August 21, 2012 by Rebecca Dekker, PhD, RN, APRN
© Copyright Evidence Based Birth®. Please see disclaimer and terms of use.

Today’s interview is with Sharon Muza, a certified doula, lamaze certified childbirth educator, and birth doula trainer. This interview is a follow-up to my evidence-based article on skin-to-skin after a Cesarean, which you can read here. Sharon offered to share with us her thoughts on how doulas can advocate for and help facilitate skin-to-skin in the operating room/theatre after a Cesarean.  

Tell us a little bit about yourself. 

I am a DONA certified birth doula and  birth doula trainer, and a Lamaze Certified Childbirth Educator teaching independent birth classes through my practice, New Moon Birth.  I also train childbirth educators through Passion for Birth and am a co-leader of the Seattle chapter of ICAN (International Cesarean Awareness Network.)  I live in Seattle, have been doing birth work for about 10 years and have two daughters and a crazy golden retriever.  I also am the community manager over at Lamaze International’s Science & Sensibility blog.

 When was the first time you saw skin-to-skin care in the operating room after a Cesarean? What was it like?

Twins by planned Cesarean. Kristine is skin-to-skin with first twin Zoe moments after birth. (Permission is NOT granted to copy or use this photo).

As a doula working with women whose birth may have ended up in a cesarean, and those working towards a VBAC, I frequently heard the women state that one of the biggest “losses” they felt was that they were unable to have immediate skin to skin with their babies.  Their hopes were always to have that opportunity when they birthed again.  I knew the benefits of immediate skin to skin, and when I was invited in the operating room to support my client, I thought we might be able to offer this to mothers as long as everyone is stable.  The first  few times I tried it with mothers, at the beginning of my doula practice almost 10 years ago, it was awkward until I started “perfecting” the approach.

How can other doulas promote skin-to-skin care after Cesareans in the facilities where they practice?

Doulas can do two things, 1) they can promote skin to skin in the operating room “birth by birth” when they are able to go in with the mother during the procedure.  Here in Seattle, many hospitals allow two support persons in the OR, so whenever I am in with my clients, and the mother is open to trying immediate skin to skin, and the baby is stable, we give it a shot.  2) On a larger scale, doulas can offer to meet with leadership at their hospitals, and do a presentation on the potential benefits and help the hospitals to figure out how everyone’s needs can be met; the mother, the baby and the facility, who has safety and logistics at the forefront, as they should.  I would enlist the hospital lactation consultants, midwives on staff, if they practice there and even the hospital ombudsman, who would be delighted to know that women are more satisfied with their experience when they have this immediate skin to skin opportunity.

Partner Dawn brings twin Milo (swaddled) to Kristine– twin Zoe is already skin-to-skin on Kristine’s chest. (Permission is NOT granted to copy or use this photo).

Additionally, this could be a “marketing” advantage for a hospital, if they could state that they regularly promote this immediate interaction between mothers and babies.  Certainly, if I were a mother who was deciding between two facilities for my hospital birth, this could be one of the things that swayed me to choose the hospital that offered this, just in case I should have a cesarean.

When I have a positive experience getting baby skin to skin in the OR and the health care providers, (doctors, labor and delivery nurses) comment on it, I take a moment to share how this could happen with many cesarean births, with a little dedicated energy by the staff in the OR, and that I am happy to share some ideas if they are interested.  Every time it happens, I am  “modeling” this possibility for future births.

What is the doula’s role during the skin-to-skin care after a Cesarean? Is this considered part of the doula’s scope of practice?

Let me take a moment to share how I go about setting the mother up for success in getting her baby skin to skin if she were to have a cesarean. (I also talk about this during childbirth classes, so all the families can plan for it.)

