Effects of Skin to Skin During Cesarean Sections1

EFFECTS OF SKIN TO SKIN DURING CESAREAN SECTIONS1

Effects of Skin to Skin on Mother-Newborn DyadsDuring Cesarean Sections

Katelyn Swanger

The Pennsylvania State University Harrisburg Campus

Abstract

A review of literature was conducted to address the PICO question: in maternal-newborn dyads, is immediate skin to skin contact post cesarean section as effective as usual care in promoting infant stability, breastfeeding and maternal satisfaction. Significant findings of this review of literature include newborn temperature regulation, decreased newborn stress, more effective breastfeeding and positive maternal opinions with the experience. The implications of these findings are that the practice of skin to skin contact immediately or early after cesarean section should be educated about and utilized more frequently in everyday practice.

Keywords: skin to skin contact, cesarean, newborn, benefits, breastfeeding, satisfaction

Effects of Skin to Skin on Mother-Newborn DyadsDuring Cesarean Sections

Skin to skin contact is the practice of placing a naked or diapered newborn on the bare chest of either their mother or father while covering them with warm blankets (Lowdermilk, Perry, Cashion & Alden, 2012). Over the past several years a large amount of research has been done to test the benefits of this practice both in the post-delivery setting and throughout infant development. Some of these benefits include thermoregulation, increased infant stability, increased infant-mother bonding, improved breastfeeding and more (Moore, Anderson, Bergman, & Dowswell, 2012). The World Health Organization (WHO) has two recommendations pertaining to this type of practice (World Health Organization, 2012). The first recommendation is that all healthy newborns should spend the first hour of their lives in skin to skin contact with their mothers for reasons pertaining to temperature regulation and breastfeeding (World Health Organization, 2012). The second recommendation is that once the mother and newborn are stable, breastfeeding should be initiated as early as possible for all able newborns(World Health Organization, 2012). With these recommendations the practice of skin to skin contact has become common during vaginal deliveries; however, “usual” or common practice after cesarean sectioninvolves separating the mother and newborn until both patients are transported into the PACU or later (Gouchon et al., 2012; Zwedberg, Blomquist, & Sigerstad, 2015). According to the CDC, for the last several years (2010-2013) around 32.7-32.8% of all births are performed via cesarean Section (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015).Studies have also shown that newborns delivered via cesarean section have lower breastfeeding rates and increased risk of developing negative outcomes, like hypothermia, than infants delivered vaginally (Zwedberg et al., 2015; Gouchon et al., 2012). Due to the benefits associated with the use of skin to skin contact and the recommendations of the World Health Organization, researchers believe that implementing skin to skin contact immediately or shortly after cesarean delivery maybe beneficial to newborns; however, there are several barriers to this practice. Zwedberg et al. (2015) identified that one of the largest barriers to implementation of skin to skin contact after cesarean section included a general lack of knowledge of both medical staff and patients about its use. Therefore, the following PICO question was developed: in maternal-newborn dyads, is immediate skin to skin contact post cesarean section as effective as usual care in promoting infant stability, breastfeeding and maternal satisfaction.

Search for Evidence and Terms

A search for evidence was conducted utilizing the Pennsylvania State University library’s collection of databases. The PubMed, CINAHL and Cochrane databases were searchedfor peer reviewed, English speaking, journal articles from the last ten years, 2005-2015. Keywords like “skin to skin contact,” “newborn,” “cesarean,”“hypothermia,” and “breastfeeding” were utilized to obtain articles during this search.The articles were then reviewed and those chosen focused on skin to skin use with cesarean sections and the newborn outcomes, breastfeeding outcomes and maternal satisfaction associated with its use.

