Using the mother’s and father’s voice and touch to improve transition at birth
*David JR Hutchon
Obstetrics And Gynecology, Memorial Hospital, Darlington, England, United Kingdom
David JR Hutchon
Obstetrics And Gynecology, Memorial Hospital
Darlington, England, United Kingdom
Published on: 2017-06-19
There are two ways to be fooled. One is to believe what isn’t true; the other is to refuse to believe what is true. Siren Kierkegaard (1813-1855). Transition from placental respiration to pulmonary respiration at birth is one of the most radical changes in both the circulation and the pulmonary function, changes which have to occur within a few minutes after birth if the baby is to survive intact. “Making the transition from the intrauterine to the extra-uterine life is probably the single most dangerous event that most of us will ever encounter in our lifetimes…the remarkable aspect of birth is that more than 90% of babies make the transition perfectly smoothly with little to no assistance required “. It is an essential element of human evolution and in over 90% of births there is no problem with this remarkable transition. It is the moment when the mother (and father) can see touch and speak directly to their newborn for the first time and exchange “conversation”. The neonate can recognize the voice of its mother (and father) and these voices have an immediate calming effect. It is now recognized that neonates cared for in isolated units where there is a lack of a parental voice and contact (where parents tend not to visit so often) leads to poor neurological outcomes [2,3].
Fetal and neonatal hearing
The maternal voice has been shown to be recognized by the newborn baby having heard it in-utero during the months before. Even before birth different processing of the maternal voice is apparent within the temporal cortex of the fetus from that of an unfamiliar female voice . After birth, it is no surprise that the mother’s voice can quickly calm a crying baby. The father’s voice can also be recognized if the fetus has been exposed sufficiently during pregnancy. There are a number of reports of a baby crying uncontrollably who stops as soon as they hear their father’s voice . Why do these babies sometimes cry excessively? Is it emotional distress as a result of separation from its mother, now exposed to a completely strange environment and strange voices? Goulet et al described how emotional closeness through vocalization and touch are important in the future parent–infant relationship . However even gentle reassuring words from the resuscitation attendant can have some beneficial effects on the recovery of the neonate, but nothing can be more reassuring than the mother’s voice [7,8]
Fetal and neonatal touch
There is less understanding about the importance of the sensation of fetal touch. However, it is common to see mothers gently massaging their gravid abdomen in the expectation that the fetus will sense her action. Gentle massage is a normal human response to calming a loved one and is likely to be just as important at birth as it is in the following years. However, for the neonate the combination of a soothing voice and a gentle maternal touch could be crucial to calming the neonate during the first few minutes after birth. Skin to skin care could be considered the ultimate in maternal touch and contact for the mother with her baby. Early skin to skin contact has been shown to have significant benefits for the neonate and is considered good obstetric and midwifery practice . Endorphins are a natural analgesic and are released in the neonate in response to the mothers calming voice and touch. The release of endorphins is thought to be underlying the mechanism for the benefit of skin to skin .
Neonatal asphyxia and transition to pulmonary respiration
For a small number of neonates there is a variable degree of difficulty during transition at birth often due to hypoxia in labor which results in depression of the respiratory center. The hypoxia, if sufficiently severe to result in respiratory depression, may also results in loss of consciousness of the neonate so that the neonate is floppy and unresponsive from loss of all muscle tone . Ventilation of the lungs in these neonates is a priority and will start to reverse these events when pulmonary circulation and respiration is established with oxygen levels rising and the hypoxia corrected. Consciousness will be restored and the neonate can hear its mother’s voice. During this phase of transition after birth it is important that the mother is close by so that the neonate has an opportunity to hear her voice. It is well recognized that, in the adult, as an individual fall into unconsciousness, hearing is the last sense to be lost. On recovery hearing is usually the first sense to return as consciousness is regained and this is likely to be similar in the neonate. If the neonate is to benefit from its mother’s voice as its sense of hearing returns, it must be close to its mother to hear her voice. For the semiconscious neonate hearing may be the only remaining sense.
