a workshop given by two research assistants about Widström's 9 Stages
of Newborn Behavior to ensure staff could recognize each stage. The
research assistants were blinded to mother's labor medications.
3.1. Statistical analysis
MAXQDA 11.0.2, 2013, a professional qualitative data analysis
software, was used to separately and independently code the video
recordings for Widström's 9 Stages. Analysis of the video recordings
provided data on achievement of suckling, the final stage reached, and
the mean time in each of Widström's 9 Stages. SPSS version 22 was used
for statistical analysis. We examined the medical record of each baby
and mother to collect the recorded demographics (i.e. gestational age,
birth weight, one-minute and five-minute Apgar scores, maternal age,
gravida and para), as well as administered amounts of any intrapartum
medication including intravenous synOT or epidural fentanyl. For the
purposes of analysis, the four study cohorts were: 1) mothers who had
received no synOT and no fentanyl (the control group), 2) mothers who
received fentanyl without synOT, 3) mothers who received synOT
without fentanyl, and 4) mothers who received both fentanyl and
synOT. Descriptive statistics were used in all of the studies for the study
populations and descriptive variables; the normally distributed results
were reported with mean and standard deviation (SD), and the re-
maining results were reported with median and (interquartile) range.
Independent t-tests on the mean time spent in each of Widström's 9
Stages, and to provide the standard deviation. A 95% confidence level
K. Brimdyr, et al.
Fig. 1. Visual illustration of the 9 Stages of Newborn Behavior while skin-to-skin during the first hour after birth, photographs copyright Healthy Children Project,
Inc. Used with permission.
was used to test statistical significance, with p < .05 being considered
a significant result. ANOVA tests were used to compare the means of the
cohort groups, with pair-wise analysis using a Bonferroni correction.
Independent t-tests using Levene's Test for Equality of Variances were
conducted between the control and each cohort group.
4. Results
Of the 96 mothers consented into the study, 63 remained in the
study. Six were erroneously consented (five were scheduled for repeat
cesareans; one had a physical abnormality that precluded breast-
feeding). Twenty-five mothers were removed from the study when they
became high-risk during labor or during the first hour after birth, for
reasons which had not been evident at the time of consent, and two
mothers were considered medication outliers (detailed information on
removed dyads are reported elsewhere [23]). Babies who were delayed
in starting skin-to-skin care for < 10 min or removed for < 10 min were
included in the research. There was no difference in suckling between
babies that were delayed or removed for < 10 minutes compared to
those who stayed in continuous skin-to-skin contact (p = .53).
The 63 low-risk mother-infant dyads were found to fall into four
cohorts: 1) 10 dyads had no exposure to synOT or fentanyl (control
group), 2) 16 dyads were exposed to fentanyl without synOT, 3) 12
32
Early Human Development 132 (2019) 30–36
dyads were exposed to synOT without fentanyl, and 4) 25 dyads were
exposed to both fentanyl and synOT. Although self-selected, the mo-
thers in the four cohorts did not differ in age (p = .44), number of
pregnancies (p = .25) or number of births (p = .57) (Table 1). The
resulting babies in the four cohorts did not differ in relation to birth
weight (p = .11), gestational age (p = .45), one-minute Apgar score
(p = .64), or five-minute Apgar score (p = .65) (Table 2).
4.1. The birth cry (stage 1)
Babies with no exposure to fentanyl or synOT (control group) had
significantly longer birth cries than babies in all three other cohorts:
those exposed to fentanyl without synOT (p < .001), those exposed to
synOT without fentanyl (p = .02), and those exposed to both fentanyl
and synOT (p = .03). Babies exposed to fentanyl without synOT had
significantly shorter birth cries than those in all three other cohorts:
those with no exposure to fentanyl or synOT (control group)
(p < .001), those exposed to synOT without fentanyl (p = .04), or
those exposed to both fentanyl and synOT (p = .02).
There were no significant differences between the cohorts in rela-
tion to the duration of the next three stages of newborn behaviors,
Relaxation (Stage 2), Awakening (Stage 3), or Activity (Stage 4)
(Table 3).
K. Brimdyr, et al. Early Human Development 132 (2019) 30–36

Table 2
Maternal-related and infant-related demographic data by cohort.
Characteristics (mean) Control cohort Cohort exposed to fentanyl without Cohort exposed to synOT without Cohort exposed to both fentanyl and
(No exposure to synOT or synOT, n = 16 fentanyl, n = 12 synOT, n = 25
fentanyl), n = 10

