Skin-to-skin contact and sudden unexpected postnatal collapse (SUPC)

For stable mothers and babies, the benefits of skin-to-skin contact, or the uninterrupted closeness of mother and baby after birth, are well-documented and myriad. Skin-to-skin has been recommended for stable mothers and babies by such esteemed organizations as the American Academy of Pediatrics (AAP), the World Health Organization (WHO), and the Neonatal Resuscitation Program (NRP). Most notably, skin-to-skin (1):

1. Increases maternal attachment
2. Encourages and supports breastfeeding
3. Aids in infant brain development
4. Supports the psychological stability of mother and baby during the vulnerable period after birth

Skin-to-skin contact after birth comes in several forms. One practice, “Kangaroo Mother Care” (or “Kangaroo Care”), occurs when the infant is placed skin-to-skin between the mother’s breasts and under her clothes. It is a common care method for premature, low birth weight, or neonatal intensive care unit (NICU) infants (2). Another form, called intermittent skin-to-skin care (SSC) is when either parent holds the baby skin-to-skin for varying, shorter periods of time. It is used with preterm and term infants, not just those in the NICU, for parental bonding and to promote breastfeeding.

A significant risk of skin-to-skin is sudden unexpected postnatal collapse (SUPC). SUPC occurs when infants considered healthy stop breathing after skin to skin due to improper placement or monitoring after birth. It commonly occurs during or after initial breastfeeding of skin-to-skin contact (3). Research has led to a clear picture of what SUPC looks like. SUPC describes an infant who (4):

• Was born after 37 weeks gestation.
• Received an APGAR score over 8 at 5 minutes.
• Collapses within 12 hours of birth.
• Requires resuscitation with positive pressure ventilation.
• Died or received ongoing intensive care due to HIE.

Unfortunately, it has been difficult for researchers to determine the number of incidents of SUPC because there has not been a consensus in the criteria for SUPC, which has varied in many cases. Some studies have considered SUPC a diagnosis in 35 weeks gestation, whereas some have considered it after 38 weeks. There have also been variations in the time it occurs after birth, from before 2, 12, 24, or 72 hours, or up to 7 days. Additionally some diagnoses have not been determined because the infant had other pathologic conditions (3).

While studies have been inconsistent on the criteria for determining SUPC, they agree on the following (3,4,5,6):

• Roughly one-third of the instances of SUPC in the U.S. occurs within 2 hours of life (3,4).
• Another third occurs between 2-24 hours of life (3,4).
• The final third occurs between 1-7 days of life (3,4).
• The median age for SUPC in babies without an underlying pathology is 70 minutes after birth (3).
• The median age for SUPC in babies with an underlying pathology is 195 minutes after birth (3).
• It is estimated that SUPC occurs in between 2.6-133 cases per 100,000 newborns.

The following factors increase the risk of SUPC in infants (3, 6, 7):

• Hospital not properly training staff
• Maternal analgesia and pain medications, especially narcotics
• Primiparous (first-time) mother
• Prone position of infant during skin-to-skin contact
• First breastfeeding session
• First 2 hours of life
• Fatigued parents
• Asphyxiating position
• Unsupervised breastfeeding
• Tired parents
• Mothers and babies falling asleep during breastfeeding
• Hospital staff member not immediately available or continuously monitoring (Lightheadedness, fatigue, or incoordination of either parent may require assistance of a staff member to provide skin-to-skin or safe care of the infant; if not provided, this can lead to a newborn fall or positioning of the newborn in a way that obstructs baby’s airway)
• Maternal distractions while holding the baby
• Maternal obesity
• Cesarean birth

SUPC is a devastating occurrence, and can lead to the following (3):

• Infant death
• Prolonged NICU care
• Hypoxic-ischemic encephalopathy (HIE)
• Neurodevelopmental disabilities
• Seizures

What can be done

In a publication by Rodriguez, Pellerite, et. al. “up to 53% (24/45) of cases were attributed to airway obstruction associated with breastfeeding, skin-to-skin contact, or prone positioning” (3).

One initiative done by Pearlman et al. showed that using a bundle of frequent RAPPT (Respiration, Activity, Pulse, Perfusion, Tone) assessment and pulse oximetry monitoring during the period of 2 hours after birth resulted in far fewer SUPC events than in the pre-intervention period (4).

The benefits of skin-to-skin contact and breastfeeding are uncontested. Because of the risk of sudden unexpected postnatal collapse (SUPC) when using skin-to-skin and during skin to skin and  breastfeeding, however, it is imperative that all medical personnel be trained in how to properly administer skin-to-skin contact. A safe environment for skin-to-skin contact and breastfeeding must be maintained by hospital staff (3).

