Running head: INTEGRATIVE REVIEW 1

Integrative Review

Deisy Herrera Cortes

Dr. Arlene Holowaychuk

NUR 4122

Bon Secours Memorial College of Nursing

April 17, 2019

“I pledge”
INTEGRATIVE REVIEW 2

Abstract

This integrative review aims to examine previous literature that has tested the connection

between skin to skin contact (SSC) and the prevention of hypothermia in neonates. Previous

studies suggest there is a positive correlation in early skin to skin contact after delivery in

improving thermoregulation. The PICO question being examined is: In term newborns is skin to

skin contact after birth more effective compared to conventional care in preventing hypothermia?

The research design is an integrative review. The Google Scholar database was used to obtain the

research articles. The search engine provided 72,500 articles and five results met the criteria.

Three out of the five articles indicated that SSC showed statistical significance in maintaining

thermoregulation. Two articles found no significant statistical evidence to indicate that early SSC

prevents hypothermia but did find significant clinical evidence that SSC supports neonates

maintain a stable temperature. Limitations to the review include lack of experience by the

researcher, limited timeframe and limited number of articles included in the review. Implications

of this review include teaching and promoting mothers to implement SSC after delivery.

Recommendations for further research include using larger sample sizes, and further exploring

how external factors affect the success of SSC.

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Integrative Review

The purpose of this integrative review is to examine previous literature that has

researched the link between skin to skin contact (SSC) and preventing hypothermia in neonates.

Hypothermia is a life-threatening problem among neonates (Ramani et al., 2017). Hypothermia

also contributes to other life-threatening illnesses such as severe infection, asphyxia and

intraventricular hemorrhage (Horn et al., 2014). Previous research also indicates that

hypothermia in neonates is more commonly seen in developing countries (Nimbalkar et al.,

Ramani et al., 2017). This indicates that there is a need for a simple intervention that can reduce

the number of neonates that develop hypothermia. The objective of this integrative review is to

examine previous research and its relation to the PICO question under consideration: In term

newborns is skin to skin contact after birth more effective compared to conventional care in

preventing hypothermia?

Design and Search Methods

The design is an integrative review. Articles were found using one main database, Google

Scholar. Search terms included ‘skin-to-skin contact’, ‘preventing’, ‘hypothermia’, ‘conventional

care’, ‘neonates’, ‘term pregnancies’. The results first yielded 72,500 articles. Filters were then

added to only scholarly, peer-reviewed, articles in the English language with publication years of

2014-2019 to abide by current research limits.

The articles were then assessed for relevance to the PICO question in consideration: In

term newborns is skin to skin contact after birth more effective compared to conventional care in

preventing hypothermia? The article was excluded if one of its variables was not SSC or

conventional care. With extensive screening, five quantitative articles were chosen to be included

in this integrative review.

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Findings and Results

Based on the five reviewed articles, the research suggested that SSC is an easy

intervention that when implemented appropriately, showed clinical and statistical significance in

maintaining euthermia in neonates (Horn et al., 2014; Nimbalkar et al., 2014; Ramani et al.,

2017; Srivastava, Gupta, Bhatnagar & Dutta, 2014; Vilinsky, Sheridan & Nugent, 2016). A

summary of each of the articles is included via appendix I. The major themes discussed for this

review include skin to skin contact and preventing hypothermia.

Skin to skin contact

Four of the five articles reviewed implemented the intervention of SSC via quantitative

studies (Horn et al., 2014; Nimbalkar et al., 2014; Ramani et al., 2017; Srivastava et al., 2014;

Vilinsky et al., 2016). In the article by Horn et al. (2014), the authors aimed to research the

incidence and prevention of hypothermia in SSC after cesarean delivery by examining two

different methods of SSC. This experimental randomized control trial was composed of 40

participants, 19 in the SSC with forced air warming group and 21 in the passive SSC warming

group. Collection data methods included taking the core temperature of neonates through a rectal

thermometer after a 20 minute bonding session. Statistical analysis was performed by using

statistics software. Incidence of hypothermia was 5% in neonates who had been placed on the

mother’s chest with warmed forced air blankets immediately after being delivered, while 81% of

the neonates placed on the mother’s chest with standard cotton blankets became hypothermic.

This concludes that there was significant statistical data (P<0.0001) to support the use of forced

air warming blankets versus standard cotton blankets during a cesarean delivery.

