|Year : 2017 | Volume
| Issue : 1 | Page : 13-19
Skin to skin: A modern approach to caesarean delivery
Aya Elsaharty, Ian McConachie
Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
|Date of Web Publication||1-Jun-2017|
Department of Anesthesia and Perioperative Medicine, Victoria Hospital, 800 Commissioners Rd E, London, Ontario – N6A 5W9
Source of Support: None, Conflict of Interest: None
Skin to skin care (SSC) after childbirth has been practiced for many years and has become part of the standard of care in many Neonatal ICUs. SSC during Cesarean Delivery is also increasingly popular in many countries. Some of the available literature have concerns regarding methodology but, overall, SSC provides benefits to the neonate in the form of maintained temperature homeostasis, cardiovascular and metabolic stability and less irritability. For the mother there is increased satisfaction, improved breastfeeding and improved bonding with her child. SSC is safe but vigilance must be maintained during SSC as there are potential risks of sudden postnatal collapse due to airway obstruction and asphyxia. There is little information in the Anesthesia literature concerning SSC. Implications for Anesthesia care providers and for Operating Room organisation are discussed.
Keywords: Anaesthesia, Caesarean Delivery, skin to skin
|How to cite this article:|
Elsaharty A, McConachie I. Skin to skin: A modern approach to caesarean delivery. J Obstet Anaesth Crit Care 2017;7:13-9
| Introduction|| |
Skin-to-skin care (SSC) after childbirth has been practised since many years. Several hospitals in various countries have or are considering introducing such practices – often as part of quality improvement initiative. This is increasingly patient driven. SSC during Caesarean Delivery (CD) is also increasingly popular in many countries.
CD is the commonest operation performed worldwide and has become very popular in recent years. Several doctors have attempted to humanise and “demedicalise” CD by improving the birthing experience, and thus, the overall maternal satisfaction. SSC represents one such initiative.
To the best of our knowledge, there is little information in the anaesthesia literature concerning SSC. However, there are implications for anaesthesia care providers and need to focus on specific perioperative considerations and concerns.
SSC involves placing a naked newborn chest down on the mother's bare chest and covering the infant with blankets to keep it dry and warm. Use of a diaper and/or a skull cap is optional in many centers. Until relatively recently, SSC has been the commonest after vaginal delivery but is becoming more commonplace in many centers after CD.
As regards the timing of placement, there is a consensus, as given below:
- Birth or immediate SSC starts during the first minute after birth
- Very early SSC begins 30–40 minutes post-birth
- Early SSC is any skin-to-skin time that takes place during the first 24 hours.
However, the recent Cochrane review defines immediate as from birth to 10 minutes and early as after 10 minutes post birth. One should, therefore, take care when assessing the timing of SSC in the literature as confusion may easily arise.
Relevance to obstetric anaesthesiologists
Obstetric anaesthesia is different in several important ways from anaesthesia for other types of surgical procedures. We facilitate bringing new life into the world, the primary patient (the mother) is usually in good health and patient satisfaction is one of the most important quality outcomes. One crucial difference from other anaesthesia subspecialties is that obstetric anaesthesia concerns itself with two patients – the mother and the foetus. This concern with the foetus extends into the early neonatal period in that it influences use of anaesthesia drugs, anaesthetic techniques, and procedures on neonatal outcomes, and overall wellbeing of both patients is a hallmark of obstetric patient care. Indeed, anything influencing care of the newborn and perinatal outcomes or potentially posing risks to the newborn is and should be of relevance to us. SSC falls into these categories.
On a broader level, anything that happens in the obstetric theatre should be of interest to an anaesthesiologist:
- Anaesthesia as a specialty is heavily involved in patient safety – that should also include the neonate in the room
- If introduced in our hospital, we will become involved with this initiative and if we are not aware of the issues we may indirectly become responsible for the safety of the newborn baby in our theatre
- Extra personnel, changes in room layout, interference with monitoring and clinical care etc., are all relevant to the anaesthesiologist
- Anaesthesia personnel will be involved in assessing the suitability of mother and baby for SSC during CD.
| History of Skin-to-skin Care|| |
Skin-to-skin after vaginal delivery
Midwifery (literally meaning “with women”) was the traditional model throughout history for caring for women through child birth and assisting with the birth process – mainly in the home. With advances in medicine and medical care, doctors became more involved with childbirth and childbirth in hospitals became the norm in many countries. There were several associated advances in the safety of childbirth and improvements in maternal and perinatal mortality, but increasingly often mothers were separated from their babies shortly after birth.