Mother
Age (years)a 28.8 (4.4) 26.9 (5.1) 29.2 (6.0) 30.0 (6.5)
Number of pregnanciesa 2.2 (1.3) 2.12 (1.3) 2.58 (1.8) 3.04 (1.6)
Number of birthsa 0.9 (1.0) 0.81 (0.91) 1.25 (1.4) 1.28 (1.3)

Infant
1 Minute Apgarb 8.00 (7,9) 8.0 (8,8) 8.0 (8,8.75) 8.0 (8,9)
5 Minute Apgarb 9.0 (9,9) 9.0 (9,9) 9.0 (9,9) 9.0 (9,9)
Gestational Agea 39.2 (0.7) 39.6 (0.8) 39.867 (1.1) 39.36 (1.3)
Birth Weight (g)a 3260 (417) 3518 (403) 3345 (387) 3203 (407)

a
Mean (SD).
b
Median (25 centile, 75 centile).

4.2. Rest (stage 5) babies exposed to synOT without fentanyl (mean 0.58 ± 0.51)
(p = .01).
Babies in the cohort exposed to synOT without fentanyl spent sig-
nificantly less time resting than the control cohort with no exposure to 4.6. Sleeping (stage 9)
synOT or fentanyl (p = .05), babies exposed to fentanyl without synOT
(p = .04), or babies exposed to fentanyl and synOT (p = .01) cohorts. Only one baby reached the Sleeping Stage, which is not unexpected,
since babies usually fall asleep between 1.5 and 2 h after birth. The one
4.3. Crawling (stage 6) baby was in the control cohort.

Babies in the control cohort were significantly faster at crawling to
the breast (spent less time crawling to the breast) than those in the
cohort with exposure to fentanyl without synOT (p = .05), synOT
without exposure to fentanyl (p < .002), or exposure to both fentanyl
and synOT (p = .04).
4.4. Familiarization (stage 7)
Babies in the cohort exposed to both fentanyl and synOT spent
significantly less time in the Familiarization Stage than babies in the
control cohort (p = .05), the cohort exposed to fentanyl without synOT
(p < .001) or the cohort exposed to synOT without fentanyl
(p < .001).
4.5. Suckling (stage 8)
Suckling was examined in terms of whether a baby reached the
stage, and began suckling, rather than the mean duration of stage, since
many babies did not reach Stage 8. Babies exposed to both fentanyl and
synOT were significantly less likely to reach this stage and begin
suckling (mean 0.16 ± 0.37) than babies in the control cohort with no
exposure to fentanyl or synOT (mean 0.70 ± 0.48) (p < .001), babies
exposed to fentanyl without synOT (mean 0.56 ± 0.51) (p < .001) or
4.7. Progress through the stages at one hour
Babies exposed to both fentanyl and synOT were significantly less
likely to progress through the stages, with a mean stage of 5.47 ( ± 1.4)
(ending at Rest/Crawling) than babies with no exposure to fentanyl or
synOT, with a mean stage of 7.10 ( ± 1.7) (p = .03) (ending at
Familiarization/Suckling) or babies exposed to synOT without fentanyl,
with a mean stage of 7.17 ( ± 11) (p = .01) (ending at Familiarization/
Suckling). The final stage for babies exposed to both fentanyl and
synOT was not significantly different than those exposed to fentanyl
without synOT with a mean stage of 6.63 ( ± 1.6) (ending at Crawling/
Familiarization).
4.8. Removed/delayed
Babies in the cohort exposed to both fentanyl and synOT were sig-
nificantly more likely to have a longer delay time between the birth and
initiation of skin-to-skin contact or removed from the mother after skin-
to-skin contact had begun. Those exposed to both fentanyl and synOT
had a mean delay of 4:31.9 ( ± 04:53.3) minutes compared to babies in
the control group, which had a mean delay of 1:13.1 ( ± 02:34.2)
(p = .01), exposure to fentanyl without synOT with a mean delay of
1:22.2 ( ± 02:16.2) (p = .02), or exposure to synOT without fentanyl

Table 3
Duration of first 7 stages of Widström's 9 stages, by cohort, mean times (SD).
Control cohort Cohort exposed to fentanyl without Cohort exposed to synOT without Cohort exposed to both fentanyl and
(No exposure to synOT or synOT, n = 16 fentanyl, n = 12 synOT, n = 25
fentanyl), n = 10

