Women and Newborn Health Nursing

Parent Newborn Teaching Plan Assignment

Purpose: To demonstrate effective teaching/learning skills for the childbearing family. Topics: Choose a topic to teach: Newborn Feeding (breastmilk or formula), Infant Safety, Newborn Care (bathing, circumcision care) Car Seat Safety, or another newborn care topic of your choosing (do not select Safe Sleep Practices/SIDs as this topic is included in another clinical activity…additional topics may be chosen with instructor approval).

Instructions:

~Research your chosen topic, using websites, textbooks, patient teaching materials from clinical setting, observation in clinical setting etc. ~Create a teaching plan on your chosen topic using patient information handouts from the facility or create a brochure with information on your topic.

~ Find two articles from a nursing or allied health journal that relates to patient education or the topic you have chosen for your teaching plan. Include the citation with any other resources you used.

~Instructor may choose one of the following options:

1.) The student may role-play the teaching session, using a student chosen by the instructor as the “parent” and the rest of the clinical group observing. 

2.) Choose one of the student’s assigned patients and deliver the teaching session. The student should invite the instructor or another student to sit in on the session.

Teaching Plan Guide:

Teaching Goals
What are the priorities? (“By the end of the teaching session, the patient will…”)

Content Outline

What will you teach? Use bullet points to organize topical information.

Methodology

How will you teach the content? What modalities will you use?

Rationale

Why have you chosen the teaching modalities?

Evaluation of Learning
How will you determine if the teaching/learning goals were met?

NUR4545 Parent Teaching Newborn Care Assignment RUBRIC

1 Point

0.5 Point

0 Point

Rubric Total 10 points:_____________________/10 Points

Abstract: The Golden Hour enco

m

passes a set of evidence-based practices that contribute to the physiologic stabilization of the mother–new-
born dyad after birth. Important elements of the Golden Hour include delayed cord clamping, skin-to-skin contact for at least an hour, the per-
formance of newborn assessments on the maternal abd

om

en, delaying non-urgent tasks (e.g., bathing the newborn) for 60 minutes, and the early
initiation of breastfeeding. The Golden Hour contributes to neonatal thermoregulation, decreased stress levels in a woman and her newborn, and
improved mother–newborn bonding. Implementation of these actions is further associated with increased rates and duration of breastfeeding.
This article explores the evidence supporting the Golden Hour and provides strategies for successfully implementing a Golden Hour protocol on
a hospital-based labor and delivery unit. http://dx.doi.org/10.1016/j.nwh.2017.10.011

Keywords: breastfeeding | Golden Hour | newborn | postpartum | skin-to-skin

The first 60 minutes after birth is a critical time for a woman and her newborn. It has been called
the “Golden Hour” (Sharma, Sharma, & Shastri, 2017). This is a time of transition for a newborn,
moving from the internal to the external uterine environment. The first hour of life requires
the rapid adaptation of multiple newborn organ systems and includes pulmonary, circulatory,
metabolic, and hemodynamic changes (Morton & Brodsky, 2016). The three key components of
the Golden Hour consist of maternal–neonatal skin-to-skin contact, delayed cord clamping, and
breastfeeding, all of which serve to improve mother–newborn bonding and neonatal adaptation
(King & Pinger, 2014; Moore, Bergman, Anderson, & Medley, 2016). Skin-to-skin care must include
the performance of newborn assessments with the newborn on his/her mother’s abdomen and
the delay of non-urgent tasks for at least 60 minutes (Crenshaw, 2014). This particular Golden
Hour intervention is especially critical, because it promotes neonatal thermoregulation, decreases
newborn stress levels, improves mother–newborn attachment, and encourages breastfeeding
(Phillips, 2013). This article explores the literature in support of the Golden Hour and describes
an evidence-based protocol for the implementation of a Golden Hour in practice sites.

