Skin-to-skin in the operating room after cesarean birth

The term ‘operating theatre’ is synonymous with operating room. These terms are used interchangeably throughout the article.

When skin-to-skin (STS) started to be provided to mom and baby couplets in the recovery room after cesarean births at her hospital– a metropolitan public hospital in Sydney, Australia– midwife Jeni Stevens, RN, RN (Hon 1st), RM, IBCLC, PhD Candidate (Clinical Midwifery Consultant of Infant Feeding) noticed something different about the mothers.

“The women looked alive,” she says. “Their faces were bright.”

It was a stark contrast to the days without STS.

“Before, women shut down,” Stevens says. As a mother herself, she empathizes and imagines the trauma of having her baby taken from her.

That look on a new mother’s face, a seemingly small nuance that some might overlook, is something actually quite profound. It’s the gateway into intricate emotions, a presage to the everlasting imprint our birth stories hold.

Aware of these intricacies, Stevens’ observations were the precursor to her research on STS contact after cesarean sections and her inspiration to do better for mothers.

STS is good for everyone

There’s a growing body of evidence that shows the benefits of STS.

STS increases maternal infant bonding, reduces postpartum hemorrhage, maintains infant temperature and heart rate, decreases the need for pain medication during surgery, reduces maternal infant stress, increases breastfeeding initiation, decreases admissions to NICU, reduces artificial supplementation, provides baby with healthy gut colonization.

What’s more, providing STS and allowing baby to self attach to the breast within the first hour or so after birth increases mothers’ confidence in their ability to breastfeed long-term, Stevens reports.

She has found that when the first breastfeed is missed, it is sometimes two to three days before a mother might directly breastfeed her baby because the baby is affected by medications post-surgery. It appears to affect their ability to suck at the breast.  In these cases, mothers express their milk until breastfeeding begins.

To avoid cases of supplementation, Stevens and her colleagues teach mothers to antenatally express their milk (which should occur under midwife/physician supervision) if there are anticipated challenges present that would interfere with breastfeeding. Even in the case of an emergency c-section, they encourage mothers to express their milk before going into theatre. Stevens’ anecdotal evidence shows that without antenatal expression, mothers typically express about .3 mLs of milk on the first day postpartum.

“With antenatal expression, it is not unusual to see one to two mLs on the first day,” she says.

Providing STS after c-sections is beneficial to the institution, too.

It’s proven economical to hospitals because it reduces admission to the NICU, (as per a new paper by Schneider, Crenshaw & Gilder, Skin-to- Skin Contact During Cesarean Surgery on Rate of Transfer of Newborn to NICU for Observation) decreases illness expenses related to not breastfeeding for both mom and baby and increases patient satisfaction.  

Cultural medicalization of birth challenges STS

Not surprisingly though, the benefits of STS are not met without challenges.

Stevens begins, when STS is taking place, it is generally not provided in the way that it is recommended by health organizations; that is immediately after birth, prolonged for over an hour and until baby has breastfed, and uninterrupted.

She has found that when asked if they’ve been provided the opportunity for STS, mothers say ‘yes and that it’s been done very well.’

“But in reality, it wasn’t,” Stevens refers to the immediate, prolonged, uninterrupted criteria.  

As detailed in A juxtaposition of birth and surgery: Providing skin-to-skin contact in the operating theatre and recovery, Stevens and colleagues show that many of the challenges of providing STS in the operating theatre have to do with the cultural medicalization of birth.

She points out that in no other instance are staff members responsible for multiple people in the operating room: mother, baby, and support person.   

“It’s a very complex situation for the staff to have to consider two other people,” Stevens comments.

Providing STS in the operating room challenges organizational staffing. Some staff members don’t feel competent enough to care for mother and baby, especially if they have never had neonatal training, Stevens explains.

She offers several solutions. We need to train staff to make them feel more comfortable.

While not part of her research, Stevens says that her hospital trained enrolled nurses on basic baby care, neonatal resuscitation, neonatal assessment and breastfeeding, so that they can supervise STS in recovery.

Other hospitals appoint student midwives responsible for the baby.

“Skin to skin is not that complex, but we have to make sure baby is safe,” Stevens says.

Time remains an issue when implementing STS in the operating room.  

Stevens points out that midwives want to be deemed efficient. They’re concerned about getting paperwork completed, so they interrupt STS to do things like weigh the baby, which is most often not of urgent medical concern.

“The thing that really alerted me is how much midwives do,” Stevens adds. “We can’t seem to let the mum and baby stay together without doing something.”

