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Helping Parents Prepare for a Cesarean Birth and Skin to Skin Contact

9 minutes

10/07/2020

According the World Health Organization, planned or scheduled Cesarean section (C-section) rates are approximately 10-15% world-wide.1 While a C-section may be planned for a variety of reasons, the birth experience itself can be of concern for parents-to-be compared to those experiencing a traditional vaginal birth. This article will provide guidance on how to help parents-to-be prepare for what happens in the delivery room during a C-section so they can develop their own birth plan accordingly. Special focus will be given to skin-to-skin contact immediately after the birth and how to ensure parents can maximize this important first step in bonding with their newborn.

Although a C-section is a relatively short procedure (approximately 1hr in total) compared with a vaginal birth, this does not diminish the personal experience of the birth. Often new parents may not be aware of the options available to them during the birth and immediately after, so it’s worth going through a checklist during their last appointment before the birth to ensure they feel fully prepared. Protocols before, during and after delivery will vary between hospitals. If possible, knowing them for your surrounding area facilities can be helpful. Parents will appreciate learning what can and cannot happen beforehand and this can help to avoid potential disappointment when developing their birth plan.

A Checklist for Educating Parents Preparing for a C-section: 2,3

  • Parents need to understand the risks associated with C-section versus a vaginal birth.

  • Make sure expectant parents understand how the delivery room is usually set-up, e.g. how many people are on the delivery team and their roles, the equipment, where the baby will be assessed.

  • Reassure the mother that she can have her birth partner present during the surgery.

  • Inform the birth partner they will be dressed in scrubs that will be provided for them when they arrive for the birth.

  • Discuss whether the parents want a screen during the surgery especially if they do not want to see the surgical procedure.

  • Tell them that they can ask the health care team in the delivery room to be quiet during the birth so that mother’s or father’s voice is the first voice their newborn hears when born.

  • Advise them to ask the delivery team to practice delayed or optimal cord clamping for maximum benefit from the placenta. This practice may vary from hospital to hospital.

  • Go through the details of the newborn assessment immediately after the baby is delivered and what they can expect.

  • Let them know that cameras/phones can be taken into the delivery room, inform the birth partner they will likely be the one taking all the pictures as the staff have their hands full! Encourage filming of baby’s assessment, e.g. weighing, etc. if permitted by the hospital. Be sure they know to ask the delivery team members if it is alright if they are in the picture as well.

  • Let parents know they may be able to play their own music during the birth; they just need to ask the delivery team.

  • Explain skin-to-skin contact (SSC), it’s importance and when it occurs. If SSC between mother and baby is not possible in the delivery room, advise the birth partner to see if they can participate in SSC in the meantime or discuss alternatives.

  • Inform parents of what happens in the recovery room and on the postpartum unit, e.g. assessment of vital signs, pain, vaginal bleeding, support to feed their baby, transferring to the postpartum unit, removal of any catheters and when the mother will be encouraged to be up and moving again.

  • Explain to parents the expected length of stay for a C-section so they can plan and be ready for the day of discharge.

  • Finally, it is worth mentioning to the parents who have a vaginal birth planned that sometimes an emergency C-section may be necessary if complications during the birth occur, so the above checklist can also be used in this case.

Skin-to-Skin Contact in the Delivery Room

Why skin-to-skin is so important

Skin to skin contact (SSC) is the natural process of placing a naked newborn on a mother’s bare chest and covering the infant with blankets to keep it warm and dry. SSC can be done immediately after birth in the delivery room. Routine care, such as cord clamp, temperature vital signs monitoring, and the first feeding can be performed. The benefits of SSC have been well-documented in research including stabilization of the newborn’s blood-oxygen levels, body temperature and respiratory rate.6 SSC is well known for encouraging the initiation breastfeeding and improving overall breastfeeding rates.6 SSC is also known to reduce infant crying, boost infant growth and development and strengthening parent-infant bonding. In one study that tracked births over a three-year period, researchers reported a significant decrease in the proportion of newborns delivered by C-section that were transferred to the NICU for observation after implementing SSC.4

Mother with baby practicing skin to skin

Did you know?