the
Golden Hour

Providing
Evidence-Based
Care During

http://crossmark.crossref.org/dialog/?doi=10.1016/j.nwh.2017.10.011&domain=pdf

Jennifer L. Neczypor
Sharon L. Holley

464 © 2017, AWHONN Volume 21 Issue 6

Background
The theory of the Golden Hour originated with the work of
Dr. R. Adams Cowley, a trauma researcher in the 1960s (Uni-
versity of Maryland Medical Center, 2017). He noted that the
use of standardized emergency management protocols in the
first hour after a traumatic event significantly improved health
outcomes and reduced mortality (Sharma et al., 2017). This
concept began to be accepted by other specialties, including
maternity and pediatric care. References to a neonatal Golden
Hour first appeared in the 1970s, when Michel Odent, a French
obstetrician, posited that newborns instinctively seek out the
maternal breast in the hour after birth (Odent, 1977). The con-
temporary conceptualization of the Golden Hour after birth
includes three main elements: (a) direct, immediate skin-to-
skin contact between a mother and her newborn, (b) delayed
cord clamping, and (c) early initiation of breastfeeding, if medi-
cally appropriate and desired by the woman (Sharma et al.,
2017; World Health Organization [WHO] & United Nations
Children’s Fund [UNICEF], 2009).

Together, these interventions prevent neonatal hypother-
mia and hypoglycemia and facilitate mother–newborn bonding
(Sharma et al., 2017; WHO & UNICEF, 2009). Both the WHO
and UNICEF’s Baby-Friendly Hospital Initiative recommend
that all healthy newborns, including those born via cesarean,
experience immediate skin-to-skin contact with their moth-
ers for at least an hour after birth (WHO & UNICEF, 2009).
This recommendation coincides well with Healthy People
2020, which aims to improve well-being for women and infants
through a broad set of strategies aimed at enhancing postpar-
tum health behaviors, including breastfeeding initiation rates
(U.S. Department of Health and Human Services, 2017).

The Golden Hour offers maternal health benefits as well.
According to Lowson, Offer, Watson, McGuire, and Renfrew
(2015), most mothers prefer to experience skin-to-skin contact
after childbirth, and those who experience skin-to-skin contact
experience less anxiety by Day 3 of the postpartum period and
are more confident in their parenting abilities at discharge when
compared with women who are separated from their newborns
after birth. Moreover, the initiation of exclusive breastfeeding,
which is facilitated by delayed cord clamping and prolonged
skin-to-skin contact, promotes more immediate mater-
nal health by contributing to more rapid uterine involution,
decreased postpartum blood loss, and increased postpartum

weight loss (WHO & UNICEF, 2009). Continued breastfeed-
ing offers further lifelong maternal health benefits such as
longer intervals between pregnancies, which allows for mater-
nal nutritional and energy replenishment, and reduced risk of
breast, ovarian, and endometrial cancer (WHO & UNICEF,
2009). Despite these recognized health benefits, women who
give birth in hospitals often do not have the opportunity to hold
their newborns until after the neonate’s bath and weight and
pediatric evaluation are complete, thus disrupting the neonate’s
physiologic transition. Time constraints on the part of the staff
and hospital policies that do not accommodate the Golden
Hour can contribute to routines such as bulb suctioning on
the perineum, immediate cord clamping, and taking the new-
born from his/her mother to obtain the weight and bathe the
newborn, all of which disrupt the normal bonding and latch-
ing processes (Koopman, Callaghan-Koru, Alaofin, Argani, &
Farzin, 2016).

Golden Hour Protocol
A Golden Hour protocol emphasizes skin-to-skin contact, or
the placing of the dried, unclothed newborn directly on his/
her mother’s chest and abdomen just after birth, before cutting
the umbilical cord (Crenshaw, 2014). There is no routine bulb
suctioning of the newborn’s mouth. Instead, a dry blanket or
towel is used to gently dry and stimulate the newborn and wipe
away secretions from the mouth and nose (Crenshaw, 2014).
After birth, delayed cord clamping is done by the maternity
care provider to allow for the placental transfusion of blood to
the newborn, which promotes improved transitional circula-
tion and red blood cell volume, increased birth weight, and
greater iron stores in infants at 6 months of age (American Col-
lege of Nurse-Midwives, 2014). Simultaneously, delayed cord
clamping decreases the need for neonatal blood transfusions
and decreases risk of necrotizing enterocolitis, iron-deficiency
anemia, and intraventricular hemorrhage (American College
of Obstetricians & Gynecologists, 2017; Mercer, Erickson-
Owens, Graves, & Haley, 2007).