Skin to Skin Contact with Cesarean Sections and Newborn Outcomes

The literature indicates that a common misconception around skin to skin contact after a cesarean delivery is that it increases the newborn’s risk of developing hypothermia due to the operating room environment (Gouchon et al., 2012). This is a concerning assumption because if an infant is hypothermic they have the potential of developing cold stress whichcan lead to increased oxygen demand and can result in negative cardiovascular and neurological effects(Lowdermilk, Perry, Cashion & Alden, 2012). Several studies were obtained that addressed this concern. The literature indicates that the use of skin to skin contact after cesarean section does not increase the risk of newborns developing hypothermia anymore than the usual care that is currently being performed (Gouchon et al., 2012; Beiranvand, Valizadeh, Hosseinabadi, & Pournia, 2014; Stevens, Schmied, Burns, & Dahlen, 2014; Moore, Anderson, Bergman, & Dowswell, 2012).Both Gouchon et al. (2012) and Beiranvand et al. (2014) randomly assigned their clients to either an intervention group that used skin to skin contact or a control group that received usual care post-operatively to find that there was no significant difference between the temperatures of the two groups.Another studyof 50 mother-infant pairs conducted by Nolan and Lawrence (2009)specifically looked at the effectiveness of utilizing the NIMs protocol, which focuses on decreases the amount of separation time between the mother and the newborn by utilizing techniques likeskin to skin contact. This study found that the infants that received implementation of this protocol had higheraverage temperatures than those that received the care that is customarily performed (Nolan & Lawrence, 2009).Other studies conducted literature reviews and meta-analyses in order to obtain their data (Steven et al., 2014; Moore et al., 2012). Overall, the misconceptions of health care employees involved with cesarean sections around the risk of hypothermia should be corrected and educated about so that it is no longer considered a barrier to implementing the practice. However, since the studies previously reviewed implemented skin to skin contact early after cesarean section, more research needs to be conducted in this area to see if the risk of hypothermia is still insignificant when skin to skin contact is implementedintra-operatively.

After reviewing the literature, several other measures were identified pertaining to newborn outcomes. The study conducted by Nolan and Lawrence (2009)discussed above also looked at several other infant outcome measures. It was determined that the infants not only had higher temperatures but they also had lower respiratory rates and higher salivary cortisol levels. These findings indicate that the infants that were placed skin to skin and had less time away from their mothers were under less stress than those that received usual care (Nolan & Lawrence, 2009). A qualitative study conducted by Frederick, Busen, Engebretson, Hurst, & Schneider (2014) also observed that the use of skin to skin contact had a calming effect for both the mother and the infant. When skin to skin contact was conducted with the partner or father figure of the newborn, which is ideal for situations where the mother is not able to perform skin to skin, itwas found that there is less newborn crying when they are placed skin to skin (Erlandsson, Dsilna, Fagerberg, & Christenson, 2007). Overall, the literature indicates that infants placed in immediate and early skin to skin contact exhibit behaviors that are indicative of being under less stress which, could indicate that they are having an easier transition to life outside of the womb.

Skin to Skin Contact with Cesarean Sections and Breastfeeding

Due to benefits associated with breastfeeding for both mothers and newborns, hospital labor and delivery units often have goals around the use and exclusivity of breastfeeding for its clients due to recommendations from WHO, Healthy People 2020 and The Joint Commission(The Joint Commission, 2015; U.S. Department of Health and Human Services, 2014; World Health Organization, 2012). Therefore, hospitals are continually looking for ways to increase their breastfeeding rates. The literature indicates that the use of skin to skin contact with cesarean section patients may help to improve breastfeeding. A common measure studied among the reviewed research articles was the initiation of infant pro-feeding behaviors like rooting and sucking. A qualitative study performed by Frederick et al. (2014) studied skin to skin contact being performed with 11 women-newborn pairs intra-operatively. During the experiment the researchers observed infant pro-feeding behaviors; however, there were no documented incidences of the newborn latching onto the mothers breast in the operating room (Frederick et al., 2014). Another study that randomly assigned 96 mother-newborn pairs to either receive skin to skin contact or usual care postoperatively observed infants receiving skin to skin contact to be significantly more ready to breastfeed than those receiving usual care (Beiranvand et al., 2014). Interestingly though when Erlandsson, et al. (2009) randomly assigned 29 infants to receive either skin to skin contact with a paternal substitute or the usual post-operative care, they observed there to be less pro-feeding behaviors among the skin to skin contact infants. The researchers attributed this to a higher level of infant comfort because they also found there to be less infant crying as well (Erlandsson, 2009).

