Society for Obstetric Anesthesia and Perinatology

Section Editor: Cynthia A. Wong

The Incidence and Prevention of Hypothermia

in Newborn Bonding after Cesarean Delivery:
ARandomized Controlled Trial
Ernst-Peter Horn, MD,* Berthold Bein, MD, Markus Steinfath, MD,
Kerstin Ramaker, MD, Birgit Buchloh, and Jan Hcker, MD

BACKGROUND: Little is known about thermoregulation of the newborn while bonding on the
mothers chest immediately after cesarean delivery. Newborn hypothermia is associated with
serious complications and should be avoided. Therefore, we evaluated whether newborns
develop hypothermia during intraoperative bonding while positioned on their mothers chests
and investigated the effects of active cutaneous warming of the mothers and babies during a
20-minute intraoperative bonding period.
METHODS: We enrolled 40 parturients scheduled for elective cesarean delivery under spinal
anesthesia. Mothers and their newborns were randomized to receive either passive insulation
or forced-air skin-surface warming during the surgical procedure and bonding period. The pri-
mary outcome was neonatal core temperature at the end of the bonding period. Core tempera-
tures of the newborns were measured with a rectal probe. Body temperatures of the mothers
were assessed by sublingual measurements. Skin temperatures, thermal comfort of the moth-
ers, and perioperative shivering were evaluated.
RESULTS: Without active warming from the beginning of the surgical procedure until the end
of the bonding period, the mean (SD) neonatal core temperature decreased to 35.9 (0.6)C.
Seventeen of 21 (81%) newborns became hypothermic (defined as a core temperature below
36.5C). Active skin-surface warming from the beginning of the surgical procedure until the end
of the bonding period resulted in a neonatal core temperature of 37.0 (0.2)C and a decreased
incidence of hypothermia (1 of 19 (5%) newborns (P < 0.0001)). In addition, active warming
increased the mean skin temperatures of the infants, maternal core and skin temperatures,
maternal thermal comfort, and reduced perioperative shivering.
CONCLUSIONS: Active forced-air warming of mothers and newborns immediately after cesarean
delivery reduces the incidence of infant and maternal hypothermia and maternal shivering, and
increases maternal comfort.(Anesth Analg 2014;118:9971002)

H
ypothermia in newborns is common with a global
prevalence up to 85% in hospitals and up to 92% at
home.1 Normal temperature at birth is between
36.5C and 37.5C with a tendency to lower values after
cesarean delivery.2 Neonatal hypothermia is commonly
defined as a core temperature below 36.5C.25 Hypothermia
contributes to neonatal mortality and morbidity, espe-
cially in preterm and low birth weight infants.6 Although
From the *Departments of Anesthesiology and Intensive Care Medicine, Re-
gio Klinikum Pinneberg, Pinneberg, Germany; Department of Anesthesiol-
ogy and Intensive Care Medicine, University Hospital Schleswig-Holstein,
Campus Kiel, Kiel, Germany; and Department of Gynecology and Obstet-
rics, Regio Klinikum Pinneberg, Pinneberg, Germany.
Accepted for publication December 9, 2013.
Funding: This study was funded by the Department of Anesthesiology and
Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus
Kiel, Kiel, Germany.
The authors declare no conflicts of interest.
This report was previously presented, in part, at the 60. Deutscher Anaesthesie
Congress (DAC), Nuernberg, Germany, April 2022, 2013.
Reprints will not be available from the authors.
Address correspondence to Jan Hcker, MD, Department of Anesthesiology
and Intensive Care Medicine, University Hospital Schleswig-Holstein, Cam-
pus Kiel, Kiel, Germany, Schwanenweg 21, 24105 Kiel, Germany. Address
e-mail to jan.hoecker@uksh.de.
Copyright 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000160
hypothermia is usually not a direct cause of death, it contrib-
utes to mortality caused by conditions such as severe infec-
tion, prematurity, and asphyxia1 as well as intraventricular
hemorrhage.7,8
There are several approaches and devices for prevention
and treatment of newborn hypothermia such as warming
mattresses, plastic wraps, bags, and caps.5,9 In addition,
skin-to-skin care on the mothers chest compared with
conventional incubator care is effective in reducing the
risk of neonatal hypothermia.5 This position is described
as the bonding position and can be held until the infant
latches onto the breast for the first feeding. A close bond
between the mother and her newborn is essential for a
close relationship and adequate growth of the infant and is
actively promoted by midwives during the first half-hour
after delivery.10,11 After vaginal delivery outside the oper-
ating room, skin-to-skin bonding of the newborn appears
safe about thermoregulatory disorders. For example, even
in preterm infants, 1 hour of skin-to-skin bonding was not
associated with hypothermia compared with those infants
placed in an incubator.12
Today, healthy parturients undergoing cesarean delivery
are awake during surgery, because neuraxial anesthesia is
the standard of care in the developed world. The thermal
outcome of the newborn who bonds on the mothers chest

