A Quality Improvement Project Focused on Women’s Perceptions of Skin-to-Skin Contact After Cesarean Birth JUDITH ANN MORAN-PETERS CHERYL ROBYN ZAUDERER SUSAN GOLDMAN JENNIFER BAIERLEIN APRIL EVE SMITH
THERE ARE MANY BENEFITS associated with skin-to-skin contact between mothers and newborn infants immediately after birth (Dalbye, Calais, & Berg, 2011; Gregson & Blacke, 2011; Hung & Berg, 2011; Price & Johnson, 2005). Despite evidence of its benefit from the literature, clinical application of skin-to-skin contact after cesarean birth may not occur in the labor and delivery (L&D) room (Nolan & Lawrence, 2009). Additionally, the perceptions of new mothers regarding the benefits associated with skin-to-skin contact immediately following cesarean birth have rarely been studied. Abstract: A quality improvement (QI) project was designed to identify women’s perceptions of the benefits of skin-to-skin contact with newborns immediately following cesarean birth. Women reported positive experiences associated with skin-to-skin contact with their newborns. A major theme that emerged was that women who had cesarean birth felt that this QI project resulted in a birthing experience comparable to that of mothers who had vaginal deliveries.Participants also experienced decreased anxiety regarding the health and welfare of their newborns, as compared to a previous cesarean birth experience in which they did not have skin-to-skin contact. DOI: 10.1111/1751-486X.12135 Keywords: breastfeeding | cesarean birth | quality improvement | skin-to-skin contact
Background Research conducted over the past 30 years has described numerous benefits associated with skin-to-skin contact between mothers and their newborn infants (Bergman, 2005; Dalbye et al., 2011; Hung & Berg, 2011; Walters, Boggs, Ludington-Hoe, Price, & Morrison, 2007; Witt, 2008). However, recent studies identify a disparity based on type of birth (Gouchon et al., 2010; Moore, Anderson, Bergman, & Dowswell, 2012); women who give birth via cesarean have less opportunity for this practice immediately postpartum (Bergman, 2005; Dalbye et al., 2011; Elliott-Carter & Harper, 2012). Direct care nurses working in the mother/baby area of a Magnet-designated hospital observed this disparity and sought to change current practice. They collaborated with physicians and other staff to eliminate barriers and create an environment that enabled mothers to have skin-to-skin contact with their newborns immediately following cesarean birth. A subsequent qualitative evaluation examined the perceived benefits mothers associated with performing skin-to-skin contact with their newborn infants. At one time, newborns remained with their mothers almost exclusively after birth (Moore et al., 2012). Although many hospitals today have implemented “Baby-Friendly” practices, newborns are often taken away from their mothers shortly after birth for routine interventions, including weighing, measuring, eye treatments, injections and bathing (Bergman, 2005; Dalbye et al., 2011; Elliott-Carter & Harper, 2012; Moore et al., 2012). Current research has revealed that the benefits of skinto-skin contact are significant (Bergman, 2005; Dalbye et al.,
Judith Ann Moran-Peters, DNSc, RN, NE-BC, BC, is an assistant vice president for nursing-critical care services and coordinator of nursing research/evidence-based practice at Huntington Hospital in Huntington, NY. Cheryl Robyn Zauderer, PhD, CNM, NPP, IBCLC, is an assistant professor at the New York Institute of Technology in Old Westbury, NY, and has a private practice in Garden City, NY. Susan Goldman, MSN, BC, RN, is the clinical nurse specialist and coordinator for student affiliations, and the maternal child clinical nurse specialist for the Department of Nursing, at Huntington Hospital in Huntington, NY. Jennifer Baierlein, MS, RNC-OB, is a staff nurse in labor and delivery and teaches prenatal classes to expectant parents at Huntington Hospital in Huntington, NY. April Eve Smith, MS, BS, RNC-OB, C-EFM, is a staff nurse in labor and delivery and teaches prenatal classes to expectant parents at Huntington Hospital in Huntington, NY; she is also an adjunct clinical professor for Stony Brook University. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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2011; Hung & Berg, 2011; Walters et al., 2007; Witt, 2008). The American Academy of Pediatrics (AAP, 2012) and the World Health Organization (WHO): Maternal and Newborn Health/ Safe Motherhood Unit (1998) advocate for skin-to-skin contact for mothers and their healthy newborns. They believe that contact should occur as soon as possible after birth, including after cesarean (AAP, 2012; WHO: Maternal and Newborn Health/ Safe Motherhood Unit, 1998). Studies indicate that parents prefer to have this experience with their newborns (Bergman, 2005; Gregson & Blacke, 2011). Dabrowski (2007) reported on a community hospital that instituted skin-to-skin contact. Staff nurses standardized it as an evidenced-based practice to promote the health and wellness of mother and baby. Many benefits were associated with this practice, such as increased breastfeeding rates, improved bonding experiences and overall satisfaction of the mothers regarding their hospital childbirth experience. Dalbye et al. (2011) conducted a qualitative study of 20 postpartum women who practiced skin-to-skin contact, and described the positive response of newborns as “affinity.” Mothers also responded positively, and expressed the desire to continue skin-to-skin contact to bond with their infants. A