Babies born by Cesarean section do not acquire maternal vaginal microbes, SSC immediately after birth promotes microbial colonization of the newborn with maternal skin microbiota. SSC also benefits the mother by reducing depressive symptoms and physiological stress during the postpartum period and strengthens the mother-infant bonding relationship.8

The stages of skin-to-skin

Timings of SSC can vary but these are the three main stages5,10

  • Immediate (first minute)

  • Very early (30-40mins)

  • Early (first 24hrs)

As part of the WHO and UNICEF’s Baby Friendly Hospital Initiative to promote breastfeeding, the guidance states that an important step is to ‘facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.15 This is recommended regardless of the method of delivery and should ideally occur within five minutes of birth.11 Various countries have incorporated this initiative into their own practices, including the United States, United Kingdom, Canada and Australia, although policies and practices can vary between healthcare providers and facilities within these countries.12

The most recent Cochrane review of the practice of early SSC for mothers and their healthy newborn infants asserts, ‘since we found no evidence of harm in any included studies, we conclude the evidence supports that early SSC should be normal practice for healthy newborns, including those born by caesarean...’17 Furthermore, while Cesarean deliveries present certain challenges regarding immediate SSC in the delivery room, the published literature, although limited, suggests that SSC can be provided safely and immediately after a c-section with the collaboration and education of staff, mothers and partners.14,18

It could be argued that SSC plays an especially important role in c-section births as this type of delivery is typically associated with reduced breastfeeding at hospital discharge compared with vaginal delivery.13 One study demonstrated that elective cesarean deliveries affects short-term breastfeeding success in about 1:4 of mother-infant couplets, citing the lack of immediate SSC contact as a key contributing factor.20 In another study, hospitals that implemented immediate SSC following a Cesarean section observed an increased rate of breastfeeding among new mothers.19

According to Senior Midwife, Marie Louise “If a planned C-section is clinically indicated, parents should be encouraged to discuss and communicate with their healthcare provider during prenatal visits their desire to initiate skin-to-skin in the delivery room. Healthcare professionals working with new parents in the delivery room play a critical role in advocating to keep mothers and babies together immediately after birth. It is essential to educate parents on the importance of immediate, uninterrupted skin-to-skin contact and early breastfeeding.”26

Knowing there may be some medical or safety reasons for delaying SSC, parents-to-be should discuss their birth plan including the desire to initiate SSC in the delivery room prior to giving birth. The delivery facility can discuss the available options regarding SSC in the delivery room at that time. For example, if the mother ends up receiving general anesthesia or experiences complications post-birth but the baby is healthy, the father or birth partner can engage in SSC with the newborn instead.

Fathers and Skin-to-Skin Contact

Despite limited studies on SSC following a Cesarean exclusively, particularly regarding the role of fathers, the research to date has largely concluded that paternal SSC is optimal for the newborn’s well-being when separated from his or her mother after a c-section.21,22,23

In one study, the fathers’ SSC had a positive impact on infant crying behavior and also appeared to facilitate coordination of the pre-feeding behavior.19 SSC has also demonstrated benefits for the fathers too: helping to facilitate the transition of expectant fathers; hastening the developing of paternal attachment; and, enhancing confidence in assuming a parenting role.21,22,23 These benefits indicate that fathers may assume a greater role in immediate post-partum care of the baby when new mothers are physically weak.19

Father practicing skin-to-skin with twin babies

“Skin-to-skin contact presents a great opportunity for fathers to be more involved from the very beginning of his baby’s life. Hospitals and healthcare providers need to expand skin-to-skin initiatives to include fathers to aid their own transition into parenthood and enhance early bonding.”26 Paternal SSC should be encouraged to be continued even after discharge to that will continue to a positive bonding experience.

