juno midwives

Picture this…the first few minutes after the birth of your baby are full of emotion, when your baby is born and you reach out to pull them close to your body, skin-to-skin. This has the power to do something incredible to you, biologically, spiritually. You try to block out the rest of the world just for these few precious moments when suddenly you are interrupted by your midwife who has a long list of tasks to do, to you and your baby. The first being to put a coloured knitted hat onto your baby’s head! A lot of people might be wondering why this is even an issue – allow me to explain.

Not only will skin to skin regulate your baby’s temperature and heart rate but it will also increase the flow of oxytocin (the love hormone) in your body. As you look into your baby’s eyes, and draw her in closer, you will smell her head. This interaction is what it is all about. A hat on your baby’s head disrupts this flow of oxytocin. Oxytocin is needed to help stimulate contractions in your uterus to prevent excessive bleeding after birth, it’s needed to initiate breastfeeding, and it helps you and your baby build a secure bond. As you can see, interrupting skin to skin even to do something seemingly so innocuous, such as placing a hat onto your baby’s head, can have a huge impact on you both.

Perhaps more alarmingly, hats can cause a baby to overheat as they obstruct the baby’s natural ability to get rid of excess heat via their heads. Overheating can lead to sudden infant death (cot death) and you will find the NHS, Lullaby Trust and Tommy’s charity all advise against wearing hats indoors. And in fact, the East Kent website contradicts itself as directly beneath the explanation for the ‘bobble hat system’ is a paragraph on safe sleeping which includes the advice to remove hats when sleeping. Can you see how the ‘bobble hat system’ completely contradicts the evidence around newborn safety and care?

As a result, the use of a hat on newborns has become a divisive one. A number of hospital trusts in England have implemented newborn hat policies in the last 5 years, including East Kent. This trust has been under scrutiny for the poor outcomes of babies under their care, so it comes as no surprise that an influx of ‘action’ is in process. One such ‘action’ is to enforce the ‘bobble hat system’.

So what is the ‘bobble hat system’?

On the East Kent website a simplified explanation can be found:

“within one hour of birth, the bobble hat assessment tool and care plan will be completed and the correct hat will be put onto your baby. This lets staff know what level of care the baby will need”. 

The language used does not imply this is up for discussion as the statement demonstrates, “the correct hat will be put onto your baby”. Therefore, in order to achieve this instruction of “within an hour” your golden hour of skin to skin will be interrupted in order for the midwife to ascertain where your baby fits into the ‘bobble hat system’. In the trust guidelines, staff are also advised to immediately apply the hat after a birth in theatre, regardless of how you have given birth or the wellbeing of your baby.

What is the aim of the ‘bobble hat system’?

It is a task oriented coding system used to identify babies with additional medical needs where observations are clinically recommended. The idea of the colours is to assist staff to identify which babies are in greater need so they can be prioritised appropriately, using a traffic light system. Red hats for the most vulnerable, amber – a mixed bag, and green for a well baby. What counts as red, amber and green is a whole other blog post! Why a well baby needs a hat at all should be questioned. My opinion is that it ‘aids’ staff understanding of the bobble hat traffic light system. Without green it wouldn’t work, right?

Flaws in the system

The ‘bobble hat system’ completely fails to acknowledge the challenges midwives face in meeting the demands of their workload. The hats are no fail safe. Newborn observations are often delayed or missed because of these challenges. Because maternity wards across the NHS are short staffed and you may find you have one midwife to 10 mums and babies and they simply can’t get round to everyone that promptly. Or maybe because handovers are so impersonal, they’re often not by the bedside of the woman and her baby, so you’re not going to even see the colour of the hat. Or equally problematic, handovers are repeatedly interrupted so important aspects of someone’s care are missed.

In practice, the focus of this ‘bobble hat system’ is not on those in need of clinical input but it seems to be more on thermoregulation (keeping baby warm). There are many ways this can be facilitated at birth and in the immediate postpartum period. For instance, we can ensure the birth space is warm by occluding drafts, closing windows, turning AC off. We can warm up towels and remove cold wet towels. We can ensure the birth pool temperature is maintained so mother and baby can bask in the warm water that little bit longer. And ultimately we can support the mother and baby to be skin to skin for as long as they wish, including during ward transfers, in theatre and recovery, and on the postnatal ward, which for the majority of the time feels like you are slowly roasting behind a set of stark curtains in a cramped four bedded bay!

What next?

The policy appears to have been established for two reasons – patient safety and temperature control. The evidence tells us that hats have no benefit on newborn thermoregulation for a term baby born without any abnormalities. But what we don’t know is what impact this policy is having on care provision for your baby. I have put this question to the staff at East Kent and I eagerly await their response. Fundamentally the benefits of not wearing a hat are huge. So we need to be asking more questions to work out what are the risks or benefits of this ‘bobble hat system’ and what do they mean to you and your baby. Only with this information can you truly make an informed decision.

And whilst it is mainly a bunch of adorable nannies knitting these newborn hats, their time might be better spent knitting blankets for the homeless!