Birth cry 00:32.4 ( ± : 44.7) 00:06.8 ( ± : 06.1)a 00:17.6 ( ± : 23.0)a 00:21.1( ± : 28.6)a
Relaxation 1:18.0 ( ± 3:32) 00:41.2 ( ± 1:15.5) 00:06.3 ( ± 0:10.2) 00:37.2 ( ± 1:13)
Awakening 10:45.9 ( ± 6:17.0) 8:19.6 ( ± 5:50.8) 6:46.9 ( ± 4:17.7) 8:01.3 ( ± 06:42.5)
Activity 10:33.6 ( ± 8:15.9) 12:30.0 ( ± 12:48.0) 11:54.4 ( ± 7:01.4) 14:27.5 ( ± 9:51.6)
Rest 17:18.7 ( ± 8:57.6) 14:25.6 ( ± 10:23.9) 10:42.4 ( ± 5:41.5)a 16:52.6 ( ± 11:06.1)
Crawling 00:31.0 ( ± 1:01.1) 1:56.2 ( ± 2:48.9)a 2:38.5 ( ± 2:44.3)a 1:04.9 ( ± 2:05.6)a
Familiarization 4:21.9 ( ± 10:03.6) 6:09.6 ( ± 8:45.7) 10:52.3 ( ± 10:32.9) 1:36.4 ( ± 2:56.7)a

ANOVA tests were used to compare the means of the cohort groups, with pair-wise analysis using a Bonferroni correction. Independent t-tests using Levene's Test for
Equality of Variances were conducted between the control and each cohort group. Key: 4:21.9 means 4 min, 21.9 s.
a
Significant compared to Control Cohort.