Hypoxia and hypovolemia
The sensation of hypoxia is well recognized to be very distressing and indeed is the principle of torture by “water boarding”. This is particularly distressing because the individual is not allowed to totally lose consciousness but is maintained at a threshold. Thus, for the neonate experiencing hypoxia at birth, it is important that everything is done to ensure a quick and steady recovery and avoid any panic feeling. Hypoxia may have depressed the respiratory center in the compromised apnoeic neonate but the sensation of hypoxia may still be present. While the neonate is being ventilated and the hypoxia is gradually resolving, it is important that the neonate is provided with as many familiar sounds and sensations as possible during this time. Panic and stress in the neonate may cause an inappropriate vaso-vagal response leading to a fall in cardiac output and cerebral circulation. In adult’s sleep apnoea is recognized to be a significant cause of apnoea. There could be a similar response in the neonate who recovers from apnoea at birth.
Early cord clamping
Early cord clamping causes hypovolemia and must be avoided at all cost. Clamping and cutting the cord immediately after birth will prevent the natural resolution of the hypoxia until eventually pulmonary respiration takes over. When there has been intrapartum cord compression early cord clamping may cause severe hypovolaemia [12,13]. In the longer term the resulting iron deficiency may also affect auditory recognition memory .
Optimal care of the asphyxiated neoante
Until recently virtually all clinical experience of neonatal resuscitation has been acquired after early cord clamping and the neonate has been moved away from its mother to the resuscitation trolley at the side of the room or sometimes next door. In this situation, there is no opportunity for the neonate to benefit from the voice of its mother or feel her touch. Thus, the only way to avoid this separation is to provide resuscitation at the side of the mother. Mother side resuscitation, as opposed to the traditional room side resuscitation, allows the mother to speak to and touch her newborn baby and aid the recovery . Although equipment is not widely available the importance of this approach is now accepted by many neonatologists . Without immediate cord clamping the relief of the cord compression will result in a restoration of the neonatal blood volume and oxygen supply. With an intact cord, there is likely to be a rapid and steady recovery in the circulation and oxygenation of the brain as the oxygenated blood returns from the placenta following the relief of the cord compression. There are known signs of stress in newborns and these are often exhibited by the baby at resuscitation . Does the baby lay down any memory of the events during resuscitation at birth? Is this traumatic event imprinted in the brain or psyche of the baby and could subsequent behaviors of the baby and child be affected by the memory of the event? These questions are unknown but are vitally important.
The presence of pain in the neonate is difficult to determine but there is no doubt that some babies are suffering pain as a result of birth. The folly of not providing anesthesia for painful interventions in neonates has now been recognized. Assistance at birth is commonest in the obstetric births of forceps or ventouse and caesarean section. These births can be quite traumatic for the neonate and most likely to inflict pain in the newborn baby. Ideally the trauma causing the pain should be avoided but if this is not feasible further distress should be avoided by mother side resuscitation when the neonate can benefit from the closeness of its mother, the sound of her voice and the release of endorphins.
Everyone hopes to hear the first cries of their baby as the first confirmation that the baby is well. Crying is the only verbal mode for a newborn baby and may play a role in helping to fully expand the lungs at birth. For the parents crying is confirmation that the baby is alive and well. When the baby remains with its mother and father they can easily see other signs of health such as movement, breathing and color, so an audible cry is not necessarily important. How much crying at birth is truly physiological? [18,19].
Immediately after birth the neonate benefits from hearing its mother’s voice and feeling her touch but this can only be achieved if the neonate remains very close to her. The effect of her voice and touch may be both immediate through a calming effect and higher levels of endorphins and the relief of pain, and in the long term, improved neurological development and bonding. While most neonates will respond rapidly to resuscitation at birth there are a few with hypoxia who require more intensive help to transition at birth. These babies must also remain next to their mother to benefit from the mother’s voice and touch with the carer providing mother side resuscitation. Mother side resuscitation at birth is greatly appreciated by mothers and fathers and this early interaction immediately after birth may assist in bonding . Clamping and cutting the cord may seem a reasonable compromise by the neonatologist with no experience of mother side resuscitation but early cord clamping is likely to increase hypoxia and significant hypovolemia rendering the neonate unconscious and unable to hear the familiar voice and feel the touch of its mother . The benefit for the baby of hearing the familiar voice of its mother (and father) and feeling her touch is clear and should be used to improve transition at birth for both the healthy neonate and those requiring assistance at birth.
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