In the article by Nimbalkar et al. (2014) the effect of early skin to skin contact after

vaginal delivery and the incidence of hypothermia was researched. This experimental,
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quantitative randomized control trial was made up of two groups, each with 50 neonates. The

intervention group would apply SSC as soon as possible while the control group was warmed

using conventional care. Temperature and heart rate values were collected on the neonates using

a digital thermometer and an oximeter. Temperature and heart rate were taken in both groups in

the first 30 minutes, at one, two, three, four, five, six, 12, 24 and 48 hours of life. Descriptive

statistics were used to analyze the data. Relative Risk was used to assess the effect of SSC.

Significant findings showed that only 4% of the neonates in the intervention group developed

hypothermia, while in the control group 32% of the neonates developed hypothermia (P<0.001).

The study concluded that SSC is an efficient intervention to prevent hypothermia in neonates,

without the need of other resources which a lot of underdeveloped countries lack.

The third article by Ramani et al. (2017) examines the use of Kangaroo Mother Care

(KMC) and if it will reduce the incidence of hypothermia compared to standard

thermoregulation. This quantitative study performs a randomized control trial in term neonates.

This study was split into two phases. Phase one included 203 participants – 101 in the

intervention group and 102 in the control group. In phase two, the number of participants

dropped to 172 – 89 of those were in the intervention group and 83 in the control group. Data

was collected by witnessing the method of KMC practiced and was documented every 10

minutes in phase one and every one to two hours in the second half of the study. Axillary

temperature was taken within 10 minutes of birth, at one hour and every 4 hours until discharge

using a digital thermometer. Descriptive statistics compared baseline characteristics.

Contingency tables were used to assess risk analysis. Significant results implied that in both

phases of the study KMC showed no significant statistical evidence to support that it prevents

hypothermia (P=0.16). However, in the second half of the study, there was no incidence of
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hypothermia in the intervention group who had a minimum of nine hours of KMC. Concluding

that there was a positive correlation between the length of KMC and an increase in temperature

at discharge.

The fourth article by Srivastava et al. (2014), aimed to assess the effect of early SSC on

the success of breastfeeding and thermoregulation in the immediate postpartum period, in

comparison to conventional care. This quantitative randomized control trial was composed of

240 mother baby dyads. Of the 240 dyads, 122 were in the intervention group which practiced

SSC and 118 that implemented conventional care in the control group. Axillary temperatures of

the neonates were recorded using a digital thermometer at the start of a two hour session and

repeated at the end of the session. Statistical analysis was conducted through appropriate

methods such as t-tests, Pearson chi-square test and non-parametric Mann-Whitney test through

relevant software. Once the temperatures were compared, the data suggested statistical

significance, none of the neonates in the control group suffered from hypothermia while 7.9% of

the neonates in the control group did (P<0.0001). In conclusion, this study supports early SSC to

prevent hypothermia in neonates.

Preventing Hypothermia

The prevention of hypothermia was an important theme across all five articles reviewed.

Three out of the five articles suggested statistical significance supporting the implementation of

SSC to prevent hypothermia in neonates (Horn et al., 2014, Nimbalkar et al.,2014, Srivastava et

al., 2014). Two of the three articles mentioned above, concluded that preventing hypothermia

could be achieved by practicing SSC versus providing conventional care (Nimbalkar et al., 2014,

Srivastava et al., 2014). The other article suggesting statistical significance further explored the

practice of SSC and researched two different methods of it during cesarean delivery. Concluding
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that a more effective way of preventing hypothermia in the operating room was by using forced

air warmer blankets during SSC (Horn et al., 2014). While the remaining two articles did not

suggest statistical significance supporting the prevention of hypothermia through SSC, clinical

significance was suggested in both articles. The duration of KMC and the neonate’s temperature

at discharge showed a positive correlation, showing that longer periods of KMC prevented

hypothermia in neonates (Ramani et al., 2017). In the study conducted by Vilinsky et al. (2016),

the researchers examined maternal and neonatal hypothermia after SSC. This experimental

quantitative study sampled 20 pregnant women going in for an elective cesarean birth. In the

group of 20 women 10 were placed in the intervention group which included being administered

warmed intravenous fluids, the other 10 women were placed in the control group where the

intravenous fluids were given at room temperature. The mother’s temperature was taken eight

times using a tympanic thermometer, while the neonate’s axillary temperature was taken five

times using a digital thermometer. Descriptive statistic methods such as t-tests and non-

parametric Mann-Whitney test were used to analyze the data. There were no statistically

significant results correlating the use of prewarmed fluids before SSC to prevent hypothermia.

However, clinically significant findings showed that 3 out of the 10 babies in the control group

became hypothermic and only one from the intervention group.

