Most of what a newborn needs in its first hour costs nothing. Several of the things done instead cause harm.

There is a version of a delivery room that most people carry in their heads from films: the baby is lifted away, held upside down, smacked into crying, cleaned up, weighed, wrapped in a blanket and handed over. Almost every element of that sequence is either unnecessary or actively counterproductive, and the evidence saying so has been settled for years.

What makes the first hour after birth worth writing about is not that it needs expensive intervention. It is the opposite. The practices with the strongest evidence behind them are close to free, which means the gap between best practice and common practice is not a funding problem but an information and habit problem — and that is the kind of gap an article can actually narrow.

The minute that changes a baby's next six months

At the moment of birth, a substantial share of the baby's blood is still in the placenta and cord. If the cord is clamped immediately, that blood stays there and is discarded.

Waiting allows placental transfusion — on the order of a third of the newborn's blood volume moves across in the first minutes, carrying iron with it. The World Health Organization recommends clamping no earlier than one minute after birth for babies who do not need resuscitation, and the benefit is not confined to the delivery room: better iron stores at birth translate into measurably lower rates of anaemia months later, which matters enormously in a country where childhood anaemia is close to universal. In preterm babies the evidence is stronger still, with reductions in mortality and in the need for transfusion.

The counterargument used to be jaundice. Delayed clamping does slightly raise the rate of jaundice needing phototherapy, and phototherapy is a manageable, treatable condition in any facility that can offer it. Weighing a small increase in a treatable condition against months of better iron status is not a close call, which is why guidelines moved.

One point of nuance worth keeping: a baby who is not breathing needs resuscitation, and that takes precedence. The recommendation is for the routine case, not a rule to be followed while a baby is in trouble.

The chest is a warming device

A newborn is very good at losing heat and poor at making it. It has a large surface area relative to its mass, it arrives wet, and it cannot shiver — it depends on burning brown fat, a limited reserve. In a delivery room at ordinary air-conditioned temperature, an undried newborn can cool alarmingly fast.

Hypothermia in newborns is one of the most under-recognised contributors to neonatal illness and death. It is not primarily a cold-climate problem; it happens routinely in warm places, because the comparison that matters is with body temperature, not with the weather.

The response is a sequence sometimes called the warm chain: keep the room warm, dry the baby immediately and thoroughly, remove the wet cloth — a wet towel left on a baby continues to cool it by evaporation — and place the baby directly against the mother's skin, covered with a dry cloth and a cap. A mother's chest regulates temperature responsively, warming a cold baby and not overheating a warm one. It is also where the baby is colonised by the mother's bacteria rather than the ward's, and where the reflexes that lead to a first feed are triggered.

Which brings up the custom that undoes all of it. Bathing a newborn in the first hours is harmful, and guidance is to delay it for at least twenty-four hours. Bathing chills a baby at exactly the wrong moment, and it washes off the vernix, the white coating that has protective and moisturising functions. Where an early bath is culturally expected, delaying it is one of the highest-value conversations a midwife or nurse can have.

Immediate contact for the smallest babies

For decades the sequence for a small or preterm baby was: stabilise in an incubator first, and allow the mother contact later.

That has changed, and the evidence behind the change is unusually strong. A large multi-country trial of immediate kangaroo mother care — continuous skin-to-skin contact with the mother started before the baby was clinically stabilised — reported a substantial reduction in mortality among low-birthweight infants compared with conventional care. The World Health Organization's guidance now recommends starting kangaroo mother care immediately after birth for preterm and low-birthweight babies, rather than waiting for stability.

This matters more in India than almost anywhere. The country records the largest absolute number of preterm births in the world, and kangaroo mother care is an intervention that works in a district hospital as well as a tertiary centre, because the equipment is the mother.

The first feed, and what displaces it

Breastfeeding within the first hour is the other high-value item on the list. Early suckling stimulates milk production and uterine contraction, and the first fluid, colostrum, is not a lesser version of milk. It is a thick, antibody-rich secretion in small volume, closer to an immune dose than a meal, and small volume is appropriate — a newborn stomach holds only a few millilitres.