May 2014 Volume 118 Number 5 www.anesthesia-analgesia.org 997

Hypothermia in Newborns Bonding after Cesarean Delivery
immediately after delivery in the operating room has not
been systematically investigated.
Therefore, the aim of our study was to evaluate whether
the newborn becomes hypothermic when bonding on the
mothers chest immediately after cesarean delivery. The
effects of active cutaneous warming of the mothers and
babies versus passive insulation during the intraoperative
bonding process were evaluated in this randomized con-
trolled trial. The primary outcome was the neonatal core
temperature at the end of the bonding period.
METHODS
This study was approved by the IRB (University Kiel,
Schwanenweg 20, 24105 Kiel, Germany; Chairperson: Prof.
Dr. H. M. Mehdorn) on February 14, 2012 (No: A 138/11)
and registered with ClinicalTrials.gov on February 12,
2013 (Identifier: NCT01793558, Principal investigator: PD
Dr. Jan Hcker).
During a 6-week period between February and April 2013,
all women scheduled for planned cesarean delivery under
spinal anesthesia in our clinic were asked to participate in
the study. Parturients were excluded if they were younger
than 18 years, classified as American ASA physical status III
or higher, or if cesarean delivery was planned under general
anesthesia. In addition, exclusion criteria were any expected
problems with the newborn such as week of gestation <36
or >42, placenta previa or abruption, meconium-stained
amniotic fluid, chorioamnionitis, or any abnormalities in
cardiotocography. We identified 63 eligible parturients, and
after obtaining written informed consent, we randomized 40
parturients for study participation (Fig.1).
Approximately, 60 minutes before the expected start
of cesarean delivery, patients arrived at the delivery ward
where a venous cannula was inserted, and an infusion of
Ringers solution was started at a rate of 500 mL/h until
end of surgery. All fluids were at room temperature. Patients
Assessed for eligibility (n = 63)
Excluded (n = 23)
Declinedto participate (n = 18)
Received general anesthesia (n = 1)
Cesarean delivery not carried out (n = 4)
Randomized (n = 40)
Allocated to receive active warming
(n = 19)
Lost to follow-up (n = 0)
Analyzed (n = 19)
998
www.anesthesia-analgesia.org
were prepared for cesarean delivery that included receiving
30 mL sodium citrate oral premedication 20 minutes preop-
eratively and were then transported into the central surgi-
cal area of the hospital. Intraoperative ambient temperature
was maintained near 23C. All operations were performed
in a single operating room. Just before initiating spinal
anesthesia, patients were randomly assigned to one of the
2 treatment groups: passive insulation (no active warming)
or active forced-air warming starting immediately after ini-
tiation of anesthesia until the end of the surgical procedure.
Randomization was performed by a nurse not involved in
the study, flipping a coin.
A 25-gauge spinal needle was inserted between the
second and third (L2-L3) or the third and fourth (L3-L4)
interspace with the patient in sitting position. When the
spinal space was identified by free flow of cerebrospinal
fluid 1.4 to 1.6 mL hyperbaric bupivacaine 0.5% and 5g
(=1 mL) sufentanil as injected slowly with the goal of
achieving a sensory level of T4. Parturients did not receive
any IV opioids.
In the active warming group, a forced-air cover (Level
1 Snuggle Warm Upper Body Blanket, Smiths Medicals,
Rockland, MA) was positioned over the upper body of the
patient laying on the operating table. A Level 1 Equator
warmer (Smiths Medicals, Rockland, MA) was set to high
level (44C) during the warming period. In the passive
insulation group, patients were covered by prewarmed cot-
ton blankets taken from a 40C heating cabinet.
The cesarean delivery began soon after adequate spi-
nal anesthesia was established. After the baby was born,
midwives assessed and cared for the newborn on an 37C
warm newborn table (Babytherm 8000, Drger, Luebeck,
Germany) for the first 5 minutes of life by drying the baby
and assessing 1- and 5-minute Apgar scores. If the 5-minute
Apgar score was 9 and the newborn was deemed stable,
he/she was positioned naked (the infant head was routinely
Figure 1. Participant Consolidated
Standards of Reporting Trials flow diagram.
Allocated to receive passive insulation
(n = 21)
Lost to follow-up (n = 0)
Analyzed (n = 21)
anesthesia & analgesia