Discussion and Implications

The articles in the review provide an understanding into the use of SSC and the

prevention of hypothermia in term neonates. The PICO question: In term newborns is skin to

skin contact after birth more effective compared to conventional care in preventing hypothermia,

was addressed based on the research findings. Research by Nimbalkar et al. (2014) and

Srivastava et al. (2014) discussed statistical significance in the implementation of early skin to
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skin contact in order to prevent hypothermia in term neonates compared to conventional care.

Statistical significance was also found in the article by Horn et al. (2014) concluding that during

cesarean deliveries SSC was more effective with the use of forced air warming blankets in

preventing hypothermia. Ramani et al. (2017) and Vilinsky et al. (2016) also tested the effect of

early SSC but did not conclude statistical significance in regard to the prevention of

hypothermia. However, clinical significance supported the use of SSC. Whether statistical or

clinical, all research studies reviewed suggested evidence that SSC is an effective and simple

intervention to promote thermoregulation in neonates. Implications of this review incorporate

educating parents about the dangers of hypothermia and encouraging moms to practice SSC after

giving birth. Promoting SSC over conventional care is an easy intervention that is especially

convenient to undeveloped countries where electricity needed for a conventional warmer is not

always available. Suggestions for further research incorporate utilizing bigger sample sizes, and

further investigating how outside elements such as the weather, influence the success of SSC in

preventing hypothermia.

Limitations

Limitations were present in this integrative review. One of the limitations was the

inexperience of the researcher. Furthermore, the integrative review is not an exhaustive review

since only five articles were included. Also, the articles researched had a restricted time frame of

five years or less.

All five articles examined were experimental quantitative studies. This lack of variability

in the methods used is a limiting factor for this review. Horn et al. (2014) and Nimbalkar et al.

(2014) identified the sample size as a limitation. Ramani et al. (2017) identified open windows

and doors as a limiting factor since weather conditions could have had an impact on the
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neonate’s temperature. Also, Srivastava et al. (2014) addressed a high attrition rate as its limiting

factor. Finally, Vilinsky et al. (2016) identified the operating room’s temperature as a limitation

due to the fact that thermal regulation of those rooms was not available at the time of the study.

Conclusion

The articles in the integrative review show the relationship between the implementation

of SSC and the prevention of hypothermia in term neonates. The results suggested that there is

both statistically and clinically significant data to positively correlate SSC and the prevention of

hypothermia, which directly relates to the PICO question. The findings indicate that appropriate

SSC performed early after birth will maintain the neonate’s temperature within the normal range,

while neonates who are given conventional care are more likely to develop hypothermia.

Additionally, the findings implicate the effectiveness of SSC after delivery as a means to

maintain neonatal thermoregulation, preventing the cascade of health issues it can cause.
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References

Horn, E., Bein, B., Steinfath, M., Ramaker, K., Buchloh, B., & Höcker, J. (2014). The incidence

and prevention of hypothermia in newborn bonding after cesarean delivery. Anesthesia &

Analgesia, 118(5), 997-1002. doi:10.1213/ane.0000000000000160

Nimbalkar, S. M., Patel, V. K., Patel, D. V., Nimbalkar, A. S., Sethi, A., & Phatak, A. (2014).

Effect of early skin-to-skin contact following normal delivery on incidence of

hypothermia in neonates more than 1800 g: Randomized control trial. Journal of

Perinatology, 34(5), 364-368. doi:10.1038/jp.2014.15

Ramani, M., Choe, E. A., Major, M., Newton, R., Mwenechanya, M., Travers, C. P., . . . Carlo,

W. A. (2018). Kangaroo mother care for the prevention of neonatal hypothermia: A

randomised controlled trial in term neonates. Archives of Disease in Childhood, 103(5),

492-497. doi:10.1136/archdischild-2017-313744

Srivastava, Smita, et al. “Effect of very early skin to skin contact on success at breastfeeding and

preventing early hypothermia in neonates.” Indian Journal of Public Health, vol. 58, no.

1, 2014, p. 22., doi:10.4103/0019-557x.128160

Vilinsky, A., Sheridan, A., & Nugent, L. E. (2016). Preventing peri-operative maternal and

neonatal hypothermia after skin-to-skin contact. Journal of Neonatal Nursing, 22(4), 163-