Medical providers must learn to simply observe, she offers. “We must learn to sit on our hands and find other things to distract us.”

Provision of STS is affected by individual knowledge of the matter.

“Some staff members really saw the value in skin-to-skin and knew the benefits, while others really didn’t know much about it, so they didn’t,” Stevens reports.

If staff members have personal knowledge or a personal experience with STS, it can make a big difference.

Still, even when hospital staff acknowledge the importance of STS, they often express difficulty envisioning how it might work in a medicalized environment.

It can be effective to educate staff by asking parents who experienced STS to speak to hospital staff about their experiences.

“Then it’s not somebody telling them what to do,” Stevens explains. “Instead, it helps them realize how much it actually makes a difference when you are providing this care.”

Individuals make the difference. Stevens watched a midwife direct a student midwife to immediately place a baby STS on its mother during a cesarean. Stevens says she hopes that student saw the impact she made on the mother baby couplet. By boosting the mother’s confidence, Stevens hopes the student’s confidence in providing this care improved too.  

Continuity of care seems to have a positive effect on providing STS.

Stevens found that when midwives care for patients throughout their entire pregnancies and establish relationships, they tend to feel obliged to do what the mothers want. When there is no continuity of care, midwives report feeling obliged focus on their colleagues needs instead (e.g. going back to the ward to reduce their workload.) To align these would be to encourage all to value STS.

One mother in her research had continuity of obstetric care.  She was offered a maternal assisted c-section, where the mother helps pull the baby from her uterus and places the baby directly onto her chest.  This was the first maternal assisted c-section in the hospital where Stevens was conducting her research, and she had the privilege of filming it and using the footage as educational material for medical students and staff members.  

“This mom got to pull her baby out of her abdomen and put the baby directly to her chest,” Stevens explains. “Just seeing her lift that baby out and own that baby straight away was just amazing.”  

Following the birth, Stevens remembers the baby pooping and peeing all over the mother, and the mother thought it was “just the most amazing thing.”

In the operating theatre setting, one must consider the placement of equipment. Where will monitoring equipment go while mother and baby are STS? Where will the drape lay while surgery continues? Will the sphygmomanometer interfere? Are mothers’ gowns easily removed to expose the chest?

STS: A human right

Despite an array of challenges, STS contact can be successfully implemented in the operating theatre and recovery room with staff members input into adjustments to existing care, Stevens finds.

“I don’t even know why any of these [challenges] should be factors,” she reflects honestly on the challenges presented. “[Skin-to-skin] needs to be the norm, and then those factors won’t be an issue.”

In the meantime while we are still struggling to provide STS as the norm, it’s vital to encourage women to have a voice, she says.

“When women question things and want anything out of the norm, people quite often get surprised and don’t know how to cope with it,” Stevens observes.

She tells the story of a woman who felt defeated that she would require a c-section, but found comfort in that she would have the opportunity for immediate STS in the operating room. But, when the anesthetist could not get the morphine in her back, she required a general anesthetic. General anesthesia voided an opportunity for STS in this hospital, but this mother persisted with her rights. Stevens and her colleague advocated for her and agreed to place the baby STS after she began to wake up from the anesthesia. The mother’s wishes were simply documented, and they proceeded with them. Ultimately, the baby went STS with father first and then to the mother as soon as she became alert in the PACU.

While women’s stories of empowerment are the ultimate triumph of providing STS care, not providing STS has serious mental health consequences on mothers and babies.

Stevens’ recollection of a woman she chatted with in an elevator is arguably the most grim outcome of medicalized birth without compassion.

The woman shared that after one of her c-sections, she only saw her baby for a split second.

“She couldn’t even map the baby’s face,” Stevens recalls her story. “She couldn’t even visualize what that baby looked like.”

When this mother was moved to the postnatal ward, she talked about how medical staff gave her a baby, and she didn’t even know if it was hers.

Seven years later, she still doesn’t know if it’s her baby. Seven years later, she refers to her daughter as ‘it.’

Meditating on her story Stevens says, “Oh my god, what do we do to these poor women and these babies?”

Stevens also tells of one mother who cannot yet get herself to look at the photos of her mother in law holding her baby before she did, five years after her birth.

“I only spoke with a handful of women,” Stevens says of her research. “How many other people are feeling that devastated? We’ve got to start prioritizing this. It’s not an option.”

In fact,  Bashi Hazard, an Australian lawyer and board member of Human Rights in Childbirth, discussed with Stevens her argument that STS contact after birth is a human right.

Stevens says, “It is time to stand up for women and their babies, be their advocates and provide this essential care.”

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