In 1991, the Baby-Friendly Hospital Initiative was launched by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), with the WHO (2018) stressing on the importance of “immediate and uninterrupted skin-to-skin contact and initiation of breastfeeding within the first hour after birth” (p.1). Breastfeeding has been associated with the child’s immunity against infection, an improved cognitive development, a lower probability of chronic illnesses later in life, and a reduction in mortality until 5 years of age (Victora et al., 2016).
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Skin-to-skin contact, also known as kangaroo care, occurs as the newborn is positioned prone directly against the mother’s belly or chest without any clothes or towels between them. Cohen et al. (2018) noted that while early skin-to-skin contact had increased the likelihood of breastfeeding initiation and continuation, breastfeeding was also more likely to happen following vaginal compared with cesarean deliveries. A survey conducted by the Centers for Disease Control and Prevention (CDC, 2015) revealed that only 78% of cesarean births in California established initial skin-to-skin contact for at least 30 minutes within 2 hours of delivery, while 94% of vaginal births implemented it within an hour of delivery. Boundy, Perrine, Barrera, Li, and Hamner (2018) also found that the rate of early skin-to-skin contact was lower after a cesarean birth compared to an uncomplicated vaginal birth. This may be attributed to medical conditions in the mother or the baby, the mother’s incapacity to perform skin-to-skin contact safely as a result of the medications received during the operation, and a disruption in the natural process of birth that results in a prolonged separation between mother and child.
There was a lower rate of cesarean deliveries from 32.0% in 2017 to 31.9% in 2018 here in the United States (Martin, Hamilton, Osterman, and Driscoll, 2019, p.6), but it is still much higher than the ideal rate of 10-15% proposed by the international healthcare community (WHO, 2015). While most studies focus on the effects of early skin-to-skin contact following a natural vaginal birth, this paper aims to explore its benefits after cesarean delivery.
During my clinical rotations in the nursery and labor and delivery departments of the Total Birth Care Center unit at Loma Linda University Children’s Hospital, I was able to observe how the newborns were managed right after delivery. As the baby is born vaginally, the naked child is placed prone on top of the mother’s abdomen while routine care is done. After the cord is clamped and separated from the placenta, the baby is usually transferred from the mother’s abdomen to her chest. When I asked the nurses about this, I was told that immediate skin-to-skin can often be done after most vaginal deliveries because the mother and baby are usually stable; and having the baby in direct contact with the mother does not interfere with routine care. In addition to this, immediate skin-to-skin contact improved the likelihood of maternal and child bonding and helped establish breastfeeding earlier.
I asked if skin-to-skin contact is less effective after a cesarean delivery since it occurs much later than if the baby was born vaginally. The nurses told me that skin-to-skin contact is still effective if it happens within an hour after delivery. They also said that cesarean deliveries will most likely indicate some degree of maternal or fetal complication, so it’s even more important that skin-to-skin contact and early breastfeeding is established to help combat these problems.
While some of the nurses mentioned that this intervention was taught and encouraged early in school, one of them said that she learned this from undergoing education and training when the hospital implemented the Baby-Friendly Hospital Initiative. The hospital also holds conferences and creates policies that ensure better outcomes for the mother and the child. When I asked about alternative methods to skin-to-skin contact following delivery, one of them mentioned the baby having skin-to-skin contact with the father instead, but that she hasn’t experienced it herself.
I was told, however, that there are instances where skin-to-skin cannot be done immediately, such as when the baby, mother, or both are experiencing any medical complications that require more intensive care and management. They said that skin-to-skin contact should still be done as soon as both parties are stable. If the mother refuses, or if there are medical complications that are too severe (baby may be transferred to NICU), skin-to-skin contact may not be done at all.
Locating Policy in the Clinical Setting
Loma Linda University Children’s Hospital has an operating policy under clinical management entitled, “Breastfeeding/infant feeding.” The policy (code CH-M-135) is checked and revised accordingly every 2 years. Its most current update is in June of 2019, with its prior revision in October of 2017. It provides guidelines that promote exclusive breastfeeding as well as practices that support optimal maternity care and infant feeding. Among these practices is the inclusion of skin-to-skin contact that should be done immediately after birth, regardless of its mode of delivery. The newborn is placed naked against the mother’s naked ventral surface. There should be no clothing between the mother and the baby except for a diaper or a hat, if deemed necessary. Routine assessment procedures can be performed while the infant is skin to skin with the mother, while routine newborn procedures are not done until the first breastfeeding is completed. After a cesarean birth, mothers and their infants should be placed in continuous, uninterrupted skin-to-skin contact as soon as the mother is responsive and alert.
The policy takes its roots from UNICEF’s and WHO’s Baby-Friendly Hospital Initiative; Baby Friendly USA and their Ten Steps to Successful Breastfeeding; the American Academy of Pediatrics (AAP) with its policy on Breastfeeding and the Use of Human Milk, and; the Academy of Breastfeeding Medicine’s (ABM) Model Maternity Policy Supportive of Breastfeeding.
