A dedicated nurse for skin-to-skin care after cesarean birth

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Skin-to-skin contact occurs when infants lie prone on a mother’s chest with no clothing or blankets separating the mother from her infant. Placing newborn infants in skin-to-skin contact with their mothers following a vaginal birth is standard practice in most US birthing facilities. The benefits of skin-to-skin care for a mother and her infant immediately after birth are well established. For example, immediate skin-to-skin contact encourages early breastfeeding initiation, which is associated with longer duration of breastfeeding, both exclusive and partial.

The World Health Organization recommends at least 60 minutes of skin-toskin contact immediately following birth; however, due to safety and staffing concerns, as well as the busy OR environment, infants born by cesarean section in the US—32% of births—may not have this experience. In addition to the OR staff’s responsibility for monitoring the safety of these infants, providing skin-to-skin care may not be possible. For example, risks of a negative impact from anesthesia in the OR and post anesthesia care unit (PACU), as well as the infant’s potential destabilization, require staff to spend time carefully monitoring both mother and infant.

Although skin-to-skin contact can reduce the infant’s risk of respiratory distress,temperature dysregulation, and hypoglycemia, OR and PACU nurses may not have the time required to comfortably maintain the infant on the mother’s chest and explain the benefits of the procedure. Additional barriers to clinical nurses providing skin-to-skin care are related to logistical and spatial concerns in the OR. The standard position of the surgical drape must be altered and space made available on the mother’s chest to place the baby.

Although providing skin-to-skin care in the OR and PACU is the standard of care at our facility, competing responsibilities, along with the requirements of the cesarean procedure, often prevent nurses from accomplishing this task. Dedicating one nurse to provide skin-to-skin care during surgery and recovery can enable more mother-infant dyads to have this experience. The purpose of this study was to examine the effect of a designated newborn nursery nurse providing skin-to-skin care in the OR and PACU for mother infant dyads after cesarean birth to support the infant’s transition to extrauterine life and breastfeeding when desired. Outcome measures included breastfeeding initiation in the first hour of life and exclusive breastfeeding throughout the hospital stay, maternal satisfaction, and the intervention’s cost.

Method and design

This Institutional Review Board approved study was conducted at a 393-bed, Magnet®-recognized community hospital in the southeastern US. Four thousand births occur annually in this facility. The cesarean birth rate is 29.9% (n = 1,196). Given that designated skin-to-skin nurses were only available on the day shift, all women admitted to labor and delivery preparing to undergo a cesarean section during the day were offered skin-to-skin care.

Mothers who wanted skin-to-skin care were asked approximately 1 hour before their cesarean birth if they wished to participate in this study. Designated skin-to-skin care nurses described the study to potential participants and gained consent. Forty-four mother-infant dyads participated. Skin-to-skin care was facilitated by six experienced (5 to 25 years) mother-baby clinical nurses who presently work on the unit.

They were trained in infants’ transition to extrauterine life, newborn physical assessment, and skills related to the safety of mother and infant. Their only responsibility in the OR and PACU was to provide skin-to-skin care. Immediately after birth, infants were dried and outfitted with a diaper and hat, then placed belly-down directly on the mother’s chest and covered with a warmed blanket.

Mothers and infants remained together in this manner without interruption unless the infant had clinical needs that required separation (n = 5), the mother requested that the infant be taken from her chest after 10 to 15 minutes (n = 2), or the mother had clinical needs that required separation (n = 5). On transfer to the mother-baby unit, dyads transitioned to standard postpartum care. The following day, one of the six designated nurses, other than the nurse who attended the birth, conducted a short bedside interview to evaluate maternal satisfaction with the experience.

The interview consisted of four yes-or-no questions, with each question followed by “why or why not?” These questions included: “Did you like the feeling of skin-to-skin contact with your new baby?” “Did you like having a nurse dedicated to help you and your baby perform skinto-skin care?” “Would you want skin-to-skin contact if you were going to have another child?” and “Would you tell your family and friends who are having babies to ask for skin-to-skin care following cesarean section?” In addition, the feeding record for each infant was monitored throughout the hospital stay for breastfeeding exclusivity.

Discussion: Assigning a designated skin-toskin care nurse trained in infants’ transition to extrauterine life and breastfeeding support to mothers giving birth by cesarean section resulted in positive outcomes related to breastfeeding and maternal satisfaction. Initiating breastfeeding in the first hour of life is an important step to long-term breastfeeding success. By having a nurse skilled in breastfeeding initiation and management, women were able to breastfeed their infants while still in the OR.

One mother stated, “Breastfeeding has gone much better than it did with my others and I feel like the skin to skin right after birth has to do with that.” Maternal satisfaction with the skin-to-skin experience provided by the designated nurses was strong. Most participants (70%, n = 31) indicated that the immediate and sustained skin-to-skin time with their infant promoted bonding.

For example, one mother stated that it was “awesome to have her the infant come to me immediately, which helped calm me down from being in the OR.” Another mother felt that the skinto-skin experience alleviated anxiety, “It was great, calming my nerves way down and helping me focus on her the infant right away.” Compared with mothers who are separated from their infants after birth, those who experience skin-to-skin bonding with their newborns are less likely to require anxiolytic medication after birth. Mothers also reported that the skin-to-skin bonding helped birth feel more natural despite surgery.

As one mother described, “It’s a good way to bond. With a c-section you feel like you miss out on a natural delivery and this compensates for that.” This is congruent with a movement in birth practice promoting “gentle” or “natural” cesarean birth. Although there aren’t standardized criteria for gentle cesarean birth, skin-to-skin contact immediately after birth and through the recovery period is included in the gentle cesarean protocol.

In the study of a rollout of gentle cesarean practice in a single facility, families reported that they felt they were experiencing a birth rather than a surgical procedure.8 Giving birth is one of the most significant life events a family will experience. Providing a designated skin-to-skin nurse eliminates early mother-infant separation and allows the family unit to remain together. As one mother described the experience, “You can never get that time back.”

Nursing management implications

This study was conducted in a midsize community hospital that serves a primarily middle-class population. Future research could focus on multiple settings serving different populations. However, based on our outcomes, hospital administrators may wish to consider designating nurses to perform skin-to-skin care to support breastfeeding and increase mothers’ satisfaction with the cesarean section experience.


Author : Kim Kjelland,  Martha Monroe,  Tyra Moore,  Hyewon Cooper


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