The power of SSC

To demonstrate the true power of SSC between parents and newborns, WaterWipes teamed up with one of the world’s leading experts on kangaroo care, Dr. Susan Ludington to track the impact of SSC on three newborns. Check out the powerful SCC video to see how SSC regulated their baby’s breathing, heart rate, oxygen levels and temperature within five minutes of being held in this position.

References
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1World Health Organization (2015) WHO Statement on Caesarean Section Rates. Retrieved September 2020 from https://apps.who.int/iris/bitstream/handle/10665/161442/WHORHR15.02_eng.pdf;jsessionid=720F375F2EF1734C5A5AE23E095EFDBD?sequence=1

2Weiss, R. (202) Giving Birth by a Surgical C-Section. Retrieved September 2020 from https://www.verywellfamily.com/giving-birth-by-c-section-2758508

3Tommy’s, 2018 What happens during a c-section. Retrieved September 2020 from: https://www.tommys.org/pregnancy-information/labour-birth/caesarean-section/what-happens-during-c-section

4World Health Organization & UNICEF. (2017). Protecting, promoting and supporting Breastfeeding in facilities providing maternity and newborn services. Retrieved September, 2020 from: https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf

5National Institute of Child Health and Human Development (2017) What are the recommendations for breastfeeding. Retrieved September 2020 from https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/recommendations

6Schneider L, Crenshaw J & Gilder R. (2017). 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. 28-33. 10.1016/j.nwh.2016.12.008. Retrieved September 2020 from: https://clinicalinnovations.com/wp-content/uploads/2017/05/1-s2.0-S1751485116303415-main2.pdf

7Chen EM, Gau ML, Liu CY, Lee TY. Effects of Father-Neonate Skin-to-Skin Contact on Attachment: A Randomized Controlled Trial. Nurs Res Pract. Retrieved September 2020 from: https://www.hindawi.com/journals/nrp/2017/8612024/

8Dominguez-Bello MG, Costello EK, Contreras M, et al. (2010) Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A. 107(26):11971–11975. doi:10.1073/pnas.1002601107. Retrieved September 2020 from: https://www.pnas.org/content/107/26/11971

9Baby-Friendly USA (2019) Interim Guidelines and Evaluation Criteria for Facilities Seeking and Sustaining Baby-Friendly Designation. Albany, NY, Baby-Friendly USA. Retrieved September 2020 from: https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/

10Elsaharty, Aya & McConachie, Ian. (2017). Skin to skin: A modern approach to caesarean delivery. Journal of Obstetric Anaesthesia and Critical Care. 7. 13. 10.4103/joacc.JOACC417. Retrieved September 2020 from: http://www.joacc.com/article.asp?issn=2249-4472;year=2017;volume=7;issue=1;spage=13;epage=19;aulast=Elsaharty

11Crenshaw JT. (2014) Healthy Birth Practice #6: Keep Mother and Baby Together- It's Best for Mother, Baby, and Breastfeeding. J Perinat Educ. 23(4):211–217. doi:10.1891/1058-1243.23.4.211 Retrieved September 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235060/

12Abdulghani, N., Edvardsson, K., & Amir, L. H. (2018). Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review. PloS one, 13(10), e0205696. https://doi.org/10.1371/journal.pone.0205696. Retrieved September 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209188/

13Guala A, Boscardini L, Visentin R, et al. (2017) Skin-to-Skin Contact in Cesarean Birth and Duration of Breastfeeding: A Cohort Study. ScientificWorldJournal. 2017:1940756. doi:10.1155/2017/1940756. Retrieved September 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610826/

14Dekker, Rebecca (2017) Evidence on: Skin-To-Skin After Cesarean. Retrieved September, 2020 from https://evidencebasedbirth.com/the-evidence-for-skin-to-skin-care-after-a-cesarean/

15Phillips, Raylene (2013) The Sacred Hour: Uninterrupted Skin to Skin Contact Immediately After Birth. NAINR 13(2):67-72. Retrieved September, 2020 from: https://www.medscape.com/viewarticle/806325_7

