Nurses' knowledge, Safe newborn positioning, Skin-to-skin contact, Sudden unexpected postnatal collapse



  1. Addison, Camilla DNP, RN, C-EFM
  2. Ludington-Hoe, Susan PhD, RN, CNM, CKC, FAAN


Purpose: Sudden unexpected postnatal collapse (SUPC) of healthy newborns in the first 2 days of life is increasing. These types of adverse events are known to be associated with unsafe positioning during skin-to-skin contact and breastfeeding. The purpose of the study was to determine maternity nurses' knowledge about SUPC and safe newborn positioning.


Design: Nurses who participate in a hosted listserv were solicited to complete a questionnaire.


Methods: An email with an embedded link to a 20-item questionnaire, the SUPC and Safe Positioning Knowledge Assessment Tool, and 16 demographic questions was sent to 605 maternity nurses in the United States who are part of a Perinatal Listserv for members of the Association of Women's Health, Obstetric and Neonatal Nurses. Scores were analyzed by mean, standard deviation, and percent correct answers.


Results: Fifty questionnaires were initiated (response rate of 8.2%), and 36 completed questionnaires (response rate of 5.9%) were analyzed. Maternity nurses' knowledge of SUPC was less than their knowledge of safe newborn positioning (61% correct vs. 72% correct; p < 0.001).


Clinical Implications: Maternity nurses need more information about SUPC and safe newborn positioning, including risk factors, and effective strategies to reduce risk of preventable newborn harm.


Article Content

Rooming-in, skin-to-skin contact (SSC) for healthy newborns, bonding opportunities, and breastfeeding are common practices during the newborn period. Yet, SSC and breastfeeding have been associated with an increase in sudden unexpected postnatal collapse (SUPC) in healthy newborns (Bass, Gartley, Lyczkowski, & Kleinman, 2018) that commonly occurs when the newborn's airway becomes obstructed (Herlenius & Kuhn, 2013). Sudden unexpected postnatal collapse can lead to serious neurologic damage as well as death (Lohr, 2017; Monnelly & Becher, 2018). Unsafe holding during SSC, breastfeeding, and rooming-in are risk factors for SUPC (Davanzo et al., 2015; Garofalo et al., 2018; Ludington-Hoe & Morgan, 2014; Simpson, 2017). Newborn falls during SSC is another risk, particularly when the mother is fatigued or medicated (Feldman-Winter & Goldsmith, 2016).

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To improve safety immediately after birth, recent reports have highlighted the need for continuous monitoring and observation of both mother and newborn (Bass et al., 2018; Feldman-Winter & Goldsmith, 2016; The Joint Commission [TJC], 2018) by health personnel during the first 2 hours after birth (which is when a third of SUPCs occur [Herlenius & Kuhn, 2013]) and regularly throughout the postpartum hospitalization (Bass et al.; Becher, Bhushan, & Lyon, 2012; Davanzo et al., 2015; Feldman-Winter & Goldsmith, 2016; Herlenius & Kuhn; Ludington-Hoe & Morgan, 2014; Pejovic & Herlenius, 2013; TJC, 2018). Nurse staffing guidelines from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2010), the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (AAP & ACOG, 2017) have specific recommendations for one-to-one nursing care for healthy mothers and babies during the first 2 hours immediately postpartum, after the critical elements of care are met (Simpson, 2015). During this time, the nurse should have no other patient care assignments beyond caring for the new mother and her baby (AAP & ACOG, 2017; AWHONN, 2010). During the postpartum and newborn inpatient stay, the maternity nurses should not be assigned more than three healthy mother-baby couplets (AAP & ACOG, 2017; AWHONN, 2010).