Studies regarding early skin-to-skin contact following cesarean delivery are scarce but are also beginning to pique interest among the health care community, partly as a result of the higher rate of cesarean deliveries compared to the last decades (Menacker and Hamilton, 2010).
Schneider, Crenshaw, and Gilder (2016) conducted a study on newborns who were provided with immediate skin-to-skin contact following cesarean delivery and their rate of transfer to the NICU thereafter. While the hospital had been designated as Baby-Friendly in 2009, immediate skin-to-skin contact in the operating room right after cesarean births only began implementation in 2013. Prior to this, skin-to-skin contact was performed after the operation had completed and when the mother had been moved to the recovery room. To determine the effect of immediate skin-to-skin contact after a cesarean birth to the rate of transfer of newborns to the NICU for observation, they collected data of all scheduled and nonemergent cesarean births between 37- and 42-weeks’ gestation between 2011 and 2015. They found that there was a lower rate of NICU transfers when the baby received immediate skin-to-skin contact during cesarean deliveries from 5.6% (January 2011 to December 2012) to 1.75% (January 2013 to December 2015). While skin-to-skin contact was practiced throughout the entire duration of the study, their findings suggest the beneficial effect of skin-to-skin contact done at an earlier time.
Guala et al. (2017) sought to determine the rate of exclusive breastfeeding at discharge and its continuity 6 months after when skin-to-skin contact between parent and child was done during a cesarean delivery compared to those who had not. The study included over 252 women who underwent a cesarean delivery at a Baby-Friendly hospital from January 2012 through December 2012. They were at least 37-weeks’ gestation, the newborn had an APGAR of >7 at the 5-minute mark, and the partners were included for when the mothers were unable to do skin-to-skin contact right away. Data was collected at the time of discharge, 3 months after, and 6 months after. They found that mothers who had done skin-to-skin contact with their babies after a cesarean delivery had a higher rate of establishing exclusive breastfeeding at the time of discharge compared to having skin-to-skin contact with the father or none at all. They also had a higher rate of continued breastfeeding at 3 and 6 months. While the rate of exclusive breastfeeding and continued breastfeeding was higher for paternal-newborn skin-to-skin contact than for babies who had not received it from either parent, it was not statistically significant enough for them to conclude the father’s influence in breastfeeding practices. They, did, however, still recommend that fathers be encouraged to provide skin-to-skin contact with their babies if the mother is unable to do it because of the opportunity to improve bonding.
Huang, Chen, and Zhang (2019) organized a study to determine the effects of skin-to-skin contact done between the father and the newborn. In 2015, the hospital started father-newborn skin-to-skin contact after cesarean delivery as an alternative when the mother is unable to perform it safely. The study collected data from newborns who were born between 37- and 42-weeks’ gestation by planned cesarean deliveries between February to June 2016 and from their respective fathers. They found that newborns had more stable heart rates, cried for a shorter amount of time, and were more likely to start crawling in search of the nipple when they had been subjected to earlier skin-to-skin contact with the father as opposed to just receiving routine care and having skin-to-skin contact with the mother much later. They also noted that the fathers who performed skin-to-skin contact with the newborn were less anxious and more likely to accept their paternal roles, resulting in more involvement with the care of the baby.
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Comparison of Research and Protocol
While all of the research and Loma Linda University Children’s Hospital’s protocol promote skin-to-skin contact regardless of the mode of delivery, the hospital policy does not go into detail as to when skin-to-skin contact should be started after cesarean delivery or for how long it should be maintained uninterrupted to ensure its benefits on the mother and infant. There is also no mention of paternal skin-to-skin contact.
During my time at the Total Birth Care Center Unit, all the nurses I observed were able to carry out skin-to-skin contact between the mother and the baby immediately after a vaginal delivery and within 30 minutes after a cesarean delivery.
After a cesarean birth, the baby was first received by the pediatrician and then examined under an infant radiant warmer. Once the baby was assessed and considered stable, the baby was snugly wrapped in a blanket with its head kept warm with a cap, and then handed over to the nursery nurse. While the operation was continuing, the nurse brought the baby over to the mother’s side, kept the cap in place, unwrapped the blanket, and gently positioned the baby perpendicular to the mother’s spine, prone and skin-to-skin over her chest. The baby’s head was tilted sideways with the mouth and nose visible to ensure adequate ventilation. Finally, a warm blanket was placed across the baby’s back. The mother held the baby with one arm over the blanket while the nurse observed them and ensured their safety. Once the operation was completed, at least 30 minutes of undisturbed skin-to-skin contact had already passed. The baby was then temporarily separated from the mother so that both could be safely transported to the recovery room. If breastfeeding had been established while she was still in the OR, routine newborn procedures (measurement of length, weight, and head circumference; giving eye ointment, vitamin K, and hepatitis B vaccine) were done before skin-to-skin contact was reestablished. The mother was educated on the benefits of skin-to-skin contact, including thermoregulation, bonding, and early initiation of breastfeeding.