Figure 2. Bonding a neonate on the chest of the mother in the active
warming group by using a forced-air cover (Level 1 Snuggle Warm
Upper Body Blanket, Smiths Medicals, Rockland, MA).
covered with a cotton cap) on the chest of the mother under
the cotton blanked in the passive insulation group or under
the forced-air cover in the actively warmed group (Fig.2),
respectively. The babies remained carefully covered in this
position for a 20-minute period of bonding observed by
the midwife and the anesthesiologist. If babies showed any
vital disturbances such as asphyxia, bradycardia, bradyp-
nea, or rectal temperature below 35.0C, the bonding was
stopped immediately, and the babies were actively warmed
by the midwife or pediatrician.
After the 20-minute bonding period, babies were sepa-
rated from the mother and placed on the newborn table for
approximately 2 minutes to measure skin temperatures.
Active warming of the mothers was stopped. The babies
were clothed and positioned again on the chest of the
mother. Mother and baby left the operating room directly
after the end of the surgical procedure.
Directly after birth, a rectal temperature probe was
inserted into the newborn and connected to a moni-
tor (IntelliVue MP50; Philips, Boeblingen, Germany) for
continuous core temperature assessment. In addition,
skin temperatures were measured (Infrared Temperature
Scanner, Model Dermatemp DT-1001, Exergen Corporation,
Watertown, MA) 5 minutes after birth and at the end of the
20-minute bonding period at chest, arm, thigh, and calf.
Mean skin temperature was calculated from these measure-
ments.13 Length and weight of the newborn were assessed
by the midwives after the end of the bonding period.
Peripheral oxygen saturation, heart rate, and mean arte-
rial blood pressure (IntelliVue MP50; Philips, Boeblingen,
Germany) of the mothers were recorded and compared at
start of the cesarean delivery and the beginning and the end
of the 20-minute bonding period.
Maternal core temperature was assessed by placing a
sublingual temperature probe (Temp-Plus II, Model 2080,
Alaris; Carefusion, San Diego, CA) into the posterior
sublingual pocket by lifting the tongue. After each mea-
surement, the probe was removed. Maternal skin tempera-
ture (Infrared Temperature Scanner, Model Dermatemp
DT-1001, Exergen Corporation, Watertown, MA) was
May 2014 Volume 118 Number 5 www.anesthesia-analgesia.org 999
assessed simultaneously on the chest at the start of surgery,
start of bonding, and after 20 minutes of bonding.
Shivering of the mother was graded by the investiga-
tor at start of the cesarean delivery and the beginning and
the end of the 20-minute bonding period by using a 4-point
scale (0=no shivering; 1=intermittent, low-intensity shiv-
ering; 2=moderate shivering; 3=continuous, intense shiv-
ering). Thermal comfort of the mother was evaluated with