Throughout history, SSC after childbirth was commonplace and babies stayed in the care of their mothers. In recent years SSC has become popular once more and increasingly preferred by many mothers.
| Kangaroo Care in the Neonatal Intensive Care Unit|| |
A form of SSC is Kangaroo Care (KC) named after the way marsupials such as Kangaroos carry their newborn young. The importance of immediate body-to-body contact between mother and baby was first suggested in 1970. This paper  also postulated that premature babies may also benefit from this early maternal contact. Subsequently, KC was promoted for premature babies in low resource settings where incubator care was in short supply. A later consensus emerged that all premature babies would benefit from this form of care  and this is now part of standard NICU practice. Implicit in the practice is the attempt to initiate breastfeeding in the NICU. The term itself seems to have been coined in 1986. In well-resourced countries, KC in NICU is seen as mainly an adjunct to the technology and other therapies that require separation of the mother from the infant. Although KC has not been well studied in extremely premature babies, available evidence in premature babies seems clear that KC promotes successful breastfeeding, temperature stability and better sleeping patterns. Mothers report improved bonding with their babies. In low-resource countries, KC has been shown to reduce infections, mortality and length of hospital stay. Follow up at 20 years suggests the benefits of KC are maintained in the form of improved neurology and social behaviours. Interestingly, the KC group had increased total grey matter, cerebral cortex and left caudate nucleus volumes compared to the standard care follow-up group.
Another study confirms that “Kangaroo mother care is a basic right of the newborn and should be an integral part of the low birth weight and full term newborn's care, in all settings, in all levels of care, and in all countries.”
Breastfeeding is considered to provide the best nutrition and immune support for new born babies. Recognising these advantages, a joint initiative by the United Nations Children's Fund (UNICEF) and the World Health Organisation (WHO) was launched in 1991 to promote universal breastfeeding. Known as the Baby-Friendly Hospital Initiative (BFHI), one of the 10 steps involves immediate SSC. This facilitates the encouragement of breastfeeding within 30 minutes of birth. No provision is made for applying different standards for birth by CD (although from a practical point of view, this is not possible on occasions where CD is performed under general anesthesia (GA)). Surgical birth is known to reduce the initiation of breastfeeding., Chaplin et al. in an exploration of maternal breastfeeding difficulties following CD under regional anesthesia, revealed the lack of true skin-to-skin contact as one of the key contributing items needing to be addressed, along with inadequate staffing and effects of physical and emotional stress of anesthesia and birth. SSC is thus seen as a crucial component of the BFHI.
According to the WHO, more than 20,000 hospitals and maternity units in 156 countries have been awarded baby-friendly status. A total of 32 countries are on course to meet the World Health Assembly target of more than 50% of babies exclusively breastfed during the first 6 months of life. In the USA, the Centre for Disease Control reported that the proportion of babies born in baby-friendly hospital increased from 1% in 2005 to 14% in 2015 and approximately 54% of hospitals were implementing a majority of the 10 steps in the BFHI in 2013. Many institutions (including my own) have invested heavily in campaigns promoting the benefits of SSC – in part to gain baby-friendly status [Figure 1].
|Figure 1: Local skin-to-skin care campaign in authors' institution. © Developed by the London-Middlesex Health Unit and reproduced with permission|
Click here to view
| Limitations of the Skin-to-skin Care Literature|| |
Much of the literature is in nursing and midwifery journals. Almost universally, studies highlighting potential risks or instances of actual harm are in medical journals (mainly paediatric journals to be precise). Concerns can be raised for some of the published literature:
- Poor methodological quality in many studies
- Lack of blinding and low numbers is also a potential problem
- No consistency regarding timing or duration of SSC – can be thought of as the “dose” of SSC
- Potential assessor bias is also an issue
- Few studies after CD compared to after vaginal delivery. Even fewer on immediate skin-to-skin in the operating room (OR)
- Studies mainly of healthy babies
- Several surveys, questionnaires and implementation reports – with potential for bias
- Control group issues (see below).
Overall, the most recent Cochrane Review of 46 trials with 3850 mother/baby dyads concluded that “Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants.”
A major concern with many studies is: What is the routine standard of care, i.e., the control group (if there is one)?
