Introduction and Context
Skin-to-skin contact (SSC) — placing a newborn, naked and dried, directly on the mother’s bare chest — is a simple, low-cost intervention that has been promoted for decades to support breastfeeding and newborn stabilization. WHO and UNICEF long recommend immediate, continuous, uninterrupted SSC as standard maternity care, and SSC is a core component of the Baby-Friendly Hospital Initiative (BFHI). Yet, hospitals worldwide still separate newborns from mothers in many births — especially after cesarean deliveries — and clinicians have asked for stronger, updated evidence about SSC’s influence not only on breastfeeding and neonatal physiology, but also on maternal outcomes such as postpartum blood loss and placental separation.
The 2025 update of the Cochrane review “Immediate or early skin-to-skin contact for mothers and their healthy newborn infants” (Moore et al.) synthesizes randomized trial evidence through 2024–2025 to clarify benefits, harms, and gaps. This article distills that review for clinicians and health systems, highlights practical recommendations, and discusses implications for policy and future research.
New Guideline Highlights
– The updated Cochrane review pooled 69 randomized trials (7290 mother–infant pairs), adding 26 new trials since the last major update. Most trials compared immediate SSC (started <10 minutes after birth) with standard hospital care.
– Main findings: immediate or early SSC probably increases exclusive breastfeeding rates through hospital discharge to one month (RR 1.36; 95% CI 1.19–1.56) and through six weeks to six months (RR 1.38; 95% CI 1.09–1.74). Evidence quality here was graded moderate (GRADE).
– SSC probably raises infant axillary temperature slightly (mean difference +0.28 °C), and probably raises infant blood glucose (MD +10.5 mg/dL). These neonatal physiological benefits were moderate-certainty.
– Evidence on maternal physiological outcomes (third-stage duration, maternal blood loss) was inconclusive and low to very-low certainty.
– Most trials were in high- or middle-income countries; none were conducted in low-income countries. Trials varied considerably in how SSC and “standard care” were defined.
Key takeaway: Immediate, continuous SSC after birth is supported by moderate-quality evidence for boosting exclusive breastfeeding and improving short-term neonatal physiological markers. Maternal physiological effects remain uncertain.
Updated Recommendations and Key Changes
How this update changes or strengthens prior guidance:
– Scope broadened: New trials included babies born by cesarean section and late preterm infants (≥34 weeks), strengthening external validity for those groups.
– Evidence base expanded: 26 additional randomized trials (total 69) provide more precise estimates of breastfeeding outcomes and neonatal physiological measures.
– Maternal outcomes: Earlier reviews noted limited data; the update confirms persistent uncertainty and highlights very limited, heterogeneous data on maternal blood loss and placental separation.
– Ethics and implementation: Authors conclude that randomizing to separation from the mother may no longer be justifiable in settings where WHO/UNICEF recommendations are the standard of care.
Why the update was needed: New randomized trials and an increased global focus on protecting breastfeeding prompted a reappraisal of SSC outcomes across birth modes and infant maturity. The expansion of trials in middle-income countries provides broader context, though important geographic gaps remain.
Topic-by-Topic Recommendations
The Cochrane review is an evidence synthesis rather than a prescriptive guideline, but its findings align with WHO/UNICEF BFHI policy. The following practical recommendations translate the review’s evidence into actionable practice points.
A. Who should receive immediate SSC?
– Recommendation: Offer immediate, continuous, uninterrupted SSC to most healthy full-term and late preterm newborns (≥34 weeks) and their mothers, regardless of vaginal or cesarean delivery, unless there are clinical contraindications (e.g., maternal hemodynamic instability, neonatal resuscitation needs).
– Evidence grade: Moderate for neonatal and breastfeeding benefits.
B. Timing and duration
– Recommendation: Start SSC as soon as practical after birth — ideally within the first 10 minutes (immediate SSC). Continue uninterrupted for at least the first hour and until after the first breastfeeding is established when feasible, consistent with WHO/UNICEF BFHI recommendations.
– Rationale: Trials that started SSC early showed improvements in exclusive breastfeeding rates and short-term neonatal physiology; WHO guidance sets the first hour as a key window for early initiation.
– Evidence grade: Moderate for breastfeeding outcomes.
C. Mode of birth (including cesarean delivery)
– Recommendation: Implement SSC after cesarean births whenever maternal and neonatal condition permit. Adjust operating-room logistics and staffing to allow SSC to begin in the OR or recovery room.
– Rationale: The updated review includes cesarean births and indicates similar direction of benefit, though practical barriers require local protocols and staff training.
D. Monitoring and safety
– Recommendation: While SSC is low risk, monitor infants for airways patency, thermal stability, and signs of hypoglycemia especially in at-risk newborns (late preterm, infants of diabetic mothers). Use objective measures only as clinically indicated.
– Rationale: SSC modestly increases axillary temperature and blood glucose, not replacing appropriate monitoring for at-risk infants.
E. Maternal physiological outcomes and shared decision-making
– Recommendation: Discuss SSC benefits for breastfeeding and newborn stabilization with families; explain that current trial evidence does not clearly show maternal benefits regarding blood loss or placental separation time.
– Rationale: Evidence on maternal outcomes is low or very low certainty; families and clinicians should balance potential maternal and neonatal benefits when planning immediate postpartum care.
F. Documentation and quality metrics
– Recommendation: Record start time and duration of SSC, whether breastfeeding was initiated during SSC, and any interruptions or reasons for separation.
