Skin-to-Skin Contact After Cesarean Births
While more hospitals have implemented skin-to-skin care after vaginal births, very few have extended this practice to the operating room (OR) after cesarean births. Yet, stable mothers and babies deserve to experience the same short- and long-term benefits of early skin-to-skin contact after cesarean births, as do those who have vaginal births. Indeed, mothers who have had a cesarean delivery often mourn the loss of a normal vaginal birth they had hoped for and are especially disappointed by not having their baby with them immediately after birth.
One mother whose baby was brought to her in the OR immediately after birth recently stated, "Having my baby skin to skin in the OR after my cesarean birth was the most meaningful experience ever. I couldn't have the vaginal birth I wanted, but at least I got to hold my baby skin to skin right after birth, which is what I had hoped for."
Another mother and father, whose twins were delivered by cesarean birth at 37 weeks gestation, watched in amazement as each boy went through the nine instinctive stages of behaviors at their own individual pace, when they were placed skin to skin on mother's chest in the OR. They were both breastfeeding within the first hour after birth, having each self-attached without assistance. These parents were delighted with how different this experience was from what occurred when their first son was born by cesarean delivery 3 years prior. Breastfeeding had been such a struggle after the customary 2–3 hour separation when their son had been taken to the nursery until after mother's recovery period.
Many other mothers have enthused at how easy breastfeeding was when their baby had an opportunity to go skin to skin immediately after cesarean birth in the OR compared to their struggles with breastfeeding after separation with their previous cesarean delivery. Breastfeeding is not impossible after early separation, but it is very often much harder. Many mothers are not prepared or are unwilling to persist in attempts to breastfeed after cesarean births with separation. This is reflected in lower breastfeeding rates after most cesarean deliveries.
Because skin to skin in the OR is such a new practice, in order for staff to be comfortable with the process, much preparation must be done prior to the first occurrence. Obstetricians, anesthesiologists and those responsible for newborn care must be educated about the evidence-based rationale for introducing skin-to-skin contact in the OR, including the many benefits for stable mothers and babies. They must also be assured that the safety and well-being of mothers and babies will always be the first priority. Knowing that they will have immediate veto power if any concerns arise goes a long way toward reducing anxiety about beginning the practice of placing babies skin to skin in the OR.
After the practice has begun, anesthesiologists are often amazed by how stable mothers are immediately after cesarean delivery when their babies are skin to skin. Because mothers are so focused on their new baby, their perception of pain is often diminished and their anxiety levels are significantly decreased, resulting in increased stability of heart rates and blood pressures. In addition, mothers and babies keep each other warm, resulting in increased temperature stability for both.
A few practical matters will make the practice go smoothly. First, the nurse who will receive the baby and do the initial drying and placing of baby on mother's chest should check with the obstetrician and anesthesiologist prior to the delivery to verify that there are no concerns for the baby or the mother's stability. Secondly, she should introduce herself to the mother and confirm that she would like to hold her baby skin to skin immediately after birth (if this has not already been done). It is helpful to ask the anesthesiologist if the mother's arm can be released from the arm board (if it has been secured) in order for her to touch her baby, and let the mother know she will need to straighten her arm every few minutes when a blood pressure must be taken. Be sure the mother's gown is unsnapped so it can be easily lowered to uncover her chest when placing the baby and be sure she is not wearing a bra. Take note of intravenous lines and poles so as to avoid them when placing the baby. Lastly, a diaper should be ready as well as warmed towels or blankets to dry and cover baby.
After the baby is delivered and the cord is clamped and cut, the receiving nurse will dry the baby, noting if he is vigorous and crying (assuring a 1-minute Apgar score of 8 or 9). After quickly drying the baby, if all is well, the nurse can diaper the baby and place the baby on the mother's chest in transverse position with the baby's head on one breast and the abdomen on the other breast, and then cover the baby with a warmed towel.
A diaper is not absolutely necessary but will avoid the possibility of meconium getting on the mother in the OR. It is much more difficult to clean up meconium in the OR than in the delivery room after a vaginal birth. An accepted practice is to diaper babies who go skin to skin in the OR, but forego the diaper after a vaginal delivery. A hat is not required to keep the baby warm when skin to skin and appears to be annoying to many babies, interfering with normal rooting. A hat can be placed when the baby is taken from the mother's chest for cares after breastfeeding. Many babies try to lift away from the hard plastic umbilical clamp if the cord is clamped short in the traditional fashion. This apparent discomfort can be easily avoided if the cord is cut and clamped 8–10 inches long, so that the clamp is not directly between baby and mother. The cord can be re-clamped and trimmed shorter at anytime after breastfeeding or at the time of the first bath.
Routine bulb suctioning should be avoided, as it is often a very negative oral experience for the baby. By far, the majority of babies are able to clear their own secretions with no trouble. If the baby is having difficulty clearing oral secretions, further evaluation is probably needed. Updated 2011 Newborn Resuscitation Program guidelines advise against routine bulb suctioning.
A nursing caregiver should visually monitor the baby while on the mother's chest until the surgery is complete, being sure the baby's head is positioned so the nares are always visible, the baby's color, perfusion and respirations remain stable, and baby doesn't slide off the mother's chest towards her neck. If this happens, the baby can be gently repositioned without being lifted off the mother's skin. If the baby advances to the crawling stage while in the OR and goes searching (or lurching) for the breast to suckle, the dad can gently grip the baby's leg or thigh to assure the baby stays on the mother's chest.
When the surgery is completed, the sterile drape has been removed and the mother is ready for transfer to the gurney for transport to the recovery room, the baby's legs can be slowly and gently moved to a vertical position so the baby's head is between the mother's breasts. The mother can cross her arms over her baby and the nurse who has been observing can place her hands on top of the mother's hands to be sure the baby is secure as the mother is turned from side to side to remove soiled linen and as she slides over to the gurney. This is a simple process and the baby need never leave the mother's chest during the transfer and en route to the recovery room, but will simply continue going through the nine instinctive stages towards the first breastfeeding.
If the baby is lifted from the mother's chest, he will become distressed and disoriented and when replaced skin to skin must start all over and advance through the stages again. The second time through will be somewhat quicker, but breastfeeding will be delayed. About 1.5–2 hours after birth, newborns fall into a deep sleep and if the nine instinctive behaviors have been interrupted several times, the baby may not be able to complete them to experience suckling until several hours later.
The good news is that when the baby awakens, if he is placed skin to skin, he will go through the stages again to find the breast and self-attach. This instinctive behavior will be present for about the first four months after birth and should be encouraged, especially in the first few days as the mother and the baby grow accustomed to breastfeeding. Babies quickly learn how to latch correctly and then will be able to consistently achieve an effective latch while clothed or wrapped in a blanket, but in the early postpartum period, being fully skin to skin (both the mother and the baby) will activate their instinctive feeding behaviors and help assure successful breastfeeding.
NAINR. 2013;13(2):67-72. © 2013 Elsevier Science, Inc.