There is a wide variation of normal practice described in studies from different countries and different hospitals:
- Practices where baby is wrapped and brought to mother and or partner in the OR to hold
- Practices where the baby is separated from mother after birth while mother is in the OR. For example, in one study SSC was only implemented later after surgery in the recovery room 
- Practices that seem unusual to many, e.g., baby placed in a cot beside the father in the recovery room but father not allowed to touch or comfort the baby – presumably solely for the purposes of a study on the benefits of paternal SSC.Enforced separation of the mother from her baby during CD is not considered normal care in many institutions. Thus, comparing SSC to normal practices such as in the examples above may be likely to generate results that may exaggerate the benefits of SSC.Conversely, studies where there was immediate and prolonged contact between all mothers and their babies in the OR may find it more difficult to show a beneficial effect of SSC.
The variations in protocols and control group care makes comparing studies and meta-analyses difficult and potentially limits applicability of the benefits of SSC for institutions with a more humane approach to keeping babies with the mother as much as possible (even in the absence of formal SSC).
| Benefits of Skin-to-skin Care|| |
There are significant potential benefits of SSC for the mother and the newborn. However, most of the literature has been centered on SSC following vaginal births with fewer studies assessing SSC during CD.
For the infant
- Immediate SSC was found to offer temperature synchrony between mother and newborn and improve thermoregulation and temperature maintenance., It was found that the infant's hands and feet were warm within 90 minutes of initiating SSC
- Not all studies have demonstrated improved temperature homeostasis in the newborn infant  – but they also have found no evidence of increased risk of hypothermia during and after SSC after CD
- Physiological stability with higher neonatal blood glucose levels 75–90 minutes following delivery in infants experiencing SCC  than those receiving standard care
- Neonatal cardio-respiratory stability and significantly lower respiratory rates were recorded in infants exposed to early SSC 
- Infants were observed to cry less when laid on their mother's chests during SCC indicating less stress.
For the mother
- Improved breast feeding outcomes in most studies:
- Early initiation and increased duration of breastfeeding , was noted when early SSC was achieved
- Women practicing SSC after CD were probably more likely to breastfeed one to four months post birth. However, increased breastfeeding duration was not proven to be statistically significant in one of the largest studies of SSC after vaginal delivery 
- Breast engorgement pain, which is a commonly encountered issue in the early postpartum period, was less for SSC than non-SSC mothers on day three post birth 
- Mothers experiencing SSC showed more confidence in child care and better bonding with their infants 
- The overall birth experience can be improved during CD – comparable to that of vaginal deliveries. This study also showed less anxiety amongst mothers regarding the health and wellbeing of their infants
- After CD, one study found less maternal pain in mothers providing SSC  but a second study reported no significant difference in maternal pain.
For the father
Some studies have examined whether SSC with the father during or after CD provides any benefits (other than potential improvements in paternal bonding).
- Paternal SSC resulted in more settled behavior and less crying by infants. However, in this study the baby was placed in a cot beside the father in the recovery room but the father was not allowed to touch or comfort the baby
- Earlier breastfeeding occurs (perhaps not surprisingly) when SSC is provided by the mother rather than the father.
Paternal SSC may be considered, for example, in post-anesthesia care unit (PACU) if the mother is unable to provide SSC due to illness, sedation or GA.
Overall, we need to be cautious when extrapolating the benefits of SSC after vaginal delivery to CD. More work is clearly required for SSC after CD. It is also uncertain whether there are differences in benefits related to the timing of SSC (immediate versus early or in the OR versus in the PACU) or from different durations of SSC.
Although these benefits may seem of little direct relevance to anaesthesiologists, the reported improvements in perinatal outcomes resulting from SSC in the theatre are undoubtedly worthwhile.
| Potential Risks of Skin-to-skin Care|| |
Overall, SSC is considered a safe practice. Indeed, one prominent website states “The researchers found NO risks related to skin-to-skin care—only benefits.”
The vulnerability of newborn infants; however, warrants careful consideration of the risks of SSC and appropriate precautions and safeguards to be in place. Numerous case reports have shown newborns requiring resuscitation as a result of hypotonia, apnea and sudden unexpected postnatal collapse (SUPC) of an apparently healthy infant occurring within the first two hours post birth. Often, this may happen during the first breastfeeding attempt or during maternal inattention, e.g., using mobile cellphones.