"Supervising skin-to-skin contact and breastfeeding continuously during the first two hours of life" (Hitchcock & Ruhl, 2019, p. 160), every 30-minute rounding by hospital personnel during nighttime and early morning for high-risk mothers (Feldman-Winter & Goldsmith, 2016), and hourly rounding so that mothers and caregivers noted to be drowsy can be assisted to place their newborn in a bassinette (Feldman-Winter & Goldsmith, 2016; TJC, 2018) have been recommended. Close observations should also occur with fathers and others holding the newborn (Feldman-Winter & Goldsmith, 2016; Ludington-Hoe & Morgan, 2014). Feldman-Winter and Goldsmith (2016) suggested frequent newborn vital signs. Ludington-Hoe and Morgan (2014) recommended frequent newborn assessment using the Respiratory, Activity, Perfusion, Position, Tone Tool (RAPPT) during the first 2 hours after birth. Use of the RAPPT was found to be associated with avoiding SUPCs when used as part of a bundled quality improvement project that included oxygen saturation monitoring of the newborn via pulse oximetry for the duration of the initial SSC at birth from 10 minutes of life continuing during postpartum recovery (Paul, Johnson, Goldstein, & Pearlman, 2019). Nurses should teach parents safe positioning so the newborn is always well oxygenated (Feldman-Winter & Goldsmith, 2016; Garofalo et al., 2018; Garofalo, Pellerite, Goodstein, Paul, & Hageman, 2019) as shown by being "pink" in any position (Garofalo et al., 2018). Nurses must know how to monitor for safe newborn positioning for SUPC prevention (Garofalo et al., 2018). Unexpected newborn complications, including SUPC, is now one of The Joint Commission perinatal care performance measures for accredited hospitals with at least 300 live births per year and for hospitals seeking Perinatal Care certification (TJC, 2019).


Few reports involving maternity nurses' knowledge of SUPC have been published (Garofalo et al., 2018; Paul et al., 2019). The AAP is working to establish standardized terminology for healthy term newborns who experience sudden and unexpected cardiorespiratory collapse (Feldman-Winter & Goldsmith, 2016; Lutz, Elliot, & Jeffrey, 2016; Tieder et al., 2016). There is no accepted definition of SUPC, thus nurses may not be familiar with this term (Ludington-Hoe, Morrison-Wilford, DiMarco, & Lotas, 2018). Other researchers have used an apparent life-threatening event (Tieder et al.) or an asphyxiation or suffocation event (Lutz et al.; Thach, 2014) to describe these types of cases. A safe positioning checklist developed by the United States Institute for Kangaroo Care (Ludington-Hoe & Morgan, 2014) was designed to improve safe positioning of the newborn. ACOG (2018) recommends using a standardized approach to newborn monitoring while breastfeeding including proper positioning and observation to avoid adverse events and includes the safe positioning checklist from Ludington-Hoe and Morgan (2014) as an example in their practice bulletin.




An email with an embedded link to a 20-item questionnaire, the SUPC and Safe Positioning Knowledge Assessment Tool, and 16 demographic questions was sent to maternity nurses in the United States who are part of a Perinatal Listserv for members of AWHONN. Submitting the questionnaire constituted consent.



The email with the embedded link to the questionnaire was posted to the Perinatal Listserv that is open to the approximately 22,000 members of AWHONN. When the email was posted, there were 605 participants. Inclusion criteria were maternity nurses who were English-speaking, were permanently assigned to a maternity unit, and had worked for at least 6 months as a maternity nurse. Exclusion criteria were nurses who had floated to the maternity unit on a temporary assignment or who were in orientation as a newly hired maternity nurse.



Knowledge was determined by the SUPC and Safe Positioning Knowledge Assessment Tool (available from the researchers). The SUPC and safe newborn positioning portions of the tool have 10 items, each consisting of: multiple choice, fill-in, and true or false questions. A correct answer equals one point and 20 points is the total possible score (i.e., the higher the score, the greater the knowledge). Sixteen demographic questions were included. The SUPC questions were derived from the literature (Becher et al., 2012; Herlenius & Kuhn, 2013; Pejovic & Herlenius, 2013); safe newborn positioning questions were developed from the Skin-to-Skin Contact Checklist (Ludington-Hoe & Morgan, 2014). Three maternity nurse experts who were not part of this study team established content validity of the questionnaire. Internal consistency reliability could not be established because some questions had only "yes/no" answers.