What does this mean? According to recent research, this means that the following steps must be taken during to protect babies during skin-to-skin contact (2, 3, 5, 6, 8):

1. An appropriately trained healthcare professional must be continuously in attendance for  skin-to-skin sessions during the first two hours of life; mothers and infants should be monitored continuously during this time.
2. Continuous monitoring and assessments of newborn breathing activity, position, tone, and color can prevent SUPC. Continuous monitoring and the use of checklists also helps this process.
3. Health care professionals should be properly trained in how to handle skin-to-skin contact in obstetric and postpartum settings. Training must include proper positioning, physiological indications that should be monitored, and maternal and newborn safety.
4. Staff members should be available to help with skin-to-skin contact any time after birth, and to prevent improper positioning and the mother falling asleep (and transition the baby to a safe sleep surface).
5. Babies need to be continuously monitored during skin-to-skin.
6. At-risk infants should be monitored continuously during the first two hours or longer after birth.
7. Infants requiring positive-pressure resuscitation should be continuously monitored and skin-to-skin contact should be delayed until they are more stable.
8. Mother should be assessed for fatigue periodically during skin-to-skin and breastfeeding.
9. Parents of newborns should be educated in how to properly hold and breastfeed an infant during skin-to-skin contact. The medical staff should educate parents without discouraging skin-to-skin or breastfeeding, but by offering details on proper positioning of the infant in order to maintain the function of the airway, emphasis on no distractions (like smartphone use or conversations) during skin-to-skin contact and breastfeeding, discussion about maternal fatigue, and assisting the mother to aid in safe sleep for the infant. For more details on the types of conversations medical professionals should have with new parents, see the Rodriguez study here.
10. The infant and mother should be monitored without lapses exceeding 10-15 minutes within the first few hours of life.
11. All medical personnel supporting mother and baby during skin-to-skin should be properly trained.
12. The arterial and venous access devices, endotracheal tube, and all other life support equipment must remain stable during skin-to-skin.
13. Correct head positioning should be verified.
14. Infants under 27 weeks gestation whose health needs require temperature regulation or a high-humidity environment should delay skin-to-skin contact until they are more stable.
15. Infants with abdominal wall and neural tube defects that need to be kept sterile before surgery should delay skin-to-skin contact until they are more stable.
16. Infants with significant hemodynamic instability characterized by wide blood pressure swings should delay skin-to-skin contact until they are more stable.
17. Infants with apnea or oxygen desaturation with handling should delay skin-to-skin until they are more stable.
18. Infants who have just had surgery and have not been declared stable should delay skin-to-skin contact until declared stable.
19. Infants with low APGAR scores or medical complications from birth require careful observation during skin-to-skin or delayed skin-to-skin contact.

It is also suggested that hospitals incorporate a team approach to determining if an infant and a parent are ready for skin-to-skin contact.

ABC Law Centers was established to focus exclusively on birth injury cases. A “birth injury” is any type of harm to a baby that occurs just before, during, or after birth. This includes issues such as oxygen deprivation, infection, and trauma. While some children with birth injuries make a complete recovery, others develop disabilities such as cerebral palsy and epilepsy.

If a birth injury/subsequent disability could have been prevented with proper care, then it constitutes medical malpractice. Settlements from birth injury cases can cover the costs of lifelong treatment, care, and other crucial resources.

1. Phillips, Raylene M. The Sacred Hour: Uninterrupted Skin-to-Skin Contact Immediately After Birth. Retrieved from https://www.researchgate.net/publication/257612445_The_Sacred_Hour_Uninterrupted_
2. Skin-to-Skin_Contact_Immediately_After_Birth/citation/download.
   Baley, J. (2015, September 1). Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. Retrieved April 8, 2020, from https://pediatrics.aappublications.org/content/136/3/596
3. Rodriguez, N., Pellerite, M., Hughes, P., Wild, B., Joseph, M., & Hageman, J. R. (2017, December 1). An Acute Event in a Newborn. Retrieved April 15, 2020, from https://neoreviews.aappublications.org/content/18/12/e717.figures-only
4. Hageman J. Sudden Unexpected Postnatal Collapse in Hospitals: An Emotional Clinical Entity. Pediatr Ann. 2019; 48: e139-e140. doi: 10.3928/19382359-20190325-01 [link]
5. Jefferies, A. L., & Canadian Paediatric Society, Fetus and Newborn Committee (2012). Kangaroo care for the preterm infant and family. Paediatrics & child health, 17(3), 141–146. https://doi.org/10.1093/pch/17.3.141
6. Feldman-Winter, L., & Goldsmith, J. P. (2016, September 1). Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Retrieved April 17, 2020, from https://pediatrics.aappublications.org/content/early/2016/08/18/peds.2016-1889
7. Simpson, Kathleen Rice. (2016). Sudden Unexpected Postnatal Collapse and Sudden Unexpected Infant Death. Retrieved April 18, 2020, from doi: 10.1097/NMC.0000000000000037.
8. Women’s Health, & Association for Women’s Health. (2016, November 9). Immediate and Sustained Skin-to-Skin Contact for the Healthy Term Newborn After Birth: AWHONN Practice Brief Number 5. Retrieved April 17, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S0884217516303525