Delayed cord clamping is not linked with an increased risk
for maternal postpartum hemorrhage or blood loss after birth
(American College of Obstetricians & Gynecologists, 2017).
Although no standardized time limits currently define early
versus delayed cord clamping, causing the exact amount of
time given before cutting the cord to vary between individual
providers and institutions, the WHO recommends clamping
the cord 1 to 3 minutes after birth, the amount of time that is
generally required for the cord to cease pulsating, whereas the
American College of Nurse-Midwives suggests waiting at least
5 minutes for term newborns who are placed skin to skin, at
least 2 minutes for term newborns positioned at or below the
level of the placenta, and 30 to 60 seconds for preterm new-
borns (American College of Nurse-Midwives, 2014).

Jennifer L. Neczypor, MSN, CNM, FNP, is a new graduate who recently
accepted a position as a certified nurse-midwife at Massachusetts
General Hospital in Boston, MA. Sharon L. Holley, DNP, CNM,
FACNM, is Chief of the Division of Midwifery at Baystate Medical
Center in Springfield, MA. The authors report no conflicts of interest or
relevant financial relationships. Address correspondence to: jennifer.lynn
.neczypor@gmail.com. O

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December 2017 Nursing for Women’s Health 465

All initial neonatal assessments should be performed with
the newborn remaining on the mother’s abdomen, maintain-
ing skin-to-skin contact and facilitating delayed cord clamping
(Crenshaw, 2014). Non-urgent tasks of care, such as weighing
and bathing the newborn, should be postponed for at least an
hour, thereby providing the woman and her newborn with
60 minutes of uninterrupted time for bonding, during which
breastfeeding can be initiated (Phillips, 2013).

Conflicting opinions regarding the timing of cord clamp-
ing exist in the case of neonates born to women with HIV
infection or hepatitis B. The WHO notes that, although some
health professionals working with HIV-positive women advo-
cate immediate cord clamping because of concerns about
infected maternal blood transfusing to the neonate during

birth, recent WHO guidelines assert that the proven benefits
of delayed cord clamping outweigh the theoretical risk of HIV
transmission (WHO, 2013, 2014). These guidelines show that
the additional 1 to 3 minutes of placental blood flow afforded
by delayed cord clamping have not been shown to increase the
risk of HIV transmission from mother to newborn and thus
encourage delayed cord clamping as a best practice for mothers
and newborns, except for those neonates in need of immedi-
ate resuscitation (WHO, 2013). After delayed cord clamping,
neonates born to women with HIV or hepatitis B infection
should be promptly bathed with gentle soap and warm water,
thus removing contaminated body fluids and minimizing pos-
sible exposure to maternal blood, before being returned to their
mothers for skin-to-skin care and, if the woman has hepatitis B
but not HIV, the initiation of breastfeeding (Nelson, Jamieson,
& Murphy, 2014).

Skin-to-skin contact increases the amount of time that new-
borns spend in the quiet alert state. Authors of a 2016 Cochrane
Review report that early skin-to-skin contact initiated in the
first 10 minutes of life improves the chances of successful breast-
feeding and successful newborn transition to the outside world
(Moore et al., 2016; Redshaw, Hennegan, & Kruske, 2014). A
dose-dependent relationship appears to exist between skin-to-
skin contact and breastfeeding. Newborns placed skin to skin

The first hour of life requires
the rapid adaptation of multiple

newborn organ systems and includes
pulmonary, circulatory, metabolic,

and hemodynamic changes

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466 Nursing for Women’s Health Volume 21 Issue 6

as well as more rapid passing of the placenta compared with
women who do not hold their newborns skin to skin (Moore
et al., 2016). Increased oxytocin levels also promote maternal
attachment to the newborn, which can improve mother–new-
born bonding, lower a woman’s plasma cortisol levels, and pro-
tect the neonate from the effects of sudden separation from the
mother, a phenomenon noted to be similar to drug withdrawal
(Biro et al., 2015; Moore et al., 2016; Redshaw et al., 2014).

