Elated, exhausted mothers who’ve just given birth are enjoying the first skin-to-skin contact with their babies and texting out the news to family and friends. If not distracted enough to look down, they see their infants peacefully sleeping. Or are they?
The first two hours after delivery are high risk for babies, even if they’ve been fine in utero and through labor and have good health screening (Apgar) scores at one and five minutes.
Easing their transition and promoting bonding between mom and baby have been the impetus behind immediate skin-to-skin contact and breastfeeding, both of which are almost universally accepted by medical professionals.
But incidences of healthy babies suffering respiratory distress in their initial hours and days outside the womb, leading to death in half the cases or serious neurological deficits in many others, are gaining attention among doctors, nurses and technicians dealing with newborn care. The very name of the event — sudden unexplained postnatal collapse (SUPC) — captures the frustration and horror that these episodes wreak on all involved.
SUPC has been linked to a number of risk factors, ranging from smartphone distraction to inexperienced mothers. Physicians like Matthew Pellerite and researchers like Nancy Rodriguez, both at NorthShore University HealthSystem Evanston, believe lives can be saved if protocols for after-birth care are revised and if new parents know what to watch for in their infants.
Even with possible remedies, efforts to address the problem have been complicated by the lack of a specific definition for SUPC, which means incidences may not be reported or they may be reported as something else. And without evidence, some hospitals and medical professionals are reluctant to acknowledge it’s an issue requiring changes to established procedures.
“About 10 years ago, in a different place, a baby died and I was shocked,” said Pellerite, a neonatalist who has 4-month-old twins. “I asked myself, how does a well baby die?
“We know a lot of risk factors are modifiable, especially with new moms,” he said. “It’s really clear that the highest risk is in the first hours, when (moms) have been through an incredible experience, are sleep deprived, maybe on pain meds, feeling overwhelmed.
“They can learn good behavior. It’s amazing the amount of information moms take in during the transition for their babies,” he said.
Rodriguez, a nurse practitioner, rose to the challenge of educating staff and parents. In developing training aids, she emphasized the importance of breastfeeding and skin-to-skin contact while pointing out that correct positioning of the baby is crucial.
“We teach the safe-sleeping position, that the baby’s nose is not smushed against the mother, that the head is not covered by a blanket,” Rodriguez said, all tactics to prevent a cutoff in breathing. She was cautioned not to frighten parents by using the word suffocation.
A nurse at the hospital came up with the phrase “pink and positioned” to describe how mom should see her infant, and it’s woven into a video shown to parents.
“It portrays how devastating (SUPC) can be on what should have been a day full of so much happiness,” Rodriguez said. “Little by little, we use the words. We don’t want parents to become anxious that they’re going to hurt the baby.”
While she wants nurses to be encouraging, she doesn’t mince words when it comes to smartphone use in the critical first hours.
“Breastfeeding and skin to skin have to be distraction-free,” Rodriguez said. “We’re so glued to our phones now that we think we’re 15 minutes on Facebook when actually it’s 45.”
Pellerite added, “Leave texting, posting to somebody else.”
Rodriguez once heard a doctor say there were too few incidences of SUPC to cause concern.
“I say, one baby is too many,” she said. “We have to talk about it, to find if there are risk factors we may be missing. There’s no other way to prevent it.”
SUPC statistics are elusive, with researchers worldwide saying there could be as few as 2.6 incidents in every 100,000 births or as many as 133 per 100,000 births. The authors of a 2016 article in the journal Nursing for Women’s Health used the number of births in the U.S. in 2013 and that range of incidents to estimate that between 91 and 4,634 newborns could be afflicted each year in this country.
The authors, Debi Ferrarello, director of parent education, and Tanya Carmichael, director of nursing education, both at Pennsylvania Hospital in Philadelphia, got interested in SUPC while trying to win the “baby friendly” designation for their facility. They were successful at that global initiative promoting breastfeeding and also at implementing a new protocol for post-delivery nurses.
They adapted what is known as the RAPP assessment for newborns (respiratory status, activity, perfusion, position) to include a positioning of the mother — not flat on her back to ensure the baby is not prone — and to have a nurse dedicated to the baby as well as the mother following delivery. The infant’s nurse checks him or her at 10, 20, 40 and 60 minutes after birth and every 30 minutes thereafter for up to the first four hours.
“Economics are such that staff time is a costly resource,” Ferrarello said, “but you have to weigh that against safety, and we know the first two hours are so important.”
She said they looked at educating mothers without the extra monitoring, but found teaching alone did not reduce the risk of SUPC. It did prompt moms to call for help sooner, making incidences less severe.
Evanston Hospital has trained nurses, patient care technicians and others about SUPC, and stepped up monitoring, but didn’t add staff. Shortly after nurses started checking moms and babies every 15 minutes after delivery, there was what Pellerite called a “save” — a baby who had to be resuscitated after the mom was distracted and didn’t notice the infant wasn’t breathing.
Carmichael said SUPC cases “go down as unexplained all the time. If the baby is able to be revived, we move forward and just say the baby had a rough start.”
Dr. Joseph Hageman, a practicing neonatalist for 35 years and now director of quality improvement in the neonatology section at the University of Chicago, wants to change that by having the Centers for Disease Control and Prevention create a standard definition for SUPC. He’s studied apnea and sudden infant death syndrome, defined as occurring six days or more after birth.
“We need a database, a well organized and systematic reporting, in order to have an idea of how frequently these events occur,” Hageman said, drawing a parallel to how SIDS had to be documented before it was thoroughly researched, which led to advising that babies sleep on their backs. That cut the SIDS death rate in half, he said.
“When a baby dies or ends up brain-damaged, people pay attention and even more if it turns into a legal issue,” he said.
Kay Manning is a freelancer.