a 100-mm visual analog scale with 3 anchored definitions:
50 mm was defined as worst imaginable cold, 0 mm as
thermally neutral, and +50 mm as insufferably hot.
In accordance with current guidelines and other studies,
hypothermia was defined as a maternal core temperature of
< 36C and a neonatal core temperature <36.5C.25
Sample size calculation for the study was performed
by using MedCalc for Windows 12.5 (MedCalc Software,
Ostend, Belgium) and based on an expected treatment effect
of 0.5C (SD 0.75 in both groups) on babies core temperatures
at the end of the bonding period. A sample size of 40 subjects,
including 10% (n = 4) dropouts, was estimated to provide
80% power for detecting a statistically significant difference
between study groups at an level of 0.05. Assumptions
were based on a previous study from our group.14
Statistical analyses were performed by using statis-
tics software GraphPad Prism 5.0 (GraphPad Software,
San Diego, CA) and R 2.11.0 (R Foundation for Statistical
Computing, Vienna, Austria). Peripheral oxygen satura-
tion, mean arterial blood pressure, and heart rate were first
averaged over time for each mother. These values were
subsequently averaged among the mothers in each group.
Continuous, normally distributed variables were analyzed
by using 1-way analysis of variance and Scheffs F test.
Differences between the groups were compared with 2 tests
and with paired and unpaired Student t test. We followed
the method of Diehr etal.15 to increase statistical power by
performing an unmatched analysis of the matched data
with changes over time.,16 Data are expressed as mean (SD)
or median (interquartile range), respectively. P < 0.05 was
considered significant.
RESULTS
All 40 subjects completed the study protocol without any
dropouts; 21 parturients were randomized to the treat-
ment (active warming) group, and 19 parturients were
randomized to the control (passive insulation) group.
Morphometric maternal characteristics and room temper-
ature were not different between groups (Table 1). Spinal
anesthesia was successfully performed in all parturients.
All newborns were stable at 5 minutes and could be placed
on the mothers chest. Active warming was well tolerated;
mothers generally reported a comfortable warm feeling.
Peripheral oxygen saturation, heart rate, and mean arterial
blood pressures did not differ between groups during the
observation period (data not shown).
At the start of the cesarean delivery, maternal core and
skin temperatures and the thermal comfort were not dif-
ferent between groups (Table 2). Maternal core tempera-
ture was not different between groups at the start of the
20-minute bonding period, nor did it differ from baseline
temperature. In the passively insulated group, maternal
skin temperatures at the beginning and the end of bonding
Hypothermia in Newborns Bonding after Cesarean Delivery