A study of Australian women’s immediate postpartum
experiences identified eight variables that are associated with
a greater likelihood of holding a newborn skin to skin during
the Golden Hour (see Box 1; Biro et al., 2015). Although not
all of these variables can be controlled by maternity nurses, it
is important that nurses are able to identify those women who
may be more at risk of not experiencing skin-to-skin con-
tact, a crucial aspect of the Golden Hour. Nurses can encour-
age women to hold their newborns skin to skin for as long as

for 31 to 60 minutes or longer are more likely to be breastfeed-
ing at 3 months postpartum than those who are held skin to skin
for only 11 to 20 minutes (Biro, Yelland, & Brown, 2015). Long-
term advantages of early skin-to-skin contact include increased
rates of exclusive breastfeeding in the first 1 to 4 months of life,
improved interactions between mother and infant, and reduced
infant crying (Redshaw et al., 2014).

The prolonged skin-to-skin contact of the Golden Hour also
assists in the physiologic stabilization of women and newborns.
The practice reduces risk for neonatal hypoglycemia by rais-
ing glucose levels, regulates newborn temperature through the
process of thermal synchrony (i.e., the woman’s chest tempera-
ture increases to warm a cold neonate and decreases to cool a
neonate who is too warm), stabilizes the newborn’s respiratory
rate and blood pressure, decreases levels of a newborn’s stress
hormones, and promotes neonatal brain development by acti-
vating the maturation of the amygdala (Phillips, 2013). Skin-
to-skin contact likewise helps stabilize the woman’s condition
in the immediate postpartum period, because it promotes
the release of oxytocin, the hormone responsible for mater-
nal relaxation; breast milk letdown; and uterine contractions,
the last of which are essential to uterine involution after birth
(Crenshaw, 2014). Critically, women who experience skin-to-
skin contact with their newborns have reduced postpartum
bleeding and a decreased risk for postpartum hemorrhage,

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The process of protocol implementation
begins with evaluating existing

institutional policies and performing
a review of the current literature

December 2017 Nursing for Women’s Health 467

breastfeeding—should be clearly noted. The protocol should
also specify medical indications, such as maternal HIV-positive
status, that render it necessary to forego certain aspects of the
Golden Hour, such as delayed cord clamping and initiation of
breastfeeding. If delayed cord clamping is not already part of a
birthing unit policy, such a policy should be created with the
support of the interprofessional group of stakeholders. The pro-
tocol should clarify when and in what capacity additional nurs-
ing support will be required in various circumstances, such as
during a surgical birth, the repair of a severe vaginal laceration,
or a postpartum hemorrhage.

If a mother is temporarily unable to participate in the
Golden Hour because of a medical condition, the protocol
should include the option of placing the newborn skin to skin
on the father or partner’s abdomen until the mother can take
the newborn to continue with early breastfeeding and skin-to-
skin contact. Protocols should also address additional staffing
needs, logistical planning, and anesthesiology support to facili-
tate the Golden Hour after cesarean birth (Mercer et al., 2007).
Postpartum care should be designed to reduce disruptions; for
example, signs can be hung on the doors to women’s rooms for
those families that desire privacy. Women’s gowns should be
removed or opened to facilitate skin to skin contact and breast-
feeding. A hospital-wide policy should be publicized that limits
the number of visitors in the first hour after birth.

desired in the immediate postpartum period and can focus on
providing education on the benefits of this intervention to par-
ents who are less likely to experience uninterrupted skin-to-
skin contact with their newborns, such as primiparous women,
women with higher-risk pregnancies, and women who experi-
ence surgical births (Biro et al., 2015).