  1. I discuss this when I meet with my clients prenatally. When we are going over their wishes during the birth, and covering the Cesarean portion, I explain that this might be an option and ask if they might be interested.  I note their preferences for myself and encourage them to include this in their birth wishes they share with the health care provider.
  2. I also share that partners may also have the option to have skin to skin time with their baby, if the mother is unwilling or not able to do it.  I invite them to consider that as well, and also encourage them to have baby get some skin to skin time after the birth, after mom has “had her fill.”
  3. I encourage them to advocate for having two support people in the OR, if the decision is made to proceed to a cesarean, so I can help.
  4. As the mother is getting ready to be taken back to the OR, I make sure she is wearing only her gown, and that her bra, camisole or other clothing has been removed.  I encourage partner to be wearing an old t-shirt under his or her OR clothing, that can be cut or ripped to make room for baby if that is what they wish.  If I am not able to go back to the OR, I am giving partner tips and reminders in the moment about how to get the mother-baby dyad together skin to skin as soon as possible.
  5. I remind partner in advance that after the baby is born, they will/can go over to the warmer and advocate for getting baby to mom ASAP, delaying things like weight, diapering, swaddling, eye antibiotics, vitamin K etc, until back in the room, unless there is a medical reason to do something immediately.  Mom can also ask for her baby to be brought to her ASAP.  The baby is usually over to mom in less than 5 minutes if everything is stable when that is the wishes of the parents.
  6. In the OR, I sit or stand behind mom/partner until the baby is born.  When the baby is born, the partner goes over to the warmer and I step in closer to mom, usually holding her hand and encouraging her to talk to her baby.  I ask partner to share what is happening and details about the baby.
  7. Partner is handed the baby, hopefully as soon as possible after the baby is dried, determined to be stable and the first set of vitals has been taken.  In the meantime, I have unsnapped mom’s gown on both sides and am ready to pull it down to the drape, when the baby comes over.
  8. When the baby is brought to mom, I help partner unwrap/unswaddle the baby, pull down mom’s gown and place the baby chest to chest (face down with the head turned toward mom) with mom, usually across both breasts.  We cover the baby/mom pair with the baby blankets and I see that partner (or I if necessary) keeps at least one hand on baby, to be sure it stays on mom’s chest.  Mom is usually able to use one hand to touch and stroke baby as well.  Sometimes the baby is nearer the nipple or sometimes just across the chest.  I am sure to respect the surgical drape that hangs across mom’s chest and keep baby “upwind” of that drape which designates the sterile field.
  9. Baby can lick, smell, move its head, taste, touch, see and hear mom.  Sometimes the baby will show signs of wanting to eat, and we gently locate baby as close to the nipple as possible, in case baby will want to latch on.  Sometimes the baby is just content to lay there taking it all in.  I make sure that the baby is well covered with heated blankets and that someone besides mom always is holding the baby in place.
  10. Usually the anesthesiologist is also up in the space by mom’s head, but s/he is doing her business and tends to leave mom alone unless necessary.
  11. If mom is not stable in any way, panicky, upset or feels nauseous, then I wait until mom is stable before encouraging skin to skin.  Sometimes, the mother asks for the baby to be removed, if she is starting to feel unwell.
  12. I find that having the baby skin to skin helps the rest of the surgery go smooth from the mother’s perspective.  She seems less anxious, is engaged with her baby and enjoys that time with her partner and baby while the surgeons finish the procedure.
  13. If the mother cannot have the baby skin to skin, then I ask partner/mother if partner wishes to do so.  If yes, I help partner to unswaddle baby and slip the baby down skin to skin under their shirt and gown/scrubs.  Sometime the neck of their shirt needs to be ripped or cut.  I encourage partner to stay close to mom while holding the baby skin to skin.
  14. If I am not allowed in the OR, then I hope that the instructions I have given the parents prenatally, and before the surgery, will help them to achieve the results they want.
  15. The OR staff seem to consistently leave the mother and baby alone, and may not even be aware that baby is skin to skin.  Once, a baby was making loud nursing noises, and the OB commented, asking what that was.  The mother responded “My baby is nursing!” and the OB replied “Wow, I didn’t know that was possible during a cesarean.” everyone laughed. Anything IS possible!
  16. I work hard to blend in, be supportive of everyone, respectful of everyone and have mother’s voice be heard.  It not my place to ever be pushy and domineering about what needs to happen.  It is the parent’s responsibility to advocate for their own wishes, I just gently encourage that by staying close and supportive.

In all the times that I have been able to be in the OR with my clients, there as never been any concerns, comments, or pushback by staff when mother has been skin to skin.  There are a couple of hospitals that occasionally do this with cesarean mothers, even when a doula is not present.

Dawn skin-to-skin with twins Zoe and Milo. (Permission is NOT granted to copy or use this photo).

To answer the question of whether this is within the doula’s scope of practice; I feel that if this is the mother’s wish, she has made an informed choice and both mother and baby are stable, then supporting the mother’s wishes and helping her and her partner to ask for what they want is certainly within my scope.

Which experience seems to work best for your Cesarean clients– immediate skin-to-skin (within a minute or two after birth), very early skin-to-skin (within 30-40 minutes ater birth), or early skin-to-skin (anytime after 40 minutes)?

In my experience, skin to skin in the OR is the ideal situation if everyone is stable and mother is willing.  Luckily, in Seattle, where I practice, stable babies stay in the OR room and both mothers and babies return together to the labor room from the OR.  Mothers do not go to “recovery” and stable babies do not go to a nursery or observation area.  If skin to skin in the OR is not possible, then immediately upon returning to the room is second best, provided that mother is stable, which is normally the case.  It is very rare to have the mom not be able to go skin to skin within the first 30 minutes.  Even in some cases, when mother has been very out of it, due to medication or exhaustion, it has been possible to get baby skin to skin with her and breastfeeding, back in the room, with my support.