After institutional review board approval, the email with an embedding link to the questionnaire was posted to the Perinatal Listserv. Inclusion and exclusion criteria answers determined access to the questionnaire. Response rates were tracked daily and once the 1-month posting period ended, data were analyzed.



Data were analyzed via SPSS 24.0. Mean, standard deviation, range, percent of correct answers, as well as normality of distribution by skew and kurtosis, were computed. If data distributed normally, a t test was conducted.



Fifty questionnaires were initiated (response rate of 8.2%), and 36 completed questionnaires (response rate of 5.9%) were included in the analysis. Two responses were excluded due to nurse practitioner or certified nurse-midwife status, nine were excluded due to temporary assignment on a maternity unit, and three were omitted due to missing data. Thirty respondents was the target to achieve a normal sampling distribution. See Table 1 for demographic characteristics of participants.

Table 1 - Click to enlarge in new windowTABLE 1. Demographic Characteristics of Respondents

Average SUPC knowledge score was 6.1 correct answers (61.0%, SD = 1.5). Of the 36 respondents, 12 (33.3%) scored above average. For these SUPC data, skew = -0.15, kurtosis = -0.47, indicating normal distribution. On safe newborn positioning, average score for all respondents was 7.2 correct answers (72.0%; SD = 1.4) and the data distributed normally (skew = -0.29 and kurtosis = -0.17). Of the 36 nurses, 15 (41.7%) scored above average. There was a significant difference between the mean scores for SUPC and safe newborn positioning of respondents (t = 3.7, p < 0.001); respondents had more knowledge of safe newborn positioning than SUPC.



Knowledge of SUPC was significantly lower than safe newborn positioning. In several quality improvement projects, there has been an assumption that nurses lacked knowledge about SUPC, which led to providing further education (Garofalo et al., 2018; Ludington-Hoe et al., 2018; Paul et al., 2019; Rodriguez, Pellerite et al., 2018). The extent of maternity nurses' knowledge about SUPC and safe positioning was not quantified nor reported in detail in the quality improvement project reports, including the Ludington-Hoe et al. (2018) report that measured nurses' knowledge about the RAPPT assessment tool, not SUPC. Comparisons of our data to previous reports of nurses' awareness or knowledge about SUPC and safe newborn positioning were not possible.


Our finding of limited knowledge may be due to several reasons. The term SUPC is still relatively new and may not be known to nurses. Consensus that SUPC is a diagnosis has not yet been reached (Bass, Gartley, & Kleinman, 2019; Feldman-Winter & Goldsmith, 2016; Garofalo et al., 2018; Goldsmith, 2013; Tieder et al., 2016). Nurses do not make the diagnosis of SUPC (Goldsmith, 2013), perhaps contributing to limited exposure to SUPC as both a term and as a condition. The term SUPC is not synonymous with asphyxia, suffocation, and strangulation (Tieder et al., 2016), which are the current acceptable diagnoses that nurses use to report healthy newborns experiencing physiologic collapse (TJC, 2018). Even though data are emerging about potential intrinsic causes of SUPC, such as a disorder of the Kolliker-Fuse Nucleus in the brain stem that impairs an accurate response to an episode of hypoxia (Lavezzi, Paradiso, Pusiol, & Piscioli, 2019) or possible high oxidative stress passed from mother to fetus at birth (Kobayashi, Iorio, & Yoshino, 2019; Marseglia, D'Angelo, Manti, Reiter, & Gitto, 2016), these data may not be known by maternity nurses.


