Infant Assessment and Reduction of Sudden Unexpected Postnatal Collapse Risk During Skin-to-Skin Contact

To encourage use of skin-to-skin contact with all healthy term infants during the first two hours of life and throughout their mothers' postpartum hospitalization, an easy, rapid newborn exam tool, the "RAPP", has been developed to enhance labor and delivery and mother-baby nurses' ability to swiftly and accurately assess newborn physiologic condition. The "RAPP" exam (respiratory activity, perfusion, and position) tool is being proposed as a way to swiftly evaluate infants' physiologic condition and position. Position of the infant is a key factor in minimizing risk of Sudden Unexpected Postnatal Collapse (SUPC). SUPC is an emerging complication of skin-to-skin contact and breastfeeding in the first hours and days post-birth. The "RAPP" exam parameters and flow sheet are discussed, risk factors for SUPC are enumerated, and a checklist to prevent SUPC is presented so skin-to-skin contact can be safely provided.

Skin-to-skin contact, also known as Kangaroo Care, has been recommended for all healthy term newborns by the American Academy of Pediatrics,[1] the American College of Obstetricians and Gynecologists,[2] the Centers for Disease Control and Prevention,[3] and the Academy of Breastfeeding Medicine[4] because of its numerous positive effects on infants and their families.[5] Skin-to-skin contact's (SSC) ability to regulate the infant's temperature and prevent hypothermia and hypoglycemia has earned SSC recognition in the Neonatal Resuscitation Program as the first step for all healthy term infants who do not require resuscitation.[6] The Neonatal Resuscitation Program guidelines state that "term infants who have good muscle tone and cry or breathe spontaneously should not be separated from the mother, but should be dried and placed in skin-to-skin contact with the mother, with both of them covered with dry linen." (6, p. S910).

Other profound and undisputed effects of SSC are improvement in initiation, duration, and exclusivity of breastfeeding and enhanced milk production.[7] Because of these lactation effects, provision of SSC immediately after birth until the first feeding at the breast is finished has been identified as the essential first step for meeting Healthy People 2020 breastfeeding goals,[8] for meeting the Association of Women's Health, Obstetric and Neonatal Nurses' perinatal core measures for excellent care,[9] and for meeting the new Joint Commission mandate that all healthy term infants born in hospitals delivering 1100 or more infants/year are exclusively breast milk fed by discharge.[10,11] Continuing SSC throughout postpartum may yield exclusive breast milk feedings at discharge.[1,12] Despite these recommendations and the Joint Commission mandate, the practice of SSC at birth is not widespread.[13–15] Reasons for slow adoption of SSC at birth are lack of knowledge/education about skin-to-skin at birth,[15,16] no standardized method or uniform practice for skin-to-skin contact,[16,17] occasional unfamiliarity with how to assess the newborn, unfamiliarity about how to position the infant for safety, discomfort with being responsible for newborn wellness – especially the infant's physiologic condition, and how to minimize risk of infant complications that can occur when infants go to breast.[18] The purposes of the manuscript are to share with maternity nursing staff how to conduct an easy newborn exam that helps the nurse identify immediate newborn physiologic condition and to share nursing interventions designed to minimize the risk of the newly-emerging complication called Sudden Unexpected Postnatal Collapse (SUPC).[19] Assessment and documentation tools are presented that can facilitate comfort, comprehensiveness, and competence in assessing infants and ensuring their safety during SSC.

How to do risk exam

Risk exam is a simple way to plan what you're going to do to minimise the chances of anybody getting hurt or causing damage to property or equipment. It's how to identify sensible measures to control the risks in your workplace.

Consider health, safety and security from the start. How can it be managed responsibly? Be clear and specific about what's going to be assessed. Concentrate on real risks – those that are most likely and which will cause the most harm. You should be competent to complete risk exams and know what could go wrong and how to control it. If you don’t know, ask someone who does.

This guide will help you understand the process so you can assess risks accurately anywhere you work, whatever you're doing, whether it's for location shoots, breaking news, large music events, in engineering workshops or even just around the office.

