August 8, 2012 by Rebecca Dekker, PhD, RN, APRN
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One of the visions that I have for EvidenceBasedBirth.com is that it be inclusive. I would like to promote evidence-based care for ALL women who give birth, regardless of the mode of birth, place of birth, or type of caregiver. This is my first evidence-based article on Cesarean birth.

What is skin-to-skin care?

Early skin-to-skin care (also called kangaroo care) is a natural process that involves placing a naked newborn chest down on the mother’s bare chest and covering the infant with blankets to keep it dry and warm.  Ideally, skin-to-skin care starts immediately after birth or shortly after birth, with the baby remaining on the mom’s chest until at least the end of the first breastfeeding session (Moore, Anderson et al. 2012). Note: Laying a baby on top of mother’s gown or on top of a towel does NOT count as skin-to-skin.

Skin-to-skin care can start at different times. There are 3 main types of early skin-to-skin care for healthy term infants:

  1. Birth or immediate skin-to-skin care starts during the first minute after birth
  2. Very early skin-to-skin care begins 30-40 minutes post-birth
  3. Early skin-to-skin is any skin-to-skin time that takes place during the first 24 hours.

A new mom does skin to skin care with her baby 2 hours after a Cesarean birth.

A new mom does skin to skin care with her baby 2 hours after a Cesarean birth.

How common is skin-to-skin care?

Skin-to-skin care is not normally done in the U.S. The Centers for Disease Control (CDC) tracks skin-to-skin care in all hospitals in the U.S. In 2009, only 43% of hospitals implemented skin-to-skin care for most women and babies within 1 hour after an uncomplicated vaginal birth. The rates of skin-to-skin care were lowest in hospitals in the Southeastern U.S. (28%) and highest in the Pacific U.S. (63%).

After a C-section, the rates of skin-to-skin care are even lower. According to the CDC, only 32% of U.S. hospitals implement skin-to-skin care for most women and babies within 2 hours after an uncomplicated Cesarean birth. The rates are lowest in the Southeast (24%) and highest in the Pacific (44%).

Importantly, the rate of Cesarean births has increased significantly in the U.S. and currently averages around 32%– or 1.4 million American babies born by Cesarean per year (Menacker and Hamilton, 2010). The low rates of skin-to-skin care provided to this population means that there are a significant number of mothers and babies who are not receiving skin-to-skin care.

If skin-to-skin is not routine after a C-section, what is the standard of care?

The routine standard of care after a Cesarean is for the baby to be taken to a warmer in the operating room, where he or she is examined, cleaned, labeled, weighed, measured, clothed, and swaddled before being introduced briefly to the parents. The baby is then taken to a nursery for further assessment and observation in a warmer, while the mother is taken to a separate recovery room, with the separation typically lasting 1 to 2 hours.

What is the evidence for skin-to-skin care?

In 2012, researchers pooled the results from 34 randomized, controlled trials in a meta-analysis (Moore, Anderson et al. 2012). The researchers found that babies who were randomly assigned to receive early skin-to-skin care were 2 times more likely to be exclusively breastfeeding at 3-6 months, compared to babies who received routine hospital care. Unfortunately, due to a lack of data, the researchers were not able to look at any differences between birth, very early, and early skin-to-skin time.

In addition to improved breastfeeding rates, benefits of early skin-to-skin care included:

For mothers:

  • Less breast engorgement/pain at 3 days
  • Less anxiety 3 days after birth

For babies:

  • More effective suckling during the initial breastfeeding session
  • Less crying– babies who received skin-to-skin care were 12 times less likely to cry during the observation period
  • Heart rate, respirations, and temperature were more likely to remain stable
  • A beneficial increase in blood sugar

The researchers found NO risks related to skin-to-skin care—only benefits. Importantly, the researchers found multiple risks to routinely separating moms from babies after birth. Separating a healthy baby from a healthy mom after birth decreases the chance of successful breastfeeding and raises the risk of the mother’s breast engorgement and anxiety, and instability of the infant’s heart rate, respiration, temperature, and blood sugar. Babies who are separated from their moms and swaddled are 12 times more likely to cry.

The benefits of skin-to-skin care are so clear that the World Health Organization recommends ALL newborns receive skin-to-skin care, no matter the baby’s weight, gestational age, birth setting, or clinical condition. (WHO, 2003)

So it sounds like skin-to-skin care is the best practice for babies. But what is the evidence for skin-to-skin care for babies who are born by Cesarean?

To look at the evidence, I searched PubMed using the terms “skin to skin” and “Cesarean,” and I limited my search to the last 10 years. I looked at any studies that described skin-to-skin after a Cesarean. I have described my findings below:

Studies on “very early” skin-to-skin care after a Cesarean

I found 3 randomized, controlled trials on very early skin-to-skin care (within 30-50 minutes after a Cesarean).