A German national reporting system has found the incidence of sudden infant death and a severe life-threatening event within 24 hours of birth to be 2.6 in 100 000 live births. In 9 of 17 infants, the event had occurred within 2 hours of birth - 9 while still in the delivery suite. A total of 12 newborns were found lifeless while lying on their mother's breast/abdomen or very close to and facing her. In 7 infants, the event was discovered by a health professional with the mother not noticing her infant's condition despite her being present and awake!
Others  report tragic events in healthy infants prone on his or her mother's abdomen during early SSC. Commonly, the mother is primiparous and the mother and infant had not been observed during the initiation of SSC and breastfeeding.
The circumstances of the majority of these cases suggest accidental asphyxia during unmonitored and unobserved SSC as the cause.
Suggested risk factors include:
- Baby prone sleeping - infant's nose pressed against the mother's breast or abdomen
- Maternal obesity
- Inexperience in new mothers with their first baby
- Maternal sedatives, analgesics
- Post-natal fatigue/exhaustion.
It is strongly recommended that newborn infants must be observed during SSC for the first few hours after birth because of the small risk of apnea during SSC in the prone position. SSC is still to be encouraged but the potential risks must not be underestimated and appropriate monitoring, support and care of the mother is crucial to maintain safety.
There is also potential for babies to be dropped if unsupported or unmonitored during SSC – especially if the mothers are fatigued or have been sedated. Use of sedation medications (especially during urgent CD) and the natural sedation associated with regional anaesthesia  must all be taken into account in assessing risks associated with SSC.
A recent position paper from the American Academy of Pediatrics  thoroughly reviewed the risks associated with SSC, encouraged vigilance and suggested practices to maintain the safety of SSC.
In our attempts to demedicalise CD we must not over trivialise a major abdominal surgical operation, which has considerable risks and a prolonged recovery period. We should always promote vaginal delivery where appropriate over CD, be aware of all the implications of rising CD rates worldwide and aspire to robust indications for CD. CD at maternal request is associated with more maternal bleeding, maternal infections and increased breastfeeding difficulties compared to vaginal deliveries. Similarly, infants born by CD at maternal request were noted to have more hypoglycemia episodes and more respiratory distress. As the patients' advocates, we should beware of hospitals potentially using SSC as a marketing tool for CD.
| Patient Suitability|| |
Anaesthesia care providers and the obstetricians are ultimately responsible for the care and safety of the mother if SSC is practiced during CD. What can be less certain in many institutions is: who is responsible for the care and safety of the baby during SSC? Neonatologists, nurses and midwives may all be involved and local policies and procedures must be established. The mother, father or other partner present are not responsible for the safety of the baby during SSC in the OR.
In general, SSC in the OR is not appropriate for:
- CD performed under GA
- Situations with high probability of maternal or fetal complications
- Sick mothers – obstetricians and anaesthesia providers to decide if mother is stable enough to provide SSC
- Sick babies – neonatologists should decide if baby is sufficiently stable and healthy enough to tolerate SSC. This may limit SSC for many urgent CDs
- Preterm babies – Many centers would not permit SSC of babies born at less than 37 weeks' gestational age
- Staffing shortages. Many centers recommend that a specific nursing or other caregiver be present in the OR to monitor the baby
- Maternal refusal.
Anaesthesia providers, obstetricians, neonatologists or nursing care givers should, at their discretion, be able to terminate SSC at any point during the CD.
| Practicalities and Implementation|| |
Collaboration between all healthcare professionals  and a formal agreed protocol is essential before implementation of SSC for CD in the OR.
- As previously mentioned, some studies report more nursing staff are needed in order that a nurse/midwife is available and responsible for the baby when SSC is being considered in the OR ,
- This may have implications for operating room costs if more staff are required to facilitate SSC
- Conversely, depending on the funding models, if more women are attracted to the hospital due to the availability of SSC, this can have positive effects on hospital finances.
Safety is paramount and staff needs to be educated and trained in the safe provision of SSC in the OR, and in particular, in the monitoring of the baby that is required because of the low risk of apnea.
Planning for individual cases
- The mother's wishes should be determined by a member of the healthcare team and should be communicated in advance to the OR team. Some mothers are initially hesitant due to fear of dropping the baby  and should be reassured
- We suggest the plan for SSC should be part of the Surgical Safety Checklist 
- Both the anaesthesia and obstetric teams should determine whether the CD is an appropriate situation for SSC
- Appropriate documentation of SSC should be made in the hospital chart as per local policies.