Know what you're planning to do – activities, locations, people, equipment, processes, substances and conditions. Think through what you're going to do in small chunks, and consider those things with a fair chance of happening. Click through the images to learn more.

What could go wrong? What are the hazards? These are the things that might cause harm. This includes physical injury, psychological injury, health hazards or personal security threats.

Know what activities you’re planning to do, what could actually happen and what could go wrong. Consider only those hazards which have a fair chance of happening and could also cause harm or damage.

Think of where you are, what locations are you in and how being there might cause harm or cause things to go wrong.

Is everybody competent and knowledgeable about what they're doing? Are there any special requirements? Are there children, pregnant women, those with disabilities? Are you using contractors?

Think of the equipment being used. Where did you get it from? Is it well maintained and fit for its intended purpose? Are people trained to use it?

Think about the weather conditions and whether that will have an impact.

Think about the weather conditions and whether that will have an impact.

Think worst case - consider emergency situations and contingency plans. If things go wrong, could these present additional hazards?

Redesign the job or substitute a substance so that the hazard is removed or eliminated. For example, avoid working at height where you can.

Replace the material or process with a less hazardous one. For example, use a small mobile working platform to access work at height instead of stepladders. Take care to ensure the alternative is safer than the original.

Use work equipment or other measures such as engineering controls to prevent falls where you can’t avoid working at height. Install or use additional machinery such as local exhaust ventilation to control risks from dust or fumes. Separate the hazard from operators through methods such as enclosing or guarding dangerous items of machinery/equipment. Give priority to measures which protect collectively over individual measures.

Identify and implement the procedures you need to work safely. For example, by reducing the time workers are exposed to hazards (eg by job rotation), prohibiting use of mobile phones in hazardous areas, increasing safety signage and performing risk exams.

Personal protective equipment (PPE) must only be used after all of the previous measures have been tried and found to be ineffective in controlling risks to a reasonably practicable level. For example, where you can’t eliminate the risk of a fall, use work equipment or other measures to minimise the distance and consequences of a fall. If chosen, PPE should be selected and fitted by the person who uses it. Workers must be trained in the function and limitation of each item of PPE.

The more complex the task or activity, the greater the potential severity and the more detail will be needed. Start your record as early as you can and keep adding to it as things come up and are decided. Share your findings and tell people what can go wrong and how it’s being managed. Do what you need to do to manage the risk and implement the controls.

Collect together all of your information to record your findings in a way that you can access later if necessary. Consider your audience and your use of language. Be clear, concise, specific and detailed, and avoid generic, vague comments. Any record produced should be simple and focused on controls. BBC risk exams are recorded in a tool called myRisks and signed off by a senior manager. If something did go wrong, the risk exam may be reviewed by the Health and Safety Executive (HSE) and discussed in court.

Make sure the details of control measures and precautions are shared with those who need to know, by the most effective way to get the message across. Use briefings to remind and reinforce key safety measures. Include safety information on call sheets, emails, noticeboards, and talk about safety in meetings. You could distribute the risk exam and ask people to read it and act on it.

Make sure control measures are put in place and carried out. Assign the task or control measure to someone in particular, and make sure they understand its importance. Check that controls are in place by monitoring and seeking assurances, or by obtaining documentary evidence of compliance.

When should you review? You should review your risk exam if situations change from your original plans, or things are different than you predicted, to check it's still accurate.

Why should you review? If there are significant changes you may need to stop the activity to revise the risk exam and introduce any new controls before continuing.

How should you record changes? Once a decision has been made you must record, inform everyone and implement the changes. Use email, make notes, record or film on camera, or brief the team.

The risk exam process is simple.

You should:

You're not on your own – help is always available.

How to do risk exam

Risk exam is a simple way to plan what you're going to do to minimise the chances of anybody getting hurt or causing damage to property or equipment. It's how to identify sensible measures to control the risks in your workplace.