“As I carried two bundles out of the OR after years of frozen sperm and fertility treatments, an emotionally stressful twin pregnancy, and a planned c-section I felt relief and then panic because I wasn’t feeling love for the babies.  They weren’t my flesh and blood…I started to fear I wouldn’t love them.  Back in the room, Sharon encouraged me to open the button down shirt she suggested I wear and I held the twins skin to skin.  In an instant the panic and fear were gone and I knew I loved these tiny, vulnerable creatures in a powerful and life-changing way.  I’m sure I would have gotten to this point eventually but what a gift to have only wasted an hour in doubt.” ~Dawn

What differences do you see between moms and babies who have immediate skin-to-skin after a Cesarean and those who don’t?

Dad (Jeremy Levin) is carrying a naked baby Natalie directly from the warmer so she can do skin-to-skin with mom (Dahlia Levin) after an unplanned repeat Cesarean. (Permission is NOT granted to copy or use this photo).

In my experience, the mothers that get skin to skin contact with their babies during the Cesarean, have a higher degree of satisfaction with the surgical procedure, even if a Cesarean was not wanted nor planned.  It makes for very positive early memories of connecting with their babies, they seem less “disturbed or anxious” about the surgery and even report less discomfort during the rest of the procedure.  They are very distracted from the surgery by engaging with their newborn in this way, and tell me in a postpartum visit how much they appreciated having this component of connection, even when they did not have the birth they were planning.  Women who have missed this opportunity share with me that they are disappointed in not being able to spend skin to skin time right away.  As I mentioned earlier, those women planning a VBAC often state that this missed opportunity with their previous birth is one that they felt very impacted by and would like to change the next time around.

“Immediate skin to skin made a difficult & unwanted situation (repeat c-section) bearable. It was night & day from my first c-section where I was separated from my newborn for several hours after birth (baby was taken to the newborn nursery with dad while I was in the recovery room by myself until I could feel my legs). It was healing and allowed for immediate bonding between the baby and her parents. It also facilitated getting breastfeeding off to a good start. Sharon was amazing at helping us cope with the reality of having another unwanted c-section and making the best of the situation by helping us bond with our baby almost as if it had been a vaginal birth.” – Dahlia and Jeremy Levin

Jeremy places baby Natalie skin-to-skin on Dahlia’s chest in the operating room. (Permission is NOT granted to copy or use this photo).

In my review of the literature, I noticed that very little research has been done on skin-to-skin in the OR after a Cesarean. What research questions would you like to see answered about skin-to-skin care after a Cesarean?

I would love to have an assessment of the newborn when placed to skin to skin in the OR compared to when the baby is just swaddled and held by partner.  Do they stabilize quicker?  Does their body temperature remain stable, are they calmer? Do mothers routinely feel more positive about the experience?  How do partners feel?  How does this affect newborn stress levels, breathing and other vital signs?  Can it be routinely done safely at every facility?  What risks can be identified if any?  Is there a long term impact on breastfeeding when this happens?  Some of the concerns I have read about immediate skin to skin in the OR is that baby will get cold, as the OR is a cold place.  Can this be compensated for by warm blankets routinely being available?  Who is responsible for the baby during skin to skin to assist the mom, assuming the doula is is not able to help? Is there an available pair of hands from a staff member?  What barriers exist in having skin to skin routinely in the OR and how can they mitigated these issues so both the staff and the mother’s concerns and needs are being met.

Dad (Jeremy) takes a turn doing skin-to-skin in the operating room. (Permission is NOT granted to copy or use this photo).

Is there anything else you would like to add?

The reality is that 1 in 3 women will have a baby born by Cesarean in 2012.  Who knows what that rate will be in the future, though my wish, of course, is that this rate is at the zenith and we see a downturn in this number.  I would like every mother’s experience to be positive, to have her feel that her voice was heard, her wishes were respected and that she got to connect with her baby in a way that felt good to her as soon as possible.  Certainly, we can figure out a way to have this happen without compromising safety of the mother or baby, making the hospital staff feel comfortable at all times and respecting the research that says that “first hour” is of critical importance to the mother baby dyad.

A mother (anonymous) does skin-to-skin with her newborn in the operating room. (Permission is NOT granted to copy or use this photo).

Doulas (and childbirth educators in the classroom teaching expectant parents) can and do play a critical role in making every birth the best that it can be.  I invite anyone who would like to discuss this, brainstorm or who has more questions to comment here, or contact me by email so that we can continue the conversation and I can offer support in whatever way I can.  I want to thank Rebecca for putting this conversation out there, examining the limited research and giving us all this forum to discuss it.

I encourage doulas who are paving the way in getting mothers and babies skin to skin in the OR to always be respectful and cooperative while supporting their clients.  The OR is not a place to alienate staff, or create division or argument but should be a place where good doula behavior is “modeled” for everyone to observe.

Please share your thoughts, comments, and questions with Sharon!

If you liked this article, you may also be interested in:

The Evidence for Skin-to-Skin after a Cesarean

A Woman’s Experience with Immediate Skin-to-Skin after a Cesarean

A First-time Mom Shares her Quest for Evidence-Based Fetal Monitoring

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