Care of the baby
- Nursing procedures will differ from site to site but it may be prudent to first dry the baby. Then, after an initial assessment, the newborn baby should be placed diagonally on the mother's chest but not lower than 1–2 cm below the nipple line. This assessment may even be done while doing SSC including the assessment by the neonatologist. A warm blanket should be placed over the mother and baby, and a hat placed on the newborn's head. Skin-to-skin is implied but the baby's back may be covered. The baby's face should be visible, the nose (and mouth if not breastfeeding) should be unobstructed and the neck straight – neither excessively bent forward nor back. A diaper is considered optional in many centers
- The nurse/midwife responsible for the baby should monitor (and document) usual vital signs such as respiratory rate and effort, presence of mucous, skin color, tone, behavioral state and feeding cues
- Close attention should be paid to maternal and baby temperature. SSC usually maintains baby temperature, but if there are any concerns regarding hypothermia, SSC should be terminated and immediate steps taken to further monitor and care for the baby
- It is beyond the scope of this review to discuss techniques and processes associated with successful breastfeeding but intraoperative breastfeeding should be encouraged.
- It is likely that more space will have to be made available at the patient head end of the OR
- The midwife/nurse caring for the baby should not stand between the anaesthesia machine/anaesthetist and the patient's head. Instead, they should remain at the mother's side and within arm's reach for easy access to the baby
- The anaesthesia care provider must have access to the mother for monitoring and patient care
- The mother should have her OR gown arranged and loosened so as to allow easy access to her skin. There should be an accompanying warm blanket. It is suggested that the anaesthetist places the ECG leads on the mother's shoulders and left side, away from the front of her chest so as to avoid interference with SSC
- Any poles used to secure surgical drapes should be place on the obstetric side of any arm rests to maximize room for SSC and permit easier access of the care giver and the baby to the mother's chest
- At the end of the surgery, the baby may be covered and given to the father or other support person present with the mother prior to removal of the surgical drapes and transfer to the recovery room. SSC may resume in the PACU.
In an effort to improve the maternal experience during CD (and facilitate SSC), some hospitals and manufacturers have developed:
- Transparent drapes
- Drapes with flaps that baby can be passed through after delivery
- Drapes that can easily be lifted up so baby can be passed to the mother and her nurse/midwife care giver.
| Implementation Problems|| |
In our hospital, SSC had been practiced for some time after vaginal delivery. Midwives were enthusiastic. Obstetrician support was initially variable. Breastfeeding support groups also were vocal in support. Hospital management was seeking BFHI certification and were broadly supportive while also expressing concerns and reservations regarding additional costs – for example, additional personnel in theatre to monitor and be responsible for the newborn baby.
The key to successful implementation revolved around communication and discussions amongst all interested parties. Multidisciplinary grand rounds were held involving presentations from obstetricians, anaesthesiologists and midwives. This, plus discussions at anaesthesia meetings largely reassured the anaesthesiologists regarding the benefits, risks, practicalities, logistics and responsibilities of the new initiative. Compromises were ultimately made; for example, regarding equipment layout in the obstetric theatres. Knowing that they will have immediate veto power of SSC if any concerns arise reduced anxieties amongst anaesthesiologists regarding SSC in the theatre. There were also some anxieties regarding education and staffing numbers amongst the obstetric nurses in the theatre.
At all times, the role of anaesthesia providers in this process has been to emphasise the importance of maintaining safety for both mother and baby.
| Conclusions and Recommendations|| |
- Despite concerns regarding the scientific validity of much of the early work on the benefits of SSC, those benefits are almost certainly of real value
- It is very likely that SSC after CD provides similar benefits and should be encouraged
- However, we should not be complacent and remain vigilant against the potential risks of SSC
- It is recommended that larger, high-quality studies be performed especially after CD
- Although anaesthesia providers may not be directly responsible for the safety of the baby during SSC at CD, we should ensure a safe environment for SSC in the OR
- Hospitals should develop protocols for SSC during CD to ensure safety and improve maternal birthing experience
- SSC must be introduced and practiced in a professional and collaborative manner
- There will be occasions when SSC cannot safely happen – and this should be respected always
- Likely increasing pressure for this to happen and likely to increasingly be driven by patient request.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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