Implementing skin-to-skin in a hospital

Alethea, a labor & delivery nurse in a small community hospital, wrote this guest post about how to implement skin-to-skin in a hospital. Sometimes a big change in policy starts with just one nurse's efforts! 


If you would like to get in touch with Alethea, please leave your email address in the comments or send me an email, which I will forward on to her. She is more than happy to answer your questions.

As expectant mothers near the end of pregnancy, they begin to prepare themselves mentally and physically for the upcoming birth of their baby. While imagining what labor and birth might be like for them, they often daydream about holding their baby in their arms for the first time, immediately after birth. It is instinctive for new mothers to want to hold their babies close, nourish them, and keep them safe and warm.

In recent years, studies have shown what mothers have known in their hearts since the beginning of time: that skin-to-skin contact immediately following birth is best for mothers and their healthy babies. Healthy newborns placed skin-to-skin on their mother have a surprisingly easy time adjusting to life outside the womb. Skin-to-skin contact helps keep babies warm. Babies also cry less, have more stable blood sugar levels, sleep more, experience less pain from painful procedures, and are interested in breastfeeding sooner than newborns who are separated from their mothers.

I am a labor and delivery nurse in a small community hospital. We attend the deliveries of 350-450 births per year. I began recognizing that it was not a part of our culture to support immediate skin-to-skin contact with new moms and babies. Often, doing as they were trained to do, nurses would whisk the baby over the warmer, clean her up, weigh her, measure her, administer baby meds, etc while the placenta was being delivered and the physician was repairing the mom’s perineum if needed. Often, I then witnessed the baby being wrapped up in multiple layers of blankets, with only his face visible to finally meet his mother mother for the first time 15-20 minutes after birth. My colleagues and I were simply task-oriented; we did not recognize what we were denying these moms and babies. We were all trained under a medical model of obstetrical care, and we were simply trying to get our jobs done as efficiently as possible. Ah, but old dogs can be taught new tricks (or ancient tricks that they just didn’t know yet)!

When I was first training as a labor and delivery nurse, I worked in a large urban city hospital that had both midwifery-model care delivered by certified nurse midwives, as well as medical-model care delivered by physicians. (Granted, some midwives seemed to function under the medical model and some physicians seemed more midwifery-model oriented, but that is another story.) In my training and subsequent employment, I witnessed the beauty and the benefits of providing immediate skin-to-skin contact between moms and babies, as it was strongly supported by the midwives with whom I worked. I feel so blessed to have had the midwifery model of care as a part of my training. Many moms and babies have benefited from what I learned from those midwives (and some physicians).

So, how did we go about changing the culture of our little community hospital? It all seems to be a bit of a blur, and I might be getting some of the details out of order. My apologies to my colleagues if that is the case! Taking into consideration that the predominate culture of our department has always been doing what is best for moms and babies, I think this particular change started with leading by example. When I attended a birth as the baby nurse (we always have two nurses attend every delivery, one for mom and one for baby), I began to put babies skin to skin with their moms. When I was the labor nurse, I urged the baby nurse to get the baby skin to skin as soon as possible, asking them to leave all the non-urgent admission tasks for me to complete later. If the baby was brought to mom all wrapped up, I would simply unwrap the baby and get him skin to skin with his mom. We began to have discussions at the nurse’s station about which of our nursing tasks can wait (most of them), and we talked about how easy it really is to do those tasks that could not wait right on the mom’s chest. For those nurses who felt they did not have time to come back later to do admission procedures on my babies, I volunteered to do everything myself. And slowly the culture started to shift.

In 2007, AWHONN published an article, Skin-to-skin Contact: Giving Birth Back to Mothers and Babies (PDF). I printed up copies of the article and left them around the department, requesting that all the nurses read it. I sent copies to the recovery room staff and anesthesiologist. Over time, I began to notice more nurses starting to incorporate skin-to-skin into their routine practices. We were gaining momentum.

Over the past couple of years, the nursing staff and physicians I work with have successfully integrated immediate skin-to-skin contact as a standard of care for healthy babies born by vaginal birth. Because we strongly believe in the importance of providing safe, quality, family centered maternity care, we are always looking for ways to improve the services we provide the new families in our community. So why stop what we now know is the right thing to do with just vaginal births?

