Skin to Skin after Cesarean

How I Practice Video Series 
Sarah Francis, MD
Asheville, North Carolina

I wanted to talk a little bit about family centered cesarean or some might call it skin to skin after cesarean delivery. This is a topic that is really important to me because a third of deliveries in the United States, as of 2012, were all cesarean deliveries and of those about ninety percent after they had a primary C-section will elect to do a repeat cesarean for a future delivery. Current standards right now in the United States at most hospitals, usually immediately after birth, the neonate is separated from the mother for any duration of time depending on where you practice, this could be anywhere from one hour to four hours. During that time period, basic routine measures such as warming and drying the infant, initial resuscitative efforts as well as measurements of the baby, weight, and early routine procedures like vitamin k and erythromycin ointment are all performed on the neonate while separated from the mother. But we know well that there’s a lot of benefits of immediate skin to skin contact with the baby to the mother immediately after birth. And those are routinely performed in most hospitals after vaginal birth within the delivery room and many organizations in the United States, as a lot of us know, support this procedure such as WHO, UNICEF, the American Academy of Physicians, and ACOG itself. So the question is why aren’t we routinely doing this for cesareans? And a lot of people, if you’ve tried to do this in practice, find that it is difficult to get people to change their routines in the operating room and the operating room is considered a much different facility than a delivery room. But for the patients this can be quite distressing to be separated from their infant, after all most of them came in to have a laboring experience and then might have found out they need a C-section for many reasons. So applying this can dramatically increase patient satisfaction within the hospital setting. There are also many other benefits such as increased breastfeeding rates, maternal bonding, maternal and infant sleep, and I can go on for a while about those. 

For me implementing this into the practice took a huge change in attitude for many people in the staff so I suggest if this is something you are interested in that you get team leaders from any staff that might be involved. At our hospital this included anesthesiology staff such as a CNRA or an anesthesiologist that routinely provides care within the labor and delivery unit; part of the pediatric staff, for us we call them stable team, which may include the neonatologist themselves, as well as nurse practitioners, or other nursing staff or respiratory therapy staff that help resuscitate neonates; as well as operating room staff such as the circulating nurse; as well as labor and delivery staff such as labor and delivery nurses that take care of both mothers and infants. We gathered all of these people together and put together a potential flowsheet of how we would provide this care for an infant. For us, at my hospital, this included a couple parts. The first part dropping the drape from the operating room drape so the mom can see the infant being born. We provide this to any vertex baby that this seems safe from both a pediatric and maternal standpoint about doing this during the delivery. For a mom this is a huge deal, if they feel safe about watching that its actually like seeing their baby being born as opposed to just being in the operating room. For us this requires no change in drapes, although you will see if you look up YouTube videos or other resources online there are a lot of different drapes people are using. But we’re just using the standard blue drape and unclipping it from the IV poles, which usually the CNRA helps us do, lowering it, and putting the patient in reverse Trendelenburg so they can see their infant being born. The second part of skin-to-skin after C-section or family centered delivery is delivering the baby, cutting and clamping the cord, and taking the baby immediately to the mother’s chest where the gown is taken down and the infant is placed skin-to-skin with the mother while the nurse is initially doing resuscitative efforts, warming and drying the baby while on the mom. This takes some maneuvering to be able to do this in discussing how to provide this care with all the people in your staff. For us, this meant talking to anesthesia; moving the EKG leads, the oxygen saturation monitor; when and how the gown of the mom will be lowered before the baby is placed there; which side of the operating room table is the nurse going to take the baby and put it on the mom; where are the blankets going to come from; where’s the suction bowl. So going through all these little logistic things with all the team members in the OR is quite important. But you will find it takes some sitting down with all the team members and discussing and kind of going through that to make a protocol that would work for your hospital. So we have both immediate skin-to-skin, where the baby is delivered and going immediately to the mom, as well as delayed where in some circumstances the infant might need to be evaluated by the pediatric team to make sure this will be safe. This can happen for many reasons, as we know such as, late pre-term infants or if there is a worrisome strip on the monitor prior to the C-section. But we feel if we can get the baby skin-to-skin with the mom within 15 to 20 minutes after birth that’s better than separating the mom for hours and hours while the baby is receiving its initial parts of care. We try to increase the skin-to-skin time as long as possible, including up until the mom is taken to the post-anesthesia care unit. And we have the nurse try to encourage the first latch happen within the operating room and if not there within the post-anesthesia care unit. All procedures routinely done on the infant is delayed as long as possible as long as the mother is okay with that. And then any vital signs or things that need to be taken on the mom when she’s in the PACU [post-anesthesia care unit] we discuss this with the nurse to see how this can be done with the infant still remaining with the mother during that whole period of time. So there’s a lot of protocols out there already as this becomes a popular topic, mostly by patient demand within the past few years we have one online but you can find many and try to adapt these to how this can work in your hospital. Again, I really believe this is an important thing to provide for moms and there is so far no immediate or long term data showing any negative effects both on infants or mothers to provide this practice. I find this to be very important and have heard lots of wonderful patient stories from moms, and this is how I practice. 

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