Two beliefs work against this. The first is that colostrum is stale or unclean and should be expressed and discarded. The second is that the baby needs something else while waiting for milk to "come in" — honey, sugar water, jaggery, ghutti, animal milk. These prelacteal feeds displace colostrum, introduce infection risk, and reduce suckling at the very moment that suckling drives supply. Honey carries a specific additional risk of infant botulism and should never be given in the first year.

India's own survey data shows how much room there is: early initiation of breastfeeding within the first hour sits at around forty per cent nationally, and exclusive breastfeeding under six months at roughly two-thirds. Both numbers have improved and both leave a large population of babies missing something that costs nothing to provide.

Almost everything a healthy newborn needs in its first hour is already present in the room. The skill is knowing which interventions to withhold.

The things that were dropped

Several once-standard practices are no longer recommended, and knowing why is useful because they persist.

Holding a baby upside down and slapping it does nothing useful; a baby who is not breathing needs airway positioning and ventilation, quickly, not percussion. Routine suctioning of the mouth and nose in a vigorous baby is not recommended either — it can provoke a reflex that slows the heart, and it is not needed when the baby is crying. Routine separation for weighing and measuring can wait an hour; nothing in it is urgent.

Some things are added, and they are small. Vitamin K at birth prevents vitamin K deficiency bleeding, a rare but devastating haemorrhage, and it is a single injection. Cord care is minimal — kept clean and dry, with nothing traditional applied to it, though in community settings with high infection risk, chlorhexidine application to the cord stump is used in India as a programme intervention. And a newborn who is not breathing at one minute needs assisted ventilation within that window, the principle behind the newborn resuscitation training that India runs under its own national programme.

Why it matters for students and researchers

Neonatal deaths make up the majority of deaths under one year, and the majority of those happen in the first week — which puts an extraordinary amount of the country's child mortality inside a window measured in hours and days. The interventions that address it are cheap and known. What is missing is consistency of practice, and that is a nursing and midwifery research problem far more than a technological one.

The useful research questions are unglamorous and local. What proportion of babies in a given facility actually receive delayed cord clamping, uninterrupted skin-to-skin contact and a feed within the hour — measured by observation rather than by register entry, which frequently disagree. What are the specific barriers on a busy labour ward: staffing, layout, the physical distance between the delivery table and the warmer, handover timing. Which counselling approaches actually shift the early-bathing custom in a given community, and which merely produce polite agreement. Whether a small change in room protocol moves the numbers, and whether the change survives six months later.

That work — pregnancy, childbirth, the postpartum period and care of the newborn, situated in individuals, families and communities — is precisely the scope of the International Journal of Midwifery Nursing and Practices (ISSN 2584-0800), a peer-reviewed hybrid open-access journal launched in 2015. For nursing and midwifery students, the first hour after birth is the clearest demonstration in clinical practice that evidence-based care is often a matter of doing less, more carefully, and that a well-documented observational study from one labour ward can be worth more than another review of the literature.

Frequently asked questions

Why is delayed cord clamping recommended?

Because a substantial share of the newborn's blood is still in the placenta at birth, and waiting at least a minute allows it to transfer, carrying iron with it. This raises iron stores and lowers the rate of anaemia months later, with stronger benefits still in preterm babies.

Does delayed clamping cause jaundice?

It slightly increases the rate of jaundice requiring phototherapy, which is readily treatable. Guidelines accept that trade-off because the iron benefit lasts months and the jaundice risk is manageable where phototherapy is available.

Why should a newborn not be bathed immediately?

Because bathing cools the baby at the point when it is least able to maintain temperature, and it removes the vernix, which is protective. Guidance is to delay the first bath for at least twenty-four hours.

What is kangaroo mother care?

Continuous skin-to-skin contact between the baby and the mother's chest, with the baby covered and usually feeding on demand. For preterm and low-birthweight babies, current WHO guidance recommends starting it immediately after birth rather than waiting for the baby to be stabilised.

Why is colostrum important?

Colostrum is the first, thick, antibody-rich secretion produced after birth. It is small in volume, which suits a newborn's stomach capacity, and functions largely as an immune dose. Discarding it or replacing it with prelacteal feeds removes that protection.

Are honey, sugar water or ghutti safe for a newborn?

No. Prelacteal feeds displace colostrum, carry infection risk and reduce the suckling that establishes milk supply. Honey additionally carries a risk of infant botulism and should not be given at all in the first year.