We all know that when cesarean birth becomes necessary, it often brings an unexpected and unwelcome separation of the mother from her newborn baby. Even when cesarean births are planned, I can’t imagine the longing so many mothers must have felt during the time they are separated from their babies. It is not uncommon for it to take between 40 minutes to over an hour be reunited with their baby. (Side note: because we are a very small hospital, we do not staff our own operating room or recovery room.) As we witnessed the gentle transition to life outside the womb with infants placed skin to skin with their mothers after vaginal birth, I began to wonder why we could not also support this amazing time for healthy moms and their babies born by cesarean.

Our department was looking for a quality improvement goal for the upcoming year. At our staff meeting in November 2010, I suggested we begin to offer and support skin-to-skin contact in the operating room. We had already tried, with inconsistent success, to bring babies back to PACU (a recovery room that is staffed with different staff than the LD unit) to breastfeed. (Again, another story as to why that hasn’t been very successful.) So why not just prevent the separation in the first place and keep the babies with mom in the OR?


My colleagues were all on board and we set a very ambitious goal of providing skin-to-skin contact in the OR for 75% of our cesarean-born babies within 3 months of beginning the initiative. I am excited to report that after two months into our initiative we have supported immediate skin-to-skin with 53% of cesarean-born babies at our hospital. We do have a little ways to go, but it is absolutely worth celebrating that over half of babies born by cesarean are now getting to spend this valuable time with their mothers.

Prior to beginning the initiative, we did a little ground work. I spoke to the head of anesthesia about our plan. While some of his colleagues were not as enthusiastic about it as I had hoped, we got the go-ahead to move forward on a case-by-case basis. As the anesthesiologists have all been able to witness the beauty of this time, they are now all very supportive (or at least not negative) about it! We also decided to clearly define the criteria for both mom and babies to participate in the initiative (stable vital signs, no O2 requirement or respiratory distress for baby, no nausea/vomiting for mom, mom wants to participate, etc). We got the full support of the Neonatal Nurse Practitioners who attend all cesareans and let the pediatricians know that the babies would not be coming back to labor and delivery for their first admission exam as soon as they previously had been. We were all set to begin on December 1st, 2010.

Just a few days before Christmas, I was working with a first-time laboring mom and her partner. Kelly was in the middle of a medically indicated induction, and was hoping for a vaginal birth with minimal intervention. As the day progressed and despite that fact that she had been working extremely hard for many hours, she experienced very little cervical change. She was exhausted and disheartened by the news. At that point she decided to receive an epidural. After many more hours, and despite exhausting all other options, there was still no cervical change. Kelly and her physician agreed that a cesarean birth was necessary. As I was preparing her for this change in plan, I let her know that there was a good possibility that at least one part of her birth plan would not be disturbed. All went as planned. Both Kelly and and her baby Simone did very well and met our defined criteria. Not only did we place Kelly and baby Simone skin to skin in the OR for nearly 30 minutes, Simone even breastfed briefly in the OR!

When she later sent me copies of the photos I took of this special time with their camera, Kelly said:

It was incredibly meaningful to have Simone with me immediately after her birth. That very special moment of togetherness is what so many mothers look forward to, and I did, too: After 9 months of pregnancy and the effort of labor, it felt like a huge reward to finally touch our baby, to face her and have her in my arms. A cesarean birth really enforces a distance between mom and child, but the opportunity to embrace Simone right away really did help me overcome those feelings of alienation. It allowed me to be one of the first to welcome her into the world, which is, I think, a mother's right--certainly it's something I think all moms hope for.

Pictures of Kelly and Simone in the OR:

 

 

 

 

Cindy, a LD RN, loves witnessing the bonding and connectedness that skin-to-skin in the OR promotes. “It makes it so much more real,” she commented. Kristi (RN) added that “it makes the surgical birth experience so much more personal and meaningful.” As a Birthing From Within mentor as well as and LD nurse, I know in my heart that cesarean birth is still a sacred time for new families. All births, cesarean or vaginal, represent not only the birth of a baby, but also the birth of a mother, a father and a family. My hope is that supporting ways to make cesarean birth feel less clinical and more sacred will save a lot of heartache, feelings of disconnectedness, and feelings of loss over an unexpected and often unwished-for outcome. Allowing moms and babies to connect immediately after any birth is the right thing to do, and I feel it is my job to protect this sacred time.

I believe that with a little time, patience and education, all LD departments can do what we are now doing to support skin-to-skin for all mothers and babies. If you are interested in learning more about how you too can bring skin-to-skin in the OR in your hospital, please don’t hesitate to contact me. (Send Rixa an email, and she will forward it on to me.)