Exclusion Criteria for the Golden Hour

Maternal
Specific maternal considerations that may render it necessary to
postpone, modify, or forego the Golden Hour include extreme
maternal exhaustion, recent opioid administration resulting in
maternal sleepiness or altered level of consciousness, perineal
lacerations in need of extensive repair, postpartum hemor-
rhage, and other maternal emergencies (Ferrarello & Hatfield,
2014; Mercer et al., 2007; Redshaw et al., 2014).

Newborn
Exclusion criteria for newborns include extreme preterm birth
(i.e., defined as any birth occurring before 34 completed gesta-
tional weeks); neonatal respiratory distress; cyanosis; elevated
infection risk as shown by a maternal temperature of 101 °F or
greater; congenital anomalies that could result in cardiopulmo-
nary problems; signs of perinatal depression such as decreased
muscle tone, bradycardia, or apnea; and the birth of a non-
vigorous neonate through meconium-stained amniotic fluid
(American Academy of Pediatrics, 2009; Moore et al., 2016).

When neonatal resuscitation is required or any of the other
specified conditions are present, a newborn should be resus-
citated and fully evaluated by the pediatric team with the ini-
tial goal of stabilizing the neonate before attempting to initiate
the Golden Hour protocol (American Academy of Pediatrics,
2009). Although the focus of this article is on the establishment
of a Golden Hour for healthy term and late preterm neonates,
it is worth noting that skin-to-skin contact, sometimes called
kangaroo mother care, significantly reduces the mortality rate
of small-for-gestational-age neonates weighing less than 2,000
g in low- and middle-income countries (Moore et al., 2016).
The creation of a Golden Hour protocol for high-risk infants
may thus be an intervention worthy of subsequent exploration
after the widespread acceptance of the Golden Hour for low-
risk newborns.

Implementing a Golden Hour Protocol
The process of protocol implementation begins with evaluat-
ing existing institutional policies and performing a review
of the current literature. When updating or creating a pro-
tocol for the Golden Hour, the importance of all three major
Golden Hour components—delayed cord clamping, immedi-
ate and prolonged skin-to-skin contact, and early initiation of

BOX 1
Variables Associated With Greater
Likelihood of Skin-to-Skin Contact
During the Golden Hour

1. Receiving midwifery care as opposed to
physician care

2. Multiparity

3. Low-risk pregnancy status

4. Being married or partnered

5. Having completed secondary school

6. Experiencing a spontaneous vaginal birth

7. Accessing private rather than public
health care

8. Giving birth to a newborn who does not
require NICU admission

Source: Biro, Yelland, and Brown (2015).

468 Nursing for Women’s Health Volume 21 Issue 6

In-Service Training
After the approval of the Golden Hour protocol through the
appropriate committees, in-service training sessions should
take place for staff, nurses, physicians, and midwives. These ses-
sions should include information on the new protocol, how to
implement the Golden Hour, how to identify when additional
assistance is required, and any pertinent information specific to
the practice setting.

Conducting a Pilot Project
Before unit-wide implementation of a new protocol, a pilot
project is a good option to evaluate what goes well and what
needs improvement. A pilot project should involve only a select
group of women, newborns, and staff members, and it can be
used to smooth out problems in the implementation and to
cultivate the support of stakeholders who may be particularly
resistant to the new protocol. Although it is not reasonable to
expect that all team members will be immediately enthusiastic
about the changes, seeking out the assistance and input of those
who are most averse to the new practice protocols during the
pilot project could help facilitate an easier transition when the
protocol is instituted unit wide.

Reaching Out to Stakeholders
When a birthing unit begins the process of implementing the
routine practice of Golden Hour care, it is crucial to identify
stakeholders who will need to be involved in the planning, cre-
ation, and revision of policies. The list of stakeholders should
include maternity providers, labor and delivery nurses, pedi-
atric and anesthesia staff, hospital administrators, information
technology professionals, pharmacy, central supply, childbirth
educators, doulas, birthing families, and visitors. The invita-
tions for other stakeholders should be based on individual
institutional requirements for workflow processes.