randomized trial conducted by Ferber and Makhoul (2004) found that newborns who were allowed skin-to-skin contact slept better and for longer periods, and seemed less jittery than newborns in the control group. Skin-to-skin contact immediately following delivery could support the newborn in adapting to the extrauterine environment. Gouchon et al. (2010) were concerned that newborns who were exposed to skin-to-skin contact, especially after a cesarean birth, could suffer from hypothermia. They conducted a study with 34 pairs of mothers and newborns after elective cesarean and compared them to newborns who were provided with routine, non-skin-to-skin contact. The results indicated that newborns who received skin-to-skin contact were not at increased risk for hypothermia, and the authors concluded that skin-to-skin contact could be implemented safely after cesarean birth (Gouchon et al., 2010). Skin-to-skin contact may be particularly important given the breastfeeding difficulties experienced by many women. Baxter (2006) conducted a study on newborn feeding with 422 women who had given birth via cesarean, and asked whether they were still breastfeeding after 18 weeks. The women who had discontinued breastfeeding did so because of pain, a difficult time with attachment, lack of support or insufficient milk. Women who gave birth by cesarean had a more difficult time with breastfeeding and bonding because they were recovering from major surgery as well as caring for a newborn. This study highlights the importance of supporting the new mother to promote breastfeeding and bonding; skin-to-skin contact with the newborn might be an effective intervention (Baxter, 2006; Ferber & Makhoul, 2004).
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Opening photo © Marie Griffin / petitenfantbaby.com
A quality improvement (QI) project was conducted to evaluate the implications of the unavailability of skin-to-skin contact following a cesarean birth and to identify perceptions of women who performed skin-to-skin contact after their second cesarean birth, particularly related to facilitation of breastfeeding, in order to compare cesarean birthing experiences in which skin-to-skin contact was and was not present.
Photo © Kati Molin / thinkstockphotos.com
STUDIES INDICATE THAT PARENTS PREFER TO HAVE THIS EXPERIENCE WITH THEIR NEWBORNS McGrath and Phillips (2009) conducted a qualitative phenomenological study involving 20 women who had given birth via cesarean to explore the issue of newborn feeding after a second cesarean birth. Several themes, some conflicting, emerged from the data; these included a very strong desire to breastfeed, a decision to not breastfeed, a prompt switch to bottle-feeding when obstacles occurred and, for some, a view that bottlefeeding was easier and more convenient. Obstacles associated with a cesarean birth included a postponement of newborn contact with the breast, separation from the newborn, lack of skin‐to‐skin contact, the troubled state of the newborn after the birth and the baby receiving a bottle in the nursery before being presented to the mother. One mother also stated that she developed engorgement resulting from the delay in contact, which made breastfeeding more difficult.
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Benefits of Skin-to-Skin Contact Skin-to-skin contact (first called “Kangaroo Care”) was first studied in the early 1980s in Bogota, Colombia (Anderson, 1999). At that time, the mortality rate among premature Colombian babies was 70 percent owing to factors such as infections, respiratory problems and a lack of bonding with a parent (Anderson, 1999). Kangaroo Care evolved in the absence of medical care; of necessity, mothers of premature infants held their babies 24 hours a day, even sleeping with infants tucked under their clothing, as if in a kangaroo’s pouch. Researchers investigating Kangaroo Care noticed a precipitous drop in mortality; in fact, premature babies experiencing Kangaroo Care were thriving. As a result, Lundington introduced the practice of Kangaroo Care to hospitals in the United States in the early 1990s (Anderson, 1999). The benefits associated with Kangaroo Care, mostly studied in neonatal intensive care units (NICU), include a stable heart rate (fewer bradycardic episodes), improvement in regular breathing (75 percent decrease in apneic episodes) and improved oxygen saturation. Additional benefits that have been demonstrated include less cold stress, longer periods of sleep, improved weight gain, better brain development, a reduction in “purposeless” activity, decreased crying, longer periods of alertness, enhanced breastfeeding and earlier hospital discharge (Chia, Sellick, & Gan, 2006; Feldman, 2004; Feldman,
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Eidelman, Sirota, & Weller, 2002; Mercer, 2004). Benefits to parents include earlier bonding with their infants and improved self-confidence in newborn care (Chia et al., 2006; Feldman, 2004; Feldman et al., 2002; Hung & Berg, 2011). According to the WHO (2013), breastfeeding is one of the best ways to ensure newborn (and child) health and survival. Breast milk is safe, contains antibodies that help protect infants from common childhood illnesses, and is readily available and inexpensive, which can help guarantee that infants receive ample nourishment. The WHO strongly suggests exclusive breastfeeding for the first 6 months of life and advises that breastfeeding should begin within an hour of birth. This can be encouraged as a part of skin-to-skin contact with newborns.