Table 1.Maternal, Neonatal, and Environment Characteristics

Group, no warming, (n = 21) Group, warming, (n = 19)
Age (y)a 31 (6) 31 (5)
Maternal weight (kg)a 90 (22) 90 (16)
Maternal height (cm)a 165 (7) 166 (7)
Maternal body mass index (kg/m2)a 33.2 (7.6) 32.7 (6.2)
Extension of the spinal block (level)b T 4 (T4-T5 [T4-T5]) T 4 (T4-T5 [T3-T5])
Neonatal gestational age (weeks)a 38 (1) 38 (2)
Neonatal weight (g)a 3319 (291) 3533 (448)
Neonatal length (cm)a 51.4 (1.8) 52.1 (2.3)
Ambient temperature during surgery (C)a 23.0 (0.8) 22.9 (0.7)
a
Data are presented as mean (SD).
b
Data are presented as median (IQR [range]). Room temperature was measured by electronic thermometry.

Table 2. Maternal Temperature Assessments and Thermal Comfort

Group, no warming, (n = 21) Group, active warming, (n = 19) P
Core temperature at start of surgery (C) 36.7 (0.5) 36.4 (0.5)
Core temperature at start of bonding (C) 36.5 (0.5) 36.4 (0.4)
Core temperature after 20-minute bonding (C) 36.0 (0.5)a 36.4 (0.4)b a
<0.0001
b
0.0007
Skin temperature at start of surgery (C) 33.8 (1.6) 34.0 (1.4)
Skin temperature at start of bonding (C) 33.3 (1.7) 35.1 (0.8)ab 0.001
a

0.0001
b

Skin temperature after 20-minute bonding (C) 32.9 (1.8) 35.3 (0.7)ab a
0.0008
b
<0.0001
Thermal comfort at start of surgery (mm) 4 (8) 0 (9)
Thermal comfort at start of bonding (mm) 6 (9) 2 (12)b b
0.014
Thermal comfort after 20 min bonding (mm) 9 (10)c 7 (10)cb b
<0.0001
cnw
0.009
caw
0.022
Thermal comfort was evaluated with a 100-mm visual analog scale: 50 mm was defined as worst imaginable cold, 0 mm as thermally neutral, and +50
mm as insufferably hot visual at the start of the cesarean delivery and at the beginning and the end of the 20-minute bonding period. Data are presented as
mean (SD).
a
Versus temperature at start of surgery.
b
Versus no warming.
cnw
Versus value at start of surgery, group no warming.
caw
Versus value at start of surgery, group active warming.

were not different from baseline skin temperature. In con-
trast, in actively warmed parturients, skin temperature
throughout bonding was significantly higher compared
with baseline skin temperature and to the passively insu-
lated mothers.
At the end of the bonding period, maternal core and skin
temperatures and thermal comfort were significantly higher
in actively warmed mothers compared with mothers with-
out active warming. Ten of the 21 passively insulated moth-
ers became hypothermic at the end of the bonding period
(48%); however, only 1 of 19 parturients in the active warm-
ing group reached hypothermia level (5%) (P=0.0007).
Length and weight of the newborns and the gestational
age did not differ between groups. Immediately after birth,
rectal temperature of the newborns was near 37.5C in
all neonates (Fig. 3). No differences in rectal temperature
between groups were detected immediately after birth,
after 1 and 5 minutes, and at the beginning of the bond-
ing period. Soon after the start of the bonding period, core
temperature decreased in both groups; the core temperature
of babies in the passive warming group was significantly
lower than babies with active warming at 5, 10, 15 and
20 minutes of bonding (Fig. 3). At the end of the bonding
period, mean (SD) rectal temperature of passively insulated
babies was 35.9 (0.6)C vs 37.0 (0.2)C in actively warmed
babies (P < 0.0001). Hypothermia was present in 17 of 21
(81%) of the passively warmed and in 1 of 19 (5%) of the
actively warmed babies (P < 0.0001).
Mean skin temperature of the infants was not different
5 minutes after birth. However, at the end of the bonding
period, it was significantly higher 35.2 (0.5)C in actively
warmed versus passively insulated infants (33.3 (1.3)C)
(Fig.4).
Intermittent low-intensity shivering (grade 1) was pres-
ent in 5 of 21 (24%) of the passively insulated and in none of
the actively warmed parturients (P < 0.0001).
Both paired and unpaired analysis15,16 of the neonatal
core temperatures from baseline to the end of the 20-minute
bonding period were P < 0.0001.
DISCUSSION
The main finding of our study was that 81% of the new-
borns became hypothermic if they received standard pas-
sive warming during skin-to-skin bonding on the mothers
chest during cesarean delivery. Active cutaneous warming
of the mothers, starting immediately after the establish-
ment of the spinal block and continued during the bonding
period, prevented hypothermia in 95% of the newborns. In
addition, active warming increased mean skin temperature
of the infants and their mothers core and skin tempera-
tures. Thermal comfort was higher, and perioperative shiv-
ering was reduced in actively warmed mothers.