Overcoming Common Barriers to
Implementation
Birth settings vary, but hospitals often have common barriers
to implementing Golden Hour processes. Although maternity
providers and nurses generally recognize the many maternal and
neonatal health benefits of the Golden Hour, they may initially
resist a new Golden Hour protocol, particularly if the protocol
alters the customary workflow. For example, the Golden Hour
can affect when a nurse obtains the newborn weight required
to admit the neonate to the newborn nursery, thus affecting
the release of the newborn’s medications from the pharmacy
(Koopman et al., 2016). This is why it is vital to address these
valid concerns with a multidisciplinary team ahead of imple-
mentation and include pharmacy staff, charge nurses, and
hospital administrators on the team during the protocol devel-
opment process and the initiation of the pilot project. This will

facilitate problem-solving before wide-scale implementation.
Preplanning for additional staffing needs and considering how
to optimize workflows will contribute to more immediate suc-
cess of the Golden Hour protocol (Mercer et al., 2007).

Other barriers identified in the literature include inadequate
nursing staffing ratios, the perception that a neonate is safer
under the warmer than on the mother’s abdomen, habitual

institutional and individual practices such as immediate cord
clamping and prompt bathing of the newborn, and limited or
no experience with initiating skin-to-skin contact in the oper-
ating room (Koopman et al., 2016). There may also be a general
lack of knowledge on the part of staff and families regarding
the importance of the Golden Hour. Overcoming this knowl-
edge deficit requires the implementation of mandatory in-ser-
vice education sessions for staff and anticipatory education for
pregnant women and their family members.

Women who experience spontaneous vaginal birth partici-
pate in skin-to-skin contact more frequently than women who
experience assisted vaginal birth and cesarean birth (Koopman
et al., 2016). Logistical and medical complications associated
with these latter two procedures, such as the limited size of
the operating room and staff concerns regarding the neonate’s
well-being, may render it more difficult to implement early
skin-to-skin contact and breastfeeding, but often this too can
be resolved with planning and forethought (Koopman et al.,
2016). For example, providing an extra nurse to participate
in the cesarean birth would enable one nurse to attend to the
needs of the newborn and allow the other to focus on helping
the mother initiate skin-to-skin contact. Ensuring the support
of anesthesiologists by providing them with a space at the pro-
tocol development table and including them in unit education
initiatives is also key to instituting the Golden Hour after cesar-
ean birth (Koopman et al., 2016).

Further obstacles to the Golden Hour involve a woman’s
desire for modesty, the desire of other family members to hold
the newborn, and constant interruptions by staff and visitors
(Ferrarello & Hatfield, 2014). New mothers often view interrup-
tions by hospital staff and guests as exhausting, stressful, and
detrimental to bonding with the newborn (Ferrarello & Hat-
field, 2014). Staff should address a woman’s privacy concerns by
keeping curtains in front of hallway doors closed and covering
a woman and her newborn with a clean dry sheet or gown while
still facilitating skin-to-skin contact and breastfeeding. Staff

Post a sign on the door to a woman’s
room that alerts visitors and staff

that the Golden Hour is in progress

December 2017 Nursing for Women’s Health 469

can also post a sign on the door to a woman’s room that alerts
visitors and staff that the Golden Hour is in progress (Ferrarello
& Hatfield, 2014). Extended family and friends hoping to meet
the newborn should receive anticipatory education prenatally
and during the intrapartum period, informing them that the
first hour after birth will be used to facilitate bonding between
the mother, partner, and neonate and that this may affect their
ability to enter the postpartum room during that time.