170. doi:10.1016/j.jnn.2016.02.002
INTEGRATIVE REVIEW
Appendix I: Summary of the Literature Tables
Article Reference
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
11
Horn, E., Bein, B., Steinfath, M., Ramaker, K.,
Buchloh, B., & Höcker, J. (2014). The
Incidence and Prevention of Hypothermia in
Newborn Bonding after Cesarean Delivery.
Anesthesia & Analgesia, 118(5), 997-1002.
doi:10.1213/ane.0000000000000160
Background: outlining the little amount of
research there is on this topic and discussing
the dangers of neonates developing
hypothermia
Problem Statement: Aim of our study was to
evaluate whether the newborn becomes
hypothermic when bonding on the mother’s
chest immediately after a C-section
None
Design: Experimental Randomized Control
trial
Philosophical underpinnings: none
Sample: 40 participants 19 intervention, 21
control
Setting: Kiel, Germany
Ethical considerations: IRB approved
Active forced-air warming: placed on the
mother’s chest after being assessed for
stability under a forced air cover
No active warming: placed on the mother’s
chest after being assessed for stability under
cotton blankets
Measurement tool: rectal thermometer,
continuous monitoring through (infrared
temperature scanner)
Data collection:
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Data Analysis Statistical analysis was performed by using

statistics software GraphPad Prism 5.0 and R.
2.11.0
Student t-tests

Findings/Discussion Forced air warming was more effective in

preventing hypothermia in neonates in
comparison to passive warming

Appraisal/Worth to practice This study suggests SSC can be more effective

after cesarean birth with the use of forced air
warming blankets versus the conventional
cotton blankets commonly used.

Article Reference Nimbalkar, S. M., Patel, V. K., Patel, D. V.,

Nimbalkar, A. S., Sethi, A., & Phatak, A. (2014).
Effect of early skin-to-skin contact following
normal delivery on incidence of hypothermia in
neonates more than 1800 g: Randomized control
trial. Journal of Perinatology, 34(5), 364-368.
doi:10.1038/jp.2014.15

Background/Problem Statement Background: Previous literature indicating a

need for a low cost intervention that would
decrease the increasing incidents of
hypothermia in neonates
Problem Statement: To evaluate the effect of
early SSC for first 24 h on incidence of
hypothermia based on standard WHO definition
in term and late-preterm newborns.

Conceptual/theoretical Framework None

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Design/ Design: Experimental quantitative study

Method/Philosophical Method: Superiority Randomized Control Trial
Underpinnings Philosophical Underpinnings: None

Sample/ Setting/Ethical Sample: 100 participants

Considerations Setting: Maternity ward of Shree Krishna
Hospital in North India
Ethical Considerations: Study was approved by
human research ethics committee of HM Patel
Centre for Medical Care and Education,
Karamsad

Major Variables Studied (and their
definition), if appropriate
Skin to skin contact: putting the neonate skin on
skin with the mother immediately after birth
Conventional care: neonates were clothed
including a cap and placed next to the mother.
Hypothermia: A temperature less than 36.5
degrees Celsius.

Measurement Tool/Data Collection Measurement tool: Smart Care Digital

Method Thermometer, Oximeter of L&T medical
Collection Method: Temp and HR were taken in
both groups in the first 30 min, at 1, 2, 3, 4, 5, 6,
12, 24 and 48 hours of life

Data Analysis Independent samples, (t-test), line diagram,

Relative Risk was used to estimate the effect of
SSC, Microsoft excel 2010
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Findings/Discussion The incidence of hypothermia in conventional

care was significantly higher as compared with
the SSC. In the SSC’s group, the temperature
went up significantly after every check.

Appraisal/Worth to practice SSC is an intervention for term and late-term

newborns that can work in all seasons across
India without using additional resources in
terms of electricity, which is often unavailable

Article Reference Ramani, M., Choe, E. A., Major, M., Newton, R.,
Mwenechanya, M., Travers, C. P., . . . Carlo, W.
A. (2018). Kangaroo mother care for the
prevention of neonatal hypothermia: A
randomised controlled trial in term neonates.
Archives of Disease in Childhood, 103(5), 492-
497. doi:10.1136/archdischild-2017-313744

Background/Problem Statement Background: Previous studies on the effect of

kangaroo mother care (KMC- another phrase
for SSC)
Problem statement: The current trial was
designed to test the hypothesis that in term
infants, the use of KMC as continuous as
possible, in combination with standard
thermoregulation care at birth or at 1 hour after
birth, will reduce hypothermia compared with
standard thermoregulation.