– Rationale: Standardized documentation enables quality improvement and future research.
Recommendation Summary (Bullet Points with Evidence Grades)
– Offer immediate SSC (<10 minutes postbirth) to healthy full-term and late preterm newborns when mother and infant clinically stable — Moderate-certainty evidence favors SSC for exclusive breastfeeding.
– Continue SSC uninterrupted for at least the first hour or until first successful breastfeeding when feasible — Best practice aligned with WHO/UNICEF BFHI.
– Provide SSC after cesarean birth whenever possible — Moderate evidence supports benefits but institutional logistics needed.
– Monitor at-risk infants (thermal stability, glucose) per standard neonatal protocols during SSC — Practice recommendation.
– Do not rely on SSC to prevent or manage maternal postpartum hemorrhage; current evidence is inconclusive — Low to very-low certainty.
Expert Commentary and Insights
Panel perspective: The Cochrane author group and specialists in maternity care interpret the expanded evidence as reinforcing immediate SSC as a standard of care for stable mother–infant dyads. Because breastfeeding is a key public-health priority with broad benefits for maternal and child health (see Victora et al., Lancet 2016), an intervention that reliably increases exclusive breastfeeding is viewed favorably.
Key controversies and practical challenges:
– Randomization ethics: Several authors note that once WHO/UNICEF immediate SSC is accepted national policy, randomized trials that require mother–infant separation may be ethically problematic.
– Cesarean births: Implementation in the operating room requires extra personnel, infection-control considerations, and modified anesthesia plans; institutions vary in readiness.
– Low-resource settings: No randomized trials were conducted in low-income countries; the generalizability of trial findings to those contexts is uncertain and demands context-specific research.
– Maternal outcomes: Clinicians often ask if SSC reduces postpartum hemorrhage or shortens the third stage of labor. Current randomized evidence is sparse and inconsistent; SSC should not replace evidence-based uterotonic prophylaxis or standard hemorrhage management.
Expert quote (paraphrased): “Immediate SSC is one of the few low-cost interventions with consistent benefits for breastfeeding and early neonatal physiology. Health systems should focus on removing logistical barriers and documenting practice to achieve wider adoption.” — maternal–newborn specialist group statement (Moore et al., 2025 Cochrane authors).
Practical Implications for Clinical Practice
Implementing immediate SSC at scale requires policy, staff training, and process changes. Practical steps include:
– Institutional policy: Make immediate, continuous SSC the default for eligible births; define clear exclusion criteria.
– Staff training: Educate obstetric, anesthesia, and neonatal teams on SSC benefits, safety checks (airway, thermal), and how to support breastfeeding initiation.
– Operating-room protocols: For cesarean births, adapt draping and anesthesia practices so SSC can begin in the OR or immediately in recovery for stable dyads.
– Documentation and audit: Add SSC start time and breastfeeding initiation to birth records and quality dashboards.
– Family education: Antenatal and immediate postpartum counseling about SSC helps families expect and accept the practice.
A brief vignette:
– Sarah, 32, has an uncomplicated scheduled cesarean at 39 weeks. The hospital policy supports SSC in the OR. After birth, the team dries the baby and places him on Sarah’s chest within five minutes while the neonate is observed. The infant initiates suckling within 30 minutes; lactation support is available. Staff document SSC start and duration and monitor newborn temperature and glucose per protocol. This simple workflow supports breastfeeding initiation without delaying necessary maternal care.
Research Gaps and Future Directions
The Cochrane update highlights several priorities:
– Conduct pragmatic trials or implementation research in low-income countries to test feasibility and benefits in those contexts.
– Study SSC among high-risk subgroups (e.g., infants of diabetic mothers, late preterm infants) with clear safety monitoring plans.
– Investigate mechanistic questions: how SSC biologically influences lactation, neonatal thermogenesis, and glucose regulation.
– Improve maternal outcomes reporting: larger, adequately powered trials should measure objective maternal endpoints (quantified blood loss, hemorrhage-related morbidity).
– Standardize definitions: Trials should clearly describe SSC dose (start time, duration, continuity) and comparator conditions to improve comparability across studies.
References
1. Moore ER, Brimdyr K, Blair A, et al. Immediate or early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2025, Issue 10. Art. No.: CD003519. DOI:10.1002/14651858.CD003519.pub5. PMID: 41120189; PMCID: PMC12540017.
2. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11:CD003519.
3. World Health Organization, United Nations Children’s Fund (UNICEF). Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services — the revised Baby-friendly Hospital Initiative. WHO/UNICEF; 2018. https://www.who.int/publications/i/item/9789241513807
4. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. 2012;129(3):e827–e841. DOI:10.1542/peds.2011-3552.
5. Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475–490. DOI:10.1016/S0140-6736(15)01024-7.
6. WHO. WHO recommendations on postnatal care of the mother and newborn. World Health Organization; 2014. https://www.who.int/publications/i/item/9789241506649
Bottom Line
The 2025 Cochrane update strengthens the evidence that immediate, continuous, uninterrupted SSC after birth supports exclusive breastfeeding and modestly benefits newborn thermal regulation and glucose levels for healthy full-term and late preterm infants, including many cesarean births. Maternal physiological benefits remain uncertain. Where feasible, SSC should be the default approach for eligible mothers and newborns, supported by local protocols, staff training, and documentation. Future research should address maternal outcomes, low-income settings, and implementation strategies that translate this compelling evidence into routine care.