In 2009, Nolan and Lawrence randomized 50 women who were having a planned repeat Cesarean to either routine separation at birth or early skin-to-skin care. In the skin-to-skin group, women were never more than 8 feet away from their infants, the infants were held cheek-to-cheek to the mothers while in the operating room, and skin-to-skin care began in the recovery room about 30-40 minutes after birth. Average baby temperatures during the first hour after birth were significantly higher in the skin-to-skin group. The researchers did not find any adverse effects to the treatment. However, the sample size in this study was really too small to tell a difference in any other outcomes.

In another study, Gouchon et al. (2010) randomized 34 women who were having a planned C-section to either routine care or skin-to-skin care. Both groups were separated from their infants after the surgery and during the recovery period. The only difference was that when the babies were returned to the mother in the postpartum room (on average 50 minutes after surgery), babies in the skin-to-skin group did skin-to-skin care with the mother for up to 2 hours, and babies in the control group were bathed, clothed, and held by the parents. There were no differences in temperature or any other outcomes between the 2 groups—the sample size was really too small to tell any differences.

In 2007, Erlandsson et al. randomized 29 babies to either routine care or skin-to-skin care with their fathers after a planned C-section. In both groups, the babies were cleaned, dried, clothed, and laid on the mother’s chest for 5-10 minutes in the operating room. Then the father and the baby went to the maternity ward, while the mother went to the post-op recovery room.  While the mother was in recovery, the babies in the skin-to-skin group did skin-to-skin care with their fathers, while babies in the control group stayed in their bassinet. The researchers found that babies who did skin-to-skin with their fathers after a Cesarean cried significantly less and became calm and drowsy more quickly than babies who were left in the bassinet. Temperature and breastfeeding outcomes were not measured.

A father does skin-to-skin with his newborn son after a Cesarean birth.

A father does skin-to-skin with his newborn son after a Cesarean birth.

Studies on “immediate” skin-to-skin care after a Cesarean

I only found one study on immediate skin-to-skin care after a Cesarean, and 2 quality improvement reports.

In 2012, Velandia et al. randomized families planning a Cesarean to immediate skin-to-skin care with the mother or immediate skin-to-skin care with the father. In both groups, the baby was placed skin-to-skin on the mother’s chest within 1 minute after birth and stayed there for 5 minutes. Afterwards, the baby either remained on the mother’s chest for 25 more minutes, or was switched to the father’s chest for 25 minutes.  After this time period, all the babies did skin-to-skin with their mothers for an additional 90 minutes. There were no adverse effects reported. Babies who spent skin-to-skin time with mothers breastfed significantly earlier than babies who had skin-to-skin with their fathers. This study was limited by its lack of a true control group and because they did not report any measurements on infant temperature, respirations, or heart rate.

There are two reports in the literature in which hospitals described implementing immediate skin-to-skin care after a Cesarean.(Smith, Plaat et al. 2008; Hung and Berg 2011) Both of these articles were quality improvement projects and not actual research studies. (You can read the 2 reports here and here). The authors did not report any adverse effects from immediate skin-to-skin care in the operating room/theatre.

**Addition, 6/23/13: In 2012, researchers at a Texas hospital did an “intervention” to help staff increase the rates of immediate skin-to-skin care. After doing formal training sessions on the benefits of skin-to-skin, the researchers videotaped 11 births (5 vaginal, 6 Cesarean) in which immediate skin-to-skin was used, and then they showed these videos to staff. This helped the staff get engaged in problem-solving in how they could make the process work smoother. Before the intervention, about 58% of moms and babies had immediate skin-to-skin care. In the months afterwards, the rate of immediate skin-to-skin care increased to 83%. Almost all of the increase was due to moms who gave birth by C-section having immediate skin-to-skin in the O.R (the hospital did not routinely do skin-to-skin in the O.R. before the study). (Crenshaw et al., 2012).

I would like to have skin-to-skin care as soon as possible after my Cesarean, but my hospital says they won’t let me. Why is that?

One of the main perceived barriers to implementing skin-to-skin care after a C-section is because hypothermia (low temperature) in babies is more common after a C-section. Babies who are born via Cesarean are at higher risk of hypothermia because the operating room temperature is kept quite cold, mothers undergoing a Cesarean may have a lower body temperature, and babies were exposed in utero to drugs that may affect their temperature (Moore, Anderson et al., 2012).

However, the limited research evidence that we have suggests that babies who undergo skin-to-skin care 30-50 minutes after a Cesarean are NOT at higher risk for hypothermia compared to infants who are kept in a warmer (Nolan and Lawrence 2009; Gouchon, Gregori et al. 2010). If a baby is not able to maintain its temperature during skin-to-skin with its mother, babies may be held skin-to-skin with father or another family member after a Cesarean (Erlandsson, Dsilna et al. 2007).