Nurses knew more about safe newborn positioning than about SUPC, perhaps due to wide awareness of safe sleep positions to prevent sudden infant death syndrome (SIDS) in older infants. Applying awareness of SIDS interventions with the knowledge of how to help a newborn breathe may have contributed to the higher scores. The majority of nurses had some knowledge about SUPC and safe newborn positioning, suggesting that nurses have familiarity with current published information (Davanzo et al., 2015; Ferrarello & Carmichael, 2016; Garofalo et al., 2018; Ludington-Hoe & Morgan, 2014; Paul et al., 2019; Rodriguez, Hageman, & Pellerite, 2018). However, more than the minimal knowledge is needed to promote newborn safety. The high number of maternity nurses with advanced education in our study most likely reflects nurses who were nurse managers, clinical nurse specialists, or clinical educators as well as bedside nurses.


A study limitation was that our data represent a small sample of maternity nurses who are AWHONN members, the majority of whom had a master's degree. The email with the link to the questionnaire was moved down onto subsequent pages as new postings were made, preventing it from being immediately seen, possibly contributing to low response rate. Sending the email only once and asking for completion of a questionnaire may have contributed to the low response rate, as may have the relatively new topic and term of SUPC.


Clinical Implications

Maternity nurses need more education about SUPC and safe newborn positioning. Hitchcock and Ruhl (2019) reviewed sudden unexpected infant death, which includes SUPCs resulting in death, and recommended that perinatal nurses need to understand and tell parents how SUPCs and safe newborn positioning can contribute to neonatal death. Their recommendation is consistent with ours that maternity nurses may need education about SUPCs and safe newborn positioning. Educational campaigns and hospital initiatives (posters, staff handouts, bulletin board, and huddle messages), as well as teaching videos are known to be effective in helping nurses learn and follow safe practices (Carlin & Moon, 2017, Lipke et al., 2018; Salm Ward & Balfour, 2016). Rodriguez, Pellerite et al. (2018) offer a video with an SUPC event to teach nurses and physicians about SUPC. The United States Institute of Kangaroo Care (2018; offers resources for education. Professional association events also provide information about both topics. Making SUPC management and safe newborn positioning items part of orientation may be helpful for nurse education and knowledge building. All maternity nurses need to be aware of risk factors for SUPC, how to support safe newborn positioning during SSC and breastfeeding, and what to tell new mothers and parents, so newborns can be as safe as possible (Killion, 2017). Nurse staffing as per AWHONN (2010) and AAP and ACOG (2017), and rounding on mother-baby couplets as per AAP (Feldman-Winter & Goldsmith, 2016) and TJC (2018) should be routine in all maternity units.


Suggested Clinical Implications


* Maternity nurses need more education about SUPC and safe newborn positioning.


* Breastfeeding and SSC care require nursing support of safe positioning and attention to newborn wellbeing.


* The immediate postpartum recovery is a time of increased risk for SUPC.


* Maternity nurses play a key role in educating mothers and parents to understand risks of unsafe newborn positioning and to prevent SUPC.


* Unit policies and practices should be consistent with recommendations from national professional organizations such as AAP, ACOG, AWHONN, and TJC for safe care during hospitalization for childbirth.


* Maternity nurses need to be aware of and follow unit procedures for vigilant monitoring and observation of newborns.


* Educational campaigns and hospital initiatives have been shown to be effective in helping nurses learn and follow safe practices; therefore, formal and informal educational techniques can assist nurses in reducing SUPC events.


* Maternal fatigue, pain status, pain medication taken, mobility, and support person availability should be part of nursing assessment for rooming-in.


* Knowledge of SUPCs and safe newborn positioning should be applied throughout the hospital stay and not just the first 2 hours post birth.


* Nurse staffing based on national standards and guidelines as per AWHONN, AAP, and ACOG, and periodic rounding on mother-baby couplets as per AAP and TJC can promote newborn safety in the hospital.


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Maternity Nurses' Knowledge about Sudden Unexpected Postnatal Collapse and Safe Newborn Positioning


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