33
K. Brimdyr, et al.
with a mean delay of 1:05.9 ( ± 02:16.5) (p = .02) cohorts.
5. Discussion
Widström et al. first documented the stages of instinctive newborn
behaviors that newborns go through during the first hour after birth [7]
when they are in skin-to-skin contact with their mothers. This was ex-
panded with production of a video illustrating the behaviors [28], a
video with practical advice for staff on implementing skin-to-skin
contact immediately after birth in order to support the 9 Stages [27], an
expanded paper about the 9 Stages [8], and a video for parents about
the 9 Stages [29]. Further projects and papers have focused on specific
elements of these Stages [21–23,30–32]. The previous papers focused
on the behavioral sequences and highlighted the phenomenon of the 9
Stages [8,33] with the proportions of newborns that experience each
stage, and the time at which each stage was achieved after birth [8,33].
Although these elements are essential in understanding the innate and
instinctive behaviors of newborns as a whole, this study, which ex-
amines the amount of time spend within each stage, allows us to un-
derstand the implications of each stage independently (a long Awa-
kening Stage, for example, would push out the start time of the other
stages). This also allows the Resting Stage to be analyzed in-
dependently, since by its definition it is interspersed between the other
stages. (Fig. 2).
The babies in the control cohort who were not exposed to epidural
fentanyl or synthetic oxytocin had significantly longer birth cries than
did babies in either of the other three cohorts. Synthetic oxytocin alone
or in conjunction with epidural fentanyl was associated with shorter
duration of a baby's initial birth cry with babies exposed to fentanyl
without synOT having the shortest cry. There are many factors during
birth that could influence the duration of birth cry, but this association
deserves further study.
Babies who had been exposed to both fentanyl and synOT were
more likely to be delayed in being reunited with their mothers or re-
moved from their mother shortly after being place in skin-to-skin con-
tact compared to babies who were not exposed or who were only ex-
posed to either fentanyl or synOT but not both. This finding adds new
information to previous studies which found high levels of intrapartum
epidural fentanyl exposure to be associated with physiologic compro-
mise in newborns shortly after birth.
Babies whose mothers were not exposed to either synOT or fentanyl
Fig. 2. The 9 Stages of Newborn Behavior per cohort over the first hour. The four cohorts are 1)control, exposed to no synOT or epidural fentanyl during labor, 2)
exposed to fentanyl (but not synOT) during labor, 3) exposed synOT (but not fentanyl) during labor, 4) exposed to both fentanyl and synOT during labor.
34
Early Human Development 132 (2019) 30–36
(control cohort) crawled more efficiently than those exposed to either
medication independently or together, with babies who were exposed
to synOT without fentanyl epidural taking the longest time to crawl to
the mother's breast during the Crawling Stage.
Babies exposed to synOT without fentanyl also spent significantly
less time resting during the first hour than babies in the other cohorts.
Rest is interspersed with the other stages throughout the first hour.
Being awake during rest (awake-rest) plays an important role in con-
solidating memories, and it is hypothesized that the periods of awake
rest during the first hour after birth, while in skin-to-skin contact with
the mother, may consolidate the newborns initial experience with
breastfeeding and self-attachment, aiding in improved breastfeeding
and supporting increased exclusivity of breastfeeding [30].
Babies who were exposed to both fentanyl and synOT spent the
shortest amount of time in the Familiarization Stage. This stage has
many elements that increase a mother's oxytocin and prolactin levels,
including licking and nuzzling the mother's nipple, and massaging her
breast. Decreasing this time to a mean of 1:36.4 min (babies exposed to
both fentanyl and synOT) compared to 4:21.9 (babies not exposed to
fentanyl or synOT) (p = .05), 6:09.6 min (babies exposed to fentanyl
but not synOT) (p < .001), or 10:52.3 min (babies exposed to synOT
but not fentanyl) (p < .001) could have consequences on the post-birth
contractions of the uterus and on the mother's milk supply.
Babies exposed to both fentanyl and synOT were significantly more
likely not to reach the stage of Familiarization by the end of the first
hour, reaching on average Stage 5.48, which is the equivalent of Rest/
Crawling. Babies in the control cohort (no exposure to fentanyl or
synOT) reached, on average, Stage 7.1 and the babies exposed to synOT
without fentanyl reached, on average, Stage 7.17 (Familiarization/
Suckling).
The first hour after birth is a once-in-a-lifetime experience for both
mother and baby. This unique time is often called a “sensitive period”
[34]. High levels of catecholamine during this time aid in attachment
and memory for the newborn [35]. Skin-to-skin contact leads to high
levels of oxytocin, which aid in attachment, bonding, milk production
and milk letdown [30]. Stimulation of mother's nipples by baby's hand
movements and by sucking leads to spikes in oxytocin and prolactin,
which directly stimulate milk production. Sucking during this time,
then, takes on increased importance as an instinctive and innate be-
havior.
The finding that only 70% of unmedicated newborns self-attached
K. Brimdyr, et al.
within the first hour may be within normal limits, since newborns
usually continue through the Stages and fall asleep in Stage 9 around
1.5–2 h after birth, while the recordings in this study stopped at one
hour. Further research could determine if the remaining 30% of un-
medicated newborns self-attach in the subsequent 30–60 min, after the
arbitrary one-hour duration of this study, and before the eventual sleep
around 1.5–2 h after birth [36].
Both synOT and epidural fentanyl are associated with alternations
in the newborn's ability to progress through the Stages to reach self-
attachment and sucking, which could have long-term negative con-
sequences. SynOT is thought to cross the fetal blood-brain barrier
during labor, negatively affecting the function of the oxytocin receptors
which are located in the infant's central nervous system [37–39]. This
may be the physiologic explanation for the finding of a negative impact
of synOT on the newborn's pre-feeding cues and reflexes. The infants of
mothers who were not exposed to synOT during labor were significantly
more likely to perform these behaviors at a high level compared to
exposed infants [40]. In addition, primitive neonatal reflexes including,
suck, jaw jerk and swallowing have been found to be inhibited when
the fetus has been exposed to synOT [41].
Fentanyl moves from the epidural space through the placenta to the
fetus [11] with a transplacental fentanyl transmission ratio of 1:892
[42]. Fentanyl exposure of > 150 micrograms via epidural during labor
has been found to negatively affect the newborn's neuro-behavioral
scores after birth [24].
The exposure of the infant to both synthetic oxytocin and fentanyl
during labor has been shown to significantly reduce the probability that
the infant will find the breast, self-attach and suckle during the first
hour [21]. The physiologic relationship between these two commonly
administered drugs is complex and unanswered [43–45] since synOT
results in stronger contractions leading to more pain and an increased
need for analgesic – in this case, fentanyl.
6. Conclusions
A strong inverse correlation was found between intrapartum ex-
posure to fentanyl and synthetic oxytocin and normal behaviors of
newborn infants during the first hour after birth, as measured by the
length of time spent in each of the various instinctive Stages of
Newborn Behaviors and the likelihood of progressing through all 9 of
the Stages in the first hour after birth. Intrapartum exposure to the
drugs fentanyl and synOT is associated with altered newborn infant
behavior, including suckling, while in skin-to-skin contact with its
mother during the first hour after birth. Knowledge of Widström's 9
Stages offers an opportunity to analyze newborn behavior whilst in the
optimal habitat of the infant.
Declarations of interest
None.
Acknowledgements
Thank you to all the mothers and infants who shared their experi-
ence with us. Thank you to Judy Blatchford for video assistance.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors.
Conflicts of interest
The authors declare no conflicts of interest.
35
Early Human Development 132 (2019) 30–36
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