 

A mom does immediate skin-to-skin with her baby in the operating room.

A mom does immediate skin-to-skin with her baby in the operating room.

Probably the biggest barrier to skin-to-skin care after a Cesarean is the culture of the operating room itself.  Several clinicians have reported the implementation of immediate skin-to-skin care (within 30 minutes after birth) in their hospitals’ operating rooms (Smith, Plaat et al. 2008; Hung and Berg 2011) The authors noted that operating room staff members were initially skeptical, reluctant, and afraid to change their routine habits and behaviors.  But after seeing the benefits of this family-friendly procedure, staff became supportive of the change.

Other barriers to skin-to-skin care after a C-section include (Smith 2008 & Hung 2011):

  • The mother may not be capable of holding the baby due to nausea or other symptoms—in this case, another family member would need to do skin-to-skin with the baby
  • Some hospitals may require a designated baby nurse to be in the O.R. or the recovery room (in addition to the mother’s nurse) so a shortage of nurses may prohibit early skin-to-skin care
  • The mother’s heart monitor stickers need to be placed on her sides, to leave a spot open on her chest for the baby
  • The mother’s gown needs to be placed so that it easily opens for the baby to lay on her bare chest
  • The mother’s blood pressure cuff and IV needs to be placed on the non-dominant arm
  • The mother’s oxygen monitor needs to be put on her toe instead of her finger
  • The baby needs to be dried and covered with multiple warm blankets (potentially bubble wrap) and a cap
  • If the skin-to-skin time is done very early (in the OR), the baby may need to be laid cross-wise across the mother’s upper chest, above the blue drape
  • Routine procedures, such as weight, measurement, and baby eye drops, need to be delayed
  • Other routine baby procedures (APGAR scores, assessment, placing the ID bracelet) need to be done on the mother’s chest
  • Bathing needs to be delayed, with priority given to the skin-to-skin time

In summary, the research we have so far demonstrates that “very early” skin-to-skin care after a Cesarean is safe and beneficial. More research is needed on “immediate” skin-to-skin care , or care that is initiated in the operating room. The low rates of skin-to-skin after Cesarean and reports from researchers suggest that women and care providers may face multiple barriers to skin-to-skin care after Cesareans.

After publishing this article, I heard from a lot of moms who say that hospital staff have told them, “It can’t be done. It’s impossible to keep moms and babies together after a Cesarean.” So as a follow-up to this article, I published an Evidence Based Birth article entitled: “Can hospitals keep moms and babies together after a Cesarean?”

If you liked this article, click here to read an interview and see photos of a mother who received immediate skin-to-skin care after a C-section.

Click here to read an interview with a doula about how she facilitates skin-to-skin care in the operating room.

Click here to see our Facebook photo album of skin-to-skin experiences in the operating room.

 

Now it’s your turn to tell us what you think! Is early or immediate skin-to-skin care available in your local hospital?  I would love to hear from some mothers who have experienced skin-to-skin care after a Cesarean, and to hear the viewpoint of some care providers as well.

References:

  1. Erlandsson, K., A. Dsilna, et al. (2007). “Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior.” Birth 34(2): 105-114.
  2. Gouchon, S., D. Gregori, et al. (2010). “Skin-to-skin contact after cesarean delivery: an experimental study.” Nurs Res 59(2): 78-84.
  3. Hung, K. J. and O. Berg (2011). “Early skin-to-skin after cesarean to improve breastfeeding.” MCN. The American journal of maternal child nursing 36(5): 318-324; quiz 325-316.
  4. Moore, E. R., G. C. Anderson, et al. (2012). “Early skin-to-skin contact for mothers and their healthy newborn infants.” Cochrane Database Syst Rev 5: CD003519.
  5. Nolan, A. and C. Lawrence (2009). “A pilot study of a nursing intervention protocol to minimize maternal-infant separation after Cesarean birth.” J Obstet Gynecol Neonatal Nurs 38(4): 430-442.
  6. World Health Organization (2003). Kangaroo mother care: A practical guide. Geneva, World Health Organization, Department of Reproductive Health and Research.
  7. Smith, J., F. Plaat, et al. (2008). “The natural caesarean: a woman-centred technique.” BJOG : an international journal of obstetrics and gynaecology 115(8): 1037-1042; discussion 1042.
  8. Velandia, M., K. Uvnas-Moberg, et al. (2012). “Sex differences in newborn interaction with mother or father during skin-to-skin contact after Caesarean section.” Acta Paediatr 101(4): 360-367.
  9. Crenshaw, J. T., Cadwell, K, et al. (2012). “Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates.” Breastfeed Med 7(2): 69-78.
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