Other common measures found during this literature review included effectiveness of breastfeeding and formula supplementation. Hung and Berg (2011) utilized a LATCH score, whichis a breastfeeding measuring tool that allows medical professionals to measure the effectiveness of breastfeeding by monitoring for an effectiveLatch,listening for an Audible swallowing, observing the Type of nipple, measuring maternal Comfort and inspecting the infant Hold (Hung & Berg, 2011). After 9 months of implementation, the researchers found that when skin to skin contact was implemented early with cesarean sections there was on average higher LATCH scores (Hung & Berg, 2011). Hung and Berg (2011) also found there to be decreased formula supplementation during hospitalization as well. Stevens et al. (2014) performed a review of literature that also looked at formula supplementation among infants that received skin to skin contactimmediately or early after cesarean section. This research found the use of skin to skin after cesarean sections to lead to a 41% decrease in formula supplementation. They also found that the newborns latched on to the mother’s nipple approximately 21 minutes earlier than those that received usual care (Stevens et al., 2014).

The last common measure among researchers studied in this literature review was exclusivity of breastfeeding. A randomized control trial performed by Gouchon et al. (2012)reported that though there was not a significant difference between groups, a greater amount of infants receiving skin to skin contact after a cesarean section were breastfeed more exclusively at discharge and at 3 months of age than those receiving usual care away from their mothers. Other researchers including Steven et al. (2014) found there to be no statistically significant difference in the exclusivity of breastfeeding among the newborns receiving skin to skin contact and those receiving the customary care. Overall, there appears to be mixed findings related to exclusivity of breastfeeding; however, there was not a significant amount of data pertaining to this topic and more research should be conducted to determine how immediate and early skin to skin contact post cesarean section effects breastfeeding exclusivity.

Skin to Skin Contact with Cesarean Sections and Maternal Satisfaction

Another measure commonly found among the literature being reviewed pertained to maternal perceptions of the use of skin to skin contact with cesarean sections both intra and post-operatively. Studies that initiated the skin to skin contact intra-operatively including Frederick et al. (2014) and Sundin and Mazac (2015) utilized qualitative methods in order obtain their data. One of the common themes developed from maternal responses during these qualitative studies included that implementation of skin to skin contact worked as a distraction from the operating room environment (Frederick et al., 2014; SundinMazac, 2015). Other disclosures included reported calming effects of the intervention, greater feelings of satisfaction among the mothers, and stating that they were able to bond with their newborn (Frederick et al., 2014; SundinMazac, 2015). Gouchon et al. (2012), who randomly assigned mothers to either receive skin to skin contact or usual care post cesarean section surveyed their clients about the experience and found that most of the mothers who received skin to skin contact reported high levels of satisfaction and feelings of improved infant bonding (Gouchon et al., 2012). Maternal pain levels were also studied and qualitatively mothers reported decreased levels of pain; however Stevens et al. (2014) and Nolan and Lawrence (2009) found there to be no statistical significance in the pain scores of the mothers who used skin to skin contact when compared to the mothers who used usual care (SundinMazac, 2015).

Gaps in the Research

Overall, this review of literature covers the basics of the effects of skin to skin contact when it is used intra-operatively and post-cesarean section; however, there are several gaps in this review of literature that would require further research. First, there are inconsistencies among the literature that was reviewed pertaining to when the skin to skin contact was initiated. Therefore, it is this researchers opinion that more randomized control trials need to be conducted that implement skin to skin contact intra-operatively, especially when looking at newborn outcome measures, like thermoregulation, in order to gain a better understanding of its effects.Also, more research should be done using a larger number of participants in order to make the data obtained more generalizable to the entire population. The last gap identified by this researcher is that more longitudinal studies need to be conducted in order to obtain more information about how skin to skin contact use in cesarean sections affects exclusivity of breastfeeding. Only one of the studies included in this review of literature measured breastfeeding exclusivity past the initial hospital stay.