Plan for Improvement
New research regarding skin-to-skin contact immediately after a cesarean delivery should be explored and incorporated more thoroughly into the hospital’s policy to motivate nurses to educate and encourage women to perform this intervention in the operating room. Aspects that can be focused on include the recommended onset or initiation of skin-to-skin contact following delivery (vaginal and cesarean), frequency, and duration of uninterrupted contact. Maternal complications and contraindications could also be explained in more detail to improve clinical judgment with the implementation of this intervention.
Barriers that hinder this practice like the risk of compromising the sterile field, the possibility of the baby falling while skin-to-skin contact is being done in an ongoing operation, the lack of adequate space at the front of the operating table, and the parent’s lack of awareness can all be minimized or prevented if proper measures are taken. The policy could be updated to include a step-by-step outline for how skin-to-skin should be established correctly and safely at the operating room. Having the father perform skin-to-skin contact with the baby if it is not safe for the mother to do it herself should also be an alternative method the hospital can take into consideration.
There was a point where I saw skin-to-skin contact as an intervention that has been studied too many times and is already so well-established since the last few decades that there’d be no reason to investigate it further. Health and medicine change and evolve every day, and even though I hear that all the time, it is so easy to forget. I realized that it’s always important to keep an open mind and have that strong desire to improve health care for everyone. Now knowing the high rate of cesarean deliveries, I see the need to increase focus on skin-to-skin contact in the operating room with an emphasis on its advocation and safe practice. I also understood that the birth of a child does not only include the care of the newborn, but the mother and the father as well. Getting the partner to accept and transition into fatherhood this early through paternal-newborn skin-to-skin contact was something that had never crossed my mind. This involvement might help the mother by allowing her to see the father’s participation as the unit that, together with her, makes the family whole and complete.
Because vaginal births occur more frequently than cesarean births, there are not enough studies that focus on skin-to-skin contact after a cesarean delivery. Regardless, current studies that are available indicate that skin-to-skin contact that is established early has shown benefits for the newborn, the mother, and the father after a vaginal or cesarean birth.
Allowing skin-to-skin contact between parent and child at the operating room as soon as possible aids the baby in transitioning from intrauterine to extrauterine life. Exclusive breastfeeding with its continuity is also more likely to occur. Although further studies may be needed to make a more substantial conclusion with the baby benefitting from skin-to-skin contact with the father, it should still be promoted as an option when the mother cannot do it herself because of the psychologic benefits it can provide the rest of the family.
With the advent of the Baby-Friendly Hospital Initiative that highlights, among others, the need to establish immediate skin-to-skin contact, the same intervention should be enforced and safely practiced in all clinical settings, including the operating room after a cesarean birth.
- Boundy, E., Perrine, C., Barrera, C., Li, R., and Hamner, H. (2018). Trends in maternity care practice skin-to-skin contact indicators: United States, 2007-2015. https://doi.org/10.1089/bfm.2018.0035
- Centers for Disease Control and Prevention. (2016). California 2015 report, CDC survey of maternity practices in infant nutrition and care (mPINC). Retrieved from https://www.cdc.gov/breastfeeding/data/mpinc/state_reports.html
- Cohen, S., Alexander, D., Krebs, N., Young, B., Cabana, M., Erdmann, P., Hays, N., Bezold, C., Levin-Sparenberg, E., Turini, M., and Saavedra, J. (2018). Factors associated with breastfeeding initiation and continuation: a meta-analysis. The journal of pediatrics, 203, 190-196. e.21. https://doi.org/10.1016/j.jpeds.2018.08.008
- Geneva: World Health Organization. (2018). Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised baby-friendly hospital initiative. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807-eng.pdf?ua=1
- Guala, A., Boscardini, L., Visentin, R., Angellotti, P., Grugni, L., Barbaglia, M., Chapin, E., Castelli, E., and Finale, E. (2017). Skin-to-skin contact in cesarean birth and duration of breastfeeding: a cohort study. The scientific world journal, 2017, 1940756. https://doi.org/10.1155/2017/1940756
- Huang, X., Chen, L., and Zhang, L. (2019). Effects of paternal skin-to-skin contact in newborns and fathers after cesarean delivery. The journal of perinatal and neonatal nursing, 33 (1), 68-73. https://doi.org/10.1097/jpn.0000000000000384
- Martin, J., Hamilton, B., Osterman, M., and Driscoll, A. (2019). Births: final data for 2018 National vital statistics reports, 68 (13), 6-7. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf
- Menacker, F. and Hamilton, B. (2010) Recent trends in cesarean delivery in the United States. National center for health statistics data brief, 35. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db35.pdf
- Schneider, L., Crenshaw, J., and Gilder, R. (2016). Influence of immediate skin-to-skin contact during cesarean surgery on rate of transfer of newborns to NICU for observation. Nursing for women’s health, 21 (1), 28-33. https://dx.doi.org/10.1016/j.nwh.2016.12.008
- Victora, C., Bahl, R., Barros, A., Franca, G., Horton, S., Krasevec, J., Murch, S., Sankar, M., Walker, N., and Rollins, N. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. https://doi.org/10.1016/S0140-6736(15)01024-7
- World Health Organization. (2015). WHO statement on cesarean section rates. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1
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