16Cadwell K, Brimdyr K, Phillips R. (2018) Mapping, Measuring, and Analyzing the Process of Skin-to-Skin Contact and Early Breastfeeding in the First Hour After Birth. Breastfeed Med. 13(7):485–492. doi:10.1089/bfm.2018.0048 Retrieved September, 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157340/

17Moore ER, Bergman N, Anderson GC, et al. (2015) Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev;25;11:CD003519. Retrieved 2020 from: https://www.cochrane.org/CD003519/PREG_early-skin-skin-contact-mothers-and-their-healthy-newborn-infants

18Stevens J, Schmied V, Burns E & Dahlen, H, (2014). Immediate or early skin-to-skin contact after a Caesarean section: A review of the literature. Maternal & Child Nutrition. 10. 10.1111/mcn.12128. Retrieved September 2020 from: https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.12128

19Brady K, Bulpitt D, Chiarelli C. (2014) An interprofessional quality improvement project to implement maternal/infant skin-to-skin contact during cesarean delivery. J Obstet Gynecol Neonatal Nurs.43(4):488–496. doi:10.1111/1552-6909.12469. Retrieved September 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491370/

20Zanardo, V., Pigozzo, A., Wainer, G., Marchesoni, D., Gasparoni, A., Fabio, S.D., Cavallin, F., Giustardi, A., & Trevisanuto, D. (2013). Early lactation failure and formula adoption after elective caesarean delivery: cohort study. Archives of disease in childhood. Fetal and neonatal edition, 98 1, F37-41. Retrieved September 2020 from: https://fn.bmj.com/content/98/1/F37

21Huang, X., Chen, L., Zhang, L. (2019) Effects of Paternal Skin-to-Skin Contact in newborns and Fathers After Cesarean Delivery. Journal of Perinatal and Neonatal Nursing 33(1): 68-73 Retrieved September 2020, from https://read.qxmd.com/read/30676465/effects-of-paternal-skin-to-skin-contact-in-newborns-and-fathers-after-cesarean-delivery

22Chen EM, Gau ML, Liu CY, Lee TY.(2017) Effects of Father-Neonate Skin-to-Skin Contact on Attachment: A Randomized Controlled Trial. Nurs Res Pract. 2017:8612024. doi:10.1155/2017/8612024. Retrieved September 2020 from: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3060-2

23Helth, T & Jarden, M (2013). Fathers' experiences with the skin-to-skin method in NICU: Competent parenthood and redefined gender roles. Journal of Neonatal Nursing. 19. 114–121. 10.1016/j.jnn.2012.06.001. Retrieved September 2020 from: https://www.clinicalkey.com/nursing/#!/content/playContent/1-s2.0-S1355184112001445?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1355184112001445%3Fshowall%3Dtrue&referrer=

24Anderzén-Carlsson A, Lamy ZC, Eriksson M. (2014) Parental experiences of providing skin-to-skin care to their newborn infant--part 1: a qualitative systematic review. Int J Qual Stud Health Well-being. 2014;9:24906. doi:10.3402/qhw.v9.24906. Retrieved September 2020 from: https://www.tandfonline.com/doi/full/10.3402/qhw.v9.24906

25Anderzén-Carlsson A, Lamy ZC, Tingvall, RM., Eriksson M. (2014) Parental experiences of providing skin-to-skin care to their newborn infant--part 2: a qualitative meta-synthesis. Int J Qual Stud Health Well-being. 9:10.3402/qhw.v9.24907. Retrieved September 2020from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197398/

26Louise, Marie (2020) The Modern Midwifes Guide to Pregnancy, Birth and Beyond. Vermillion, London ISBN 978-1-78504-296-6

About the authors

Kathryn Mikulencak is a Board Certified Pediatric Clinical Nurse Specialist from the United States working in a large metropolitan Level III Neonatal Intensive Care Unit. Marie Louise is an NHS Midwife, a PTLLS adult educator and hypnobirthing teacher from the UK and Author of The Modern Midwife's Guide to Pregnancy, Birth and Beyond.

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