Consider health, safety and security from the start. How can it be managed responsibly? Be clear and specific about what's going to be assessed. Concentrate on real risks – those that are most likely and which will cause the most harm. You should be competent to complete risk exams and know what could go wrong and how to control it. If you don’t know, ask someone who does.

This guide will help you understand the process so you can assess risks accurately anywhere you work, whatever you're doing, whether it's for location shoots, breaking news, large music events, in engineering workshops or even just around the office.

Know what you're planning to do – activities, locations, people, equipment, processes, substances and conditions. Think through what you're going to do in small chunks, and consider those things with a fair chance of happening. Click through the images to learn more.

What could go wrong? What are the hazards? These are the things that might cause harm. This includes physical injury, psychological injury, health hazards or personal security threats.

Know what activities you’re planning to do, what could actually happen and what could go wrong. Consider only those hazards which have a fair chance of happening and could also cause harm or damage.

Think of where you are, what locations are you in and how being there might cause harm or cause things to go wrong.

Is everybody competent and knowledgeable about what they're doing? Are there any special requirements? Are there children, pregnant women, those with disabilities? Are you using contractors?

Think of the equipment being used. Where did you get it from? Is it well maintained and fit for its intended purpose? Are people trained to use it?

Think about the weather conditions and whether that will have an impact.

Think about the weather conditions and whether that will have an impact.

Think worst case - consider emergency situations and contingency plans. If things go wrong, could these present additional hazards?

Redesign the job or substitute a substance so that the hazard is removed or eliminated. For example, avoid working at height where you can.

Replace the material or process with a less hazardous one. For example, use a small mobile working platform to access work at height instead of stepladders. Take care to ensure the alternative is safer than the original.

Use work equipment or other measures such as engineering controls to prevent falls where you can’t avoid working at height. Install or use additional machinery such as local exhaust ventilation to control risks from dust or fumes. Separate the hazard from operators through methods such as enclosing or guarding dangerous items of machinery/equipment. Give priority to measures which protect collectively over individual measures.

Identify and implement the procedures you need to work safely. For example, by reducing the time workers are exposed to hazards (eg by job rotation), prohibiting use of mobile phones in hazardous areas, increasing safety signage and performing risk exams.

Personal protective equipment (PPE) must only be used after all of the previous measures have been tried and found to be ineffective in controlling risks to a reasonably practicable level. For example, where you can’t eliminate the risk of a fall, use work equipment or other measures to minimise the distance and consequences of a fall. If chosen, PPE should be selected and fitted by the person who uses it. Workers must be trained in the function and limitation of each item of PPE.

The more complex the task or activity, the greater the potential severity and the more detail will be needed. Start your record as early as you can and keep adding to it as things come up and are decided. Share your findings and tell people what can go wrong and how it’s being managed. Do what you need to do to manage the risk and implement the controls.

Collect together all of your information to record your findings in a way that you can access later if necessary. Consider your audience and your use of language. Be clear, concise, specific and detailed, and avoid generic, vague comments. Any record produced should be simple and focused on controls. BBC risk exams are recorded in a tool called myRisks and signed off by a senior manager. If something did go wrong, the risk exam may be reviewed by the Health and Safety Executive (HSE) and discussed in court.

Make sure the details of control measures and precautions are shared with those who need to know, by the most effective way to get the message across. Use briefings to remind and reinforce key safety measures. Include safety information on call sheets, emails, noticeboards, and talk about safety in meetings. You could distribute the risk exam and ask people to read it and act on it.

Make sure control measures are put in place and carried out. Assign the task or control measure to someone in particular, and make sure they understand its importance. Check that controls are in place by monitoring and seeking assurances, or by obtaining documentary evidence of compliance.

When should you review? You should review your risk exam if situations change from your original plans, or things are different than you predicted, to check it's still accurate.

Why should you review? If there are significant changes you may need to stop the activity to revise the risk exam and introduce any new controls before continuing.

How should you record changes? Once a decision has been made you must record, inform everyone and implement the changes. Use email, make notes, record or film on camera, or brief the team.

The risk exam process is simple.

You should:

You're not on your own – help is always available.