Women and their partners are more likely to support the
Golden Hour when given anticipatory education during pre-
natal visits or childbirth education classes. This should include
information about maternal fatigue and cultural expectations.
Many women, especially those intending to breastfeed, desire
early skin-to-skin contact (Ferrarello & Hatfield, 2014); how-
ever, it is worth noting that some women prefer to have their
newborns bathed before they hold them (Mercer et al., 2007).
These women may benefit from additional prenatal coun-
seling and education on the importance of Golden Hour inter-
ventions; however, the woman should make the final choice.
Discussions with a woman and her family in the intrapartum
period will facilitate a clear understanding of what will happen
immediately postpartum with regard to Golden Hour proto-
cols, ensuring that there are no misunderstandings.

Financial Implications

Implementation Costs
Financial costs related to implementing a Golden Hour pro-
tocol will vary at each institution but will likely include items

such as policy updates, information technology support, and
the creation of educational materials for mothers, families,
hospital personnel, and the larger community. Other expenses
may include advertising costs and spending associated with the
execution of a pilot project. Time costs include planning meet-
ings and training staff in person or via computer-based train-
ing. Information technology will need to be involved if there
are any necessary changes to the electronic health record or
if Web site development is required for public informational
resources. Pharmacy systems may need to interact with sup-
ply and information technology to facilitate the dispensing
of newborn medications such as vitamin K and antibiotic eye
ointment in light of the new protocols. Anticipated overhead
expenditures require discussions with hospital administrators
to determine where the funds for initial startup will come from.

Population Impact
There are financial costs and gains associated with implement-
ing the Golden Hour. These costs and gains affect individual
and population health as well as health care systems. Cost sav-
ings and financial gains are related to improving the short- and
long-term health outcomes for the newborn and are generated
by the initiation of interventions done during the Golden Hour,
such as early breastfeeding and immediate skin-to-skin con-
tact, both of which promote long-term, exclusive breastfeeding
(Lowson et al., 2015). In 2014, the global sales of breast milk
substitutes totaled $44.8 billion, and the per-person expendi-
ture for breast milk substitute in high-income countries (total
retail sales divided by the population of children ages 0–36 Ph

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470 Nursing for Women’s Health Volume 21 Issue 6

Improved breastfeeding practices worldwide would also
prevent 823,000 deaths a year in children younger than 5
years and 20,000 deaths per year in women due to breast can-
cer (Rollins et al., 2016). Encouraging breastfeeding in the
first hour after birth may improve parental productivity in the
workplace, because the long-term success of breastfeeding,
which is more likely with early initiation of the act, means that
parents do not have to take off as much time for early child-
hood illnesses such as otitis media, asthma, gastroenteritis,
necrotizing enterocolitis, and atopic dermatitis, because the
risk for these diseases is reduced in children who are breast-
fed (Bartick & Reinhold, 2010). Moreover, longer durations
of breastfeeding diminish long-term risks for obesity, thus
reducing financial burdens on insurance companies and tax-
payers by decreasing the costs of care associated with chronic
health conditions related to overweight and obesity (Bartick
& Reinhold, 2010). Finally, breastfeeding for at least 6 months
can decrease the devastating costs of premature infant death
or sudden infant death syndrome, because 74% of the excess
costs incurred in the United States by not breastfeeding are
associated with premature death (Bartick & Reinhold, 2010).
Naturally, the emotional costs of such tragedies cannot be
estimated, and this lends poignant support to the need for
Golden Hour protocols.

Quality Measures and Financial Gains
Insurance companies are now working with health care sys-
tems to improve managed care bundles, a process sometimes
called value-based health care. These types of bundled sets for

months, corrected for population growth) was approximately
$2,528 (Rollins et al., 2016). It is estimated that if 90% of fami-
lies in the United States breastfed exclusively for 6 months,
there would be an annual savings of $13 billion related to
direct and indirect costs and the ultimate economic impact of
those costs. A British analysis of the economics of the Golden
Hour showed that for every 1 pound ($1.22 U.S.) invested in
the promotion of early breastfeeding and skin-to-skin contact,
between 4 and 13.82 pounds ($4.87–$16.81 U.S.) of cost-saving
benefits are generated (Lowson et al., 2015). The Golden Hour
therefore provides “substantial economic benefits compared to
costs,” because implementation primarily involves inexpensive
interventions involving maternal education and staff engage-
ment (Lowson et al., 2015, para. 62). However, only 23% of
infants in the United States are currently breastfeeding at 1 year
of age, resulting in an estimated cost of $17.4 billon (Bartick,
2013; Bartick & Reinhold, 2010; Lessen & Kavanagh, 2015)—a
cost that can be reduced through the implementation of the
Golden Hour.