Conceptual/theoretical Framework None

Design/ Design Method: Experimental Randomised

Method/Philosophical Control Trial
Underpinnings Philosophical Underpinnings: None
INTEGRATIVE REVIEW
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
15
Sameple: split into two phases
1→ 203; 101 intervention 102 control
2→ 172; 89 intervention 83 control
Setting University Teaching Hospital in Lusaka,
Zambia
Ethical Considerations: IRB approval
KMC: Kangaroo mother care (SSC): infants were
dried and placed on the mother’s chest
immediately after birth
Standard thermoregulation care: based on the
WHO thermoregulation care protocol including
immediate drying, early breast feeding,
appropriate bundling and mother and baby
together
Incidence of moderate to severe hypothermia:
Moderate hypothermia (axillary temperature of
32-35.9 degrees C), severe hypothermia (below 32
degrees C)
Measurement Tool: digital thermometer (allheart,
Calabasas, California, USA)
Temperature was taken at birth (within 10 mins),
at 1 hour and every 4 hours until discharge
All data was analysed using Sigmaplot V.12.) for
Windows (Systat Software, San Jose California,
USA).
The proportion of neonates with moderate or
severe hypothermia did not differ between the
KMC and control groups at 1 hour after birth. The
proportion of neonates with moderate or severe
hypothermia did not differ between the KMC and
control groups at discharge.
The trial did show that the longer KMC is
properly done, it has a positive correlation with
increased temperature.
This trial showed that statistically KMC did not
reduce hypothermia during the first hours after
birth. However the intervention showed clinical
evidence to support the intervention of KMC in
promoting thermoregulation
INTEGRATIVE REVIEW 16

Article Reference Srivastava, Smita, et al. “Effect of Very Early

Skin to Skin Contact on Success at
Breastfeeding and Preventing Early
Hypothermia in Neonates.” Indian Journal of
Public Health, vol. 58, no. 1, 2014, p. 22.,
doi:10.4103/0019-557x.128160

Background/Problem Statement Previous studies outlining the benefit SSC has

on breastfeeding and thermoregulation in
neonates

Conceptual/theoretical Framework none

Design/ Design: Experimental Quantitative

Method/Philosophical Method: Randomized control trial
Underpinnings Philosophical underpinnings: none

Sample/ Setting/Ethical Considerations Sample: 298 mother and baby dyads

Setting Tertiary care multispecialty hospital in
Haryana, India
Ethical Considerations: Approved by the
Hospital’s ethics committee

Major Variables Studied (and their Success of breastfeeding

definition), if appropriate Thermoregulation by SSC

Measurement Tool/Data Collection BFAT score were used to assess the baby’s
Method suckling
Digital thermometers were used to take the
baby’s temperature

Data Analysis Appropriate analysis was done using t-tests,

pearson chi-square test and non parametric
Mann-Whitney test through relevant software.

Findings/Discussion All of the neonates in the intervention group

were euthermic while 7.9% of the neonates in
the control group were found to have developed
hypothermia.
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Appraisal/Worth to practice Study indicated that early SSC provided benefit

to successful suckling and thermoregulation.

Article Reference Vilinsky, A., Sheridan, A., & Nugent, L. E.

(2016). Preventing peri-operative maternal and
neonatal hypothermia after skin-to-skin contact.
Journal of Neonatal Nursing, 22(4), 163-170.
doi:10.1016/j.jnn.2016.02.002

Background/Problem Statement Background: Previous studies outlining the

benefits of SSC while stating the lack of research
on the intervention being implemented after C-
sections
Problem Statement: The objective of the study is
to identify if active peri-operative warming of the
mothers compared to the current practice
contributes to preventing peri-operative neonatal
temperature drop during/after skin-to-skin
contact up to 2 h post delivery

Conceptual/theoretical Framework None

Design/ Design method: Experimental randomized

Method/Philosophical control trial
Underpinnings Philosophical underpinnings: none

Sample/ Setting/Ethical Sample: 20 women (10 to each group)

Considerations Setting: Large maternity hospital in Ireland
Ethical Considerations: granted by an Irish
Maternity Hospital’s research ethics committee.

Major Variables Studied (and their Maternal temperatures

definition), if appropriate Newborn temperatures
SSC duration
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Measurement Tool/Data Collection Tools: tympanic thermometer, digital

Method thermometer
Data collection: took maternal temperature 8
times and the neonate’s 5

Data Analysis Descriptive statistics were used during the data

analysis of the study, with parametric tests such
as 2 tailed, Student’s t-tests, non-parametric tests
like 2-tailed Mann-Whitney test
Software: SPSS version 22 SPSS Inc., Chicago,
IL USA

Findings/Discussion There were no statistical significant differences

between temperatures of newborn in the
intervention and usual care groups.
Findings were clinically significant since 3 out of
the 10 babies in the control group became mildly
hypothermic compared to only 1 from the
intervention group.

Appraisal/Worth to practice This study was the first of its kind, it provided
information regarding the study of SSC
intervention compared to conventional care in
mothers who gave birth through C-sections