1000
www.anesthesia-analgesia.org anesthesia & analgesia
 A 38 higher skin temperatures before skin-to-skin contact miti-
* * * * gated infant heat loss. We hypothesize that both factors may
37.5
play a role, but these mechanisms must be investigated in
37 further studies.
T rectal (C)

36.5
In fact, neonates are at high risk for hypothermia,17
especially if they are premature, have low birth weight or
36 = no warming a low Apgar score, or are delivered by cesarean delivery.8
35.5 = active warming

Spontaneous labor, prolonged rupture of membranes, and

antenatal steroid administration have been associated with
birth 1 min 5 min 0 5 10 15 20 decreased risk of hypothermia.8
bonding After vaginal delivery, it is a common practice to place
Time (min) the newborn skin to skin on the mothers chest. This bond-
B ing position of the newborn for the first 30 minutes of life is
favored by most midwives to provide close interaction between
Time (min) P values
bonding mother and her child.11 Disruptions in maternalinfant bond-
ing are correlated with pediatric bronchial asthma and were
No warming Active warming Active vs.
found to be related to physical separation at birth.18 Mothers
(versus versus No warming
who received extra contact exhibited significantly more affec-
temperature at temperature at
tionate behavior toward their infants than did the mothers
birth) birth
who received routine care.19 As a result, midwives and moth-
0 0.0001 0.022 0.06
ers encourage bonding procedures not only after deliveries
5 <0.0001 <0.0001 <0.0001 outside operating rooms but also during cesarean delivery in
10 <0.0001 <0.0001 <0.0001 awake mothers under spinal or epidural anesthesia.
To our knowledge, no randomized trial has investigated
15 <0.0001 <0.0001 <0.0001
the consequences of (mild) hypothermia in mature, healthy
20 <0.0001 <0.0001 <0.0001 neonates. Although negative effects (i.e., acidosis, hypox-
emia) seem likely in this population, effects on morbidity
Figure 3. A, Neonatal rectal temperatures (C) at birth and during
and mortality remain speculative. Nevertheless, prevention
the 20-minute bonding period. Data are presented as mean (SD); *P
vs no warming; P vs temperature at birth. B, Detailed P values for of hypothermia is considered one of the most essential ele-
active warming versus no warming during bonding period and versus ments of neonatal care. Forced-air warming systems with
temperature at birth. a ring-shaped cover as well as warming mattresses, plas-
tic wraps, bags, or caps have been found to be efficient for
36.5
36
maintaining body temperature.5,20
35.5 Mothers are also at risk of developing hypothermia dur-
T mean skin (C)

35 ing the procedure even when spinal21 or epidural anesthe-

34.5
34
33.5
33
= no warming
32.5 = active warming
32
5 min
after birth
Figure 4. Neonatal mean skin temperature (C) 5 minutes after birth
and after the 20-minute bonding period. Mean skin temperature was
an average of skin temperatures of the chest, arm, thigh, and calf.13
Data are presented as mean (SD); *P < 0.0001 vs no warming;
P < 0.0001 vs temperature 5 minutes after birth.
To our knowledge, this is the first clinical study demon-
strating the rapid decrease of core temperature in newborns
during bonding on the mothers chest without any active
warming. Without active cutaneous warming, mean mater-
nal skin temperature was 2.4C lower, and mean neonatal
temperature approximately was 2C lower than with active
cutaneous warming. However, active warming as per-
formed did not prevent a decrease of core temperature dur-
ing bonding from 37.5 (0.2)C to 37.0 (0.2)C. Nevertheless,
only one of 19 newborns became hypothermic, defined as a
core temperature lower than 36.5C.
Given our study design, we cannot clearly differenti-
ate whether the forced-air warming blanket applied dur-
ing bonding or prewarming of maternal skin resulting in
sia14 is performed. Intraoperative lower body forced-air
*
warming alone does not prevent intraoperative hypother-
mia or shivering in women undergoing elective cesarean
delivery with spinal anesthesia.21
Our study may be criticized because the temperature of
20 min the warm air was set to 44C during the warming period
bonding that may have caused hyperthermia in the newborns.
Lower temperatures, other neonatal warming devices, or
warming either mother or newborn were not investigated
but could be studied as topics of future research. However,
our data showed that even this air temperature was not able
to prevent a decrease in core temperature during bonding.
Further, we measured rectal temperatures in the newborns
and sublingual temperatures in the mothers that might dif-
fer from core temperatures. However, rectal temperature is
close to core temperature, and the recommended method
of temperature assessment in infants aged <2 years.22,23 In
adult patients, sublingual temperature has been demon-
strated to provide a high correlation with tympanic mem-
brane temperature24 that reflects the temperature of the core
thermal compartment.25
In our study, we planned a 20-minute bonding period
for practical reasons because this is the average time period
required to finish a cesarean delivery operation after clamp-
ing the umbilical cord. Longer bonding periods would not
have been appropriate because at the end of surgery the