Conclusion

In conclusion, the literature shows that when skin to skin contact is initiated either immediately or early after Cesarean section delivery it can have significant positive outcome for newborns, breastfeeding and maternal satisfaction. Temperature and respiratory regulation, decreased stress, less crying, increased pro-feeding behaviors, decreased formula supplementation, earlier breastfeeding, and improved bonding are just some of the benefits identified. These findings indicate that clinically, if the intervention of skin to skin contact after cesarean section would be implemented more exclusively, hospitals may see improvements in breastfeeding rates, patient satisfaction and newborn outcomes which follows the recommendations of the WHO and the Joint Commission (World Health Organization, 2012; The Joint Commission, 2015). Although a lot of positive results are found more research still needs to be conducted specifically looking at implementation of skin to skin contact in the intra-operative area in order to improve the reliability, validity and generalizability of the research. Overall, however, it can be concluded that this practice is beneficial for mother-newborn dyads and clinically education should be implemented to both medical staff and patients in order to increase the use of this practice.

References

Beiranvand, S., Valizadeh, F., Hosseinabadi, R., & Pournia, Y. (2014). The effects of skin-to-

skin contact on temperature and breastfeeding successfulness in full-term newborns after

cesarean delivery.International Journal of Pediatrics, 2014, 846486.

doi:10.1155/2014/846486

Erlandsson, K., Dsilna, A., Fagerberg, I., & Christenson, K. (2007). Skin-to-skin care with the

father after cesarean birth and its effect on newborn crying and prefeeding behavior.

Birth: Issues in Perinatal Care, 34(2), 105-114. doi:

10.1111/j.1523-536X.2007.00162.x

Frederick, A. C., Busen, N. H., Engebretson, J. C., Hurst, N. M., Schneider, K. M.(2014).

Exploring the skin-to-skin contact experience during cesarean section.Journal of the

American Association of Nurse Practitioners.doi: 10.1002/2327-6924.12229

Gouchon, S., Gregori, D., Picotto, A., Patrucco, G., Nangeroni, M., & Di Giulio, P. (2010). Skin-

to-skin contact after cesarean delivery: An experimental study. Nursing Research, 59(2),

78-84. doi:10.1097/NNR.0b013e3181d1a8bc

Hung, K. J., & Berg, O. (2011).Early skin-to-skin after cesarean to improve breastfeeding.The

American Journal of Maternal/Child Nursing, 36(5), 318-324. doi:

10.1097/NMC.0b013e3182266314

Joint Commission, The. (2015). Specifications manual for joint commission national quality core

measures: Perinatal care (version 2015B2). Retreived from

Lowdermilk, D.L., Perry, S. E., Cashion, K., & Alden, K. R. (2012).Maternity & women’s

health care. (10thed.). St. Louis, MO: Mosby Inc.

Martin, J. A., Hamilton, B. E., Osterman, M., Curtin, S. C., Mathews, T. J. (2015). Births: Final

data for 2013. National Vital Statistics Reports, 64(1).

Moore, E. R., Anderson, G. C., Bergman, N., Dowswell, T. (2012). Early skin-to-skin contact for

mothers and their healthy newborn infants (review). Cochrane Database of Systematic

Reviews, 5.doi: 10.1002/14651858.CD003519.pub3

Nolan, A., & Lawrence, C. (2009). A pilot study of a nursing intervention protocol to minimize

maternal-infant separation after cesarean birth. Journal of Obstetric, Gynecologic, &

Neonatal Nursing, 38(4), 430-442. doi: 10.1111/j.1552-6909.2009.01039.x

Smith, J., Plaat, F., & Fisk, N.M. (2008). The natural caesarean: A woman-centred technique.

BJOG: An International Journal of Obstetrics & Gynaecology, 115(8), 1037-1042.

doi:10.1111/j.1471-0528.2008.01777.x

Stevens, 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(4), 456-473. doi:10.1111/mcn.12128

Sundin, C. S., & Mazac, L. B. (2015). Implementing skin-to-skin care in the operating room after

cesarean birth. The American Journal of Maternal/Child Nursing, 40(2), 249-255. doi:

10.1097/NMC.0000000000000142

U.S. Department of Health and Human Services. (2014). Healthy people 2020: Maternal, infant,

and child health. Retrieved from

Zwedberg, S., Blomquist, J., & Sigerstad, E. (2015). Midwives’ experiences with mother-infant

skin-to-skin contact after a caesarean section: ‘Fighting an uphill battle.’ Midwifery,

31(1), 215-220. doi: 10.1016/j.midw.2014.08.014