A vital contributor to our
project’s success was ongoing open

communication and dissemination
of information provided by our

physician–nurse dyad leadership team

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December 2017 Nursing for Women’s Health 471

References
American Academy of Pediatrics. (2009). Sample hospital breast-

feeding policy for newborns. Safe and Healthy Beginnings:
Breastfeeding Support Tools for Clinicians. Retrieved from https://
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/
Breastfeeding/Documents/Hospital_Breastfeeding_Policy

American College of Nurse-Midwives. (2014). Delayed umbilical
cord clamping [Position statement]. Retrieved from http://www
.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILE
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maternity care take into account the cost of providing mater-
nity services, outcomes, and quality measures. Implementation
of the Golden Hour as an evidence-based approach to provid-
ing newborn and postpartum care may have a positive impact
on long-term cost savings for maternal and pediatric care. By
implementing this low-cost set of interventions, there may be
improvements with regard to newborn care, particularly as
related to cost savings from decreased NICU admissions for
neonatal necrotizing enterocolitis and gastroenteritis (Lowson
et al., 2015).

With managed care bundles, if outcomes meet certain
quality measures and costs of care are reduced, health care
facilities may be able to spend less and retain more of the
bundled payment, possibly improving their financial gains
(Moriates, Arora, & Shah, 2015). Additionally, there are hid-
den financial benefits for quality measures such as increased
maternal satisfaction, which affect reimbursements to facili-
ties and to providers. Because most mothers report greater
satisfaction with their birth experiences when they are able to
hold their newborns sooner and for longer durations of time
immediately after birth (Biro, Yelland, & Brown, 2015), as is
stipulated by the Golden Hour, it can be inferred that such
interventions will lead to financial gain for individual insti-
tutions (Redshaw et al., 2014). The larger health care system
impact of the Golden Hour is the potential to keep overall
health care costs down and therefore maintain lower insur-
ance premiums—for example, through the potential reduc-
tion in rates of breast and ovarian cancer among women who
breastfeed (Lowson et al., 2015) and through decreases in feel-
ings of depression and anxiety self-reported by women who
experience skin-to-skin contact with their newborns (Red-
shaw et al., 2014).

Conclusion
Implementing an evidence-based Golden Hour protocol can
improve breastfeeding rates, decrease maternal and neonatal
morbidity, and promote mother–newborn bonding, with mini-
mal cost and probable financial gain for hospitals. Although
not all stakeholders will initially support this practice change,
education for staff and families can help overcome logisti-
cal and institutional barriers, as well as attitudes and habits,
that do not facilitate the Golden Hour. Providing women and
newborns with the benefits of immediate skin-to-skin contact,
delayed cord clamping, and early initiation of breastfeeding can
improve health outcomes, rendering it imperative for birthing
units in hospitals to implement the Golden Hour in their prac-
tice settings. NWH

http://crossmark.crossref.org/dialog/?doi=10.1016/j.nwh.2017.10.011&domain=pdf

472 Nursing for Women’s Health Volume 21 Issue 6

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Group. (2016). Why invest, and what it will take to improve

It seems that barely a day goes by without

a new drug being released—or perhaps

recalled. How can you stay on top of it all?

Read “Rx,” a clinical practice column appearing

three times a year in Nursing for Women’s Health.

It covers the latest developments in prescription and

over-the-counter pharmacotherapeutics—everything

from the HPV vaccine to over-the-counter weight

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