May 2014 Volume 118 Number 5 www.anesthesia-analgesia.org 1001

Hypothermia in Newborns Bonding after Cesarean Delivery
motherinfant dyad is typically moved from the operating
room to a recovery area. To our knowledge, there are no
studies demonstrating any effect of shorter or longer bond-
ing periods than 20 minutes.
Finally, we investigated healthy and stable newborns.
Therefore, we cannot comment on the effects of forced-air
skin-surface warming in preterm infants or very low birth
weight or neonates with other conditions.
In summary, most newborns became hypothermic during a
20-minute bonding period on the mothers chest during cesar-
ean delivery in the operating room although they were covered
with warm blankets. Hypothermia was prevented by active
warming of the mothers and the babies with 44C forced-air
warming during the skin-to-skin bonding period. E
DISCLOSURES
Name: Jan Hcker, MD.
Contribution: This author helped design the study, analyze the
data, and write the manuscript.
Attestation: Jan Hcker has seen the original study data,
reviewed the analysis of the data, approved the final manuscript,
and is the author responsible for archiving the study files.
Name: Berthold Bein, MD.
Contribution: This author helped design the study.
Attestation: Berthold Bein has seen the original study data,
reviewed the analysis of the data, and approved the final
manuscript.
Name: Ernst-Peter Horn, MD.
Contribution: This author helped design the study, analyze the
data, and write the manuscript.
Attestation: Ernst-Peter Horn has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Kerstin Ramaker, MD.
Contribution: This author helped conduct the study.
Attestation: Kerstin Ramaker has seen the original study data,
reviewed the analysis of the data, and approved the final
manuscript.
Name: Markus Steinfath, MD.
Contribution: This author helped design the study.
Attestation: Markus Steinfath has seen the original study data
and approved the final manuscript.
Name: Birgit Buchloh.
Contribution: This author helped conduct the study.
Attestation: Birgit Buchloh has seen the original study data and
approved the final manuscript.
This manuscript was handled by: Cynthia A. Wong, MD.
ACKNOWLEDGMENTS
We would like to thank Rita Kipf, R.N. and Ingeborg Meyer,
R.N. for their assistance with the study.
REFERENCES
1. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global bur-
den of neonatal hypothermia: systematic review of a major
challenge for newborn survival. BMCMed 2013;11:24
2. Christensson K, Siles C, Cabrera T, Belaustequi A, de la Fuente
P, Lagercrantz H, Puyol P, Winberg J. Lower body tempera-
tures in infants delivered by caesarean section than in vaginally
delivered infants. Acta Paediatr 1993;82:12831
3. Clinical-Practice-Guideline. The management of inadver-
tent perioperative hypothermia in adults. The National
Collaborating Centre for Nursing and Supportive Care commis-
sioned by National Institute for Health and Clinical Excellence
1002
www.anesthesia-analgesia.org
(NICE): April 2008. Available at: http://guidance.nice.org.uk/
CG65 Accessed 14062013
4. Belsches TC, Tilly AE, Miller TR, Kambeyanda RH, Leadford A,
Manasyan A, Chomba E, Ramani M, Ambalavanan N, Carlo WA.
Randomized trial of plastic bags to prevent term neonatal hypo-
thermia in a resource-poor setting. Pediatrics 2013;132:e65661
5. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S.
Interventions to prevent hypothermia at birth in preterm
and/or low birthweight infants. Cochrane Database Syst Rev
2010:1:CD004210
6. Leadford AE, Warren JB, Manasyan A, Chomba E, Salas AA,
Schelonka R, Carlo WA. Plastic bags for prevention of hypo-
thermia in preterm and low birth weight infants. Pediatrics
2013;132:e12834
7. Rong Z, Liu H, Xia S, Chang L. Risk and protective factors
of intraventricular hemorrhage in preterm babies in Wuhan,
China. Childs Nerv Syst 2012;28:207784
8. Miller SS, Lee HC, Gould JB. Hypothermia in very low birth
weight infants: distribution, risk factors and outcomes.
JPerinatol 2011;31 Suppl 1:S4956
9. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and effi-
cacy of Trans-warmer mattress for preterm neonates: results of
a randomized controlled trial. JPerinatol 2011;31:7804
10. Kennell J, McGrath S. Starting the process of mother-infant
bonding. Acta Paediatr 2005;94:7757
11. Dunn DM, White DG. Interactions of mothers with their new-
borns in the first half-hour of life. JAdv Nurs 1981;6:2715
12. Bauer K, Uhrig C, Sperling P, Pasel K, Wieland C, Versmold
HT. Body temperatures and oxygen consumption during skin-
to-skin (kangaroo) care in stable preterm infants weighing less
than 1500 grams. JPediatr 1997;130:2404
13. Ramanathan NL. A new weighting system for mean surface
temperature of the human body. JAppl Physiol 1964;19:5313
14. Horn EP, Schroeder F, Gottschalk A, Sessler DI, Hiltmeyer N,
Standl T, Schulte am Esch J. Active warming during cesarean
delivery. Anesth Analg 2002;94:40914
15. Diehr P, Martin DC, Koepsell T, Cheadle A. Breaking the
matches in a paired t-test for community interventions when
the number of pairs is small. Stat Med 1995;14:1491504
16. Proschan MA. On the distribution of the unpaired t-statistic
with paired data. Stat Med 1996;15:105963
17. Macario A, Dexter F. What are the most important risk factors
for a patients developing intraoperative hypothermia? Anesth
Analg 2002;94:21520
18. Madrid A. Helping children with asthma by repairing mater-
nal-infant bonding problems. AmJ Clin Hypn 2005;48:199211
19. Anisfeld E, Lipper E. Early contact, social support, and mother-
infant bonding. Pediatrics 1983;72:7983
20. Asaga T, Komatsu H, Chujo K, Ueki M, Yokono S, Ogli K.
[Efficacy of ring-shape cover in active skin surface warming in
neonatesa retrospective comparative study with conventional
methods]. Masui 1997;46:13627
21. Butwick AJ, Lipman SS, Carvalho B. Intraoperative forced
air-warming during cesarean delivery under spinal anesthe-
sia does not prevent maternal hypothermia. Anesth Analg
2007;105:14139
22. Batra P, Saha A, Faridi MM. Thermometry in children. JEmerg
Trauma Shock 2012;5:2469
23. Robinson JL, Seal RF, Spady DW, Joffres MR. Comparison of
esophageal, rectal, axillary, bladder, tympanic, and pulmonary
artery temperatures in children. JPediatr 1998;133:5536
24. Hcker J, Bein B, Bhm R, Steinfath M, Scholz J, Horn EP.
Correlation, accuracy, precision and practicability of periop-
erative measurement of sublingual temperature in comparison
with tympanic membrane temperature in awake and anaesthe-
tised patients. EurJ Anaesthesiol 2012;29:704
25. Sessler DI. Temperature monitoring and perioperative thermo-
regulation. Anesthesiology 2008;109:31838
anesthesia & analgesia