Impetus for Quality Improvement Despite the evidence linking skin-to-skin contact with improved outcomes, many hospitals fail to integrate this practice into daily use because of barriers in obstetric settings. These barriers are more common for new mothers undergoing cesarean birth (Elliott-Carter & Harper, 2012; Ferber & Makhoul, 2004; Gouchon et al., 2010). Spurred by the “Ten Steps to Successful Breastfeeding,” QI project jointly sponsored by the WHO and UNICEF, the L&D unit at our community hospital introduced skin-to-skin contact in April 2009 as an evidence-based nursing practice with new mothers immediately post-delivery, but only for vaginal births. Feedback from patients and nurses indicated high
satisfaction and other positive outcomes; subsequently, L&D nurses were determined to provide this experience after cesarean birth as well. The first step was to identify barriers to skin-to-skin contact immediately following cesarean birth. A collaborative group, including obstetric nurses, obstetricians and anesthesiologists identified key barriers and proposed solutions (see Box 1). To be able to assess the effects of this QI project, investigators conducted a qualitative evaluation in which mothers were asked the following questions: (1) What are your perceptions of the benefits of performing skin-to-skin contact with your newborn infant immediately following delivery? and (2) What differences do you note between your current cesarean birth experience, where immediate skin-to-skin contact was performed, and your previous elective cesarean birth experience when performing skin-to-skin contact was not the standard of care?
Conceptual Framework The investigators selected Mercer’s Maternal Role Attainment Theory as the conceptual framework for this study; Mercer recommends replacing the term “maternal role attainment” with “becoming a mother”(Mercer, 2004). According to Mercer (2004) renaming the process recognizes the larger life-transforming experience women go through when they become mothers, and that women continue to grow as mothers throughout their children’s lives. Mercer’s work is an appropriate conceptual fit for this study because it describes the process by which new mothers gather information and seek new expert
BOX 1
Barriers and Solutions to Implementing Skin-to-Skin Contact After Cesarean
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Barriers Major surgery with sterile draping decreases ability to provide skin-to-skin contact.
Solutions Skin-to-skin contact was initiated within 2 hours of birth.
Pain and sedation medications used during cesarean alters a mother’s mental status, and, therefore, the ability to safely hold her newborn.
Anesthesiologists were asked to not automatically sedate mothers after surgery, due to the benefits of skin-to-skin and breastfeeding.
Standard practice specified transporting babies born via cesarean immediately to the nursery for admission assessment, a process that required several hours.
Delayed bathing the infants upon arrival from the operating room so that their temperatures would remain stable. This act would facilitate a quicker reunion in the L&D recovery room and enable skinto-skin contact and breastfeeding.
After transport to the nursery, newborns were not returned to the L&D area. Babies born via cesarean joined their mothers for the first time in a regular room on the postpartum unit, after a significant amount of time had passed.
Through effective communication, collaboration of all members and education allowed for positive outcomes regarding this change in practice.
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models. Providing opportunities for mothers to engage in skinto-skin contact immediately following cesarean birth is an evidence-based nursing practice that represents a new expert model of patient care for mothers and their newborn infants (Dalbye et al., 2011).
Methods Written consent was obtained from participants, and on the third postpartum day a direct-care nurse from the L&D unit interviewed English-speaking mothers who had experienced
ADDITIONAL BENEFITS THAT HAVE BEEN DEMONSTRATED INCLUDE LESS COLD STRESS, LONGER PERIODS OF SLEEP, IMPROVED WEIGHT GAIN, BETTER BRAIN DEVELOPMENT, A REDUCTION IN “PURPOSELESS” ACTIVITY, DECREASED CRYING, LONGER PERIODS OF ALERTNESS, ENHANCED BREASTFEEDING AND EARLIER HOSPITAL DISCHARGE
Magnet status, achieved by less than 10 percent of all U.S. hospitals, is a prestigious award granted by the American Nurses’ Credentialing Center for excellence in nursing services. In 2009, this hospital had 1,547 births with an overall cesarean birth rate of 42 percent (n = 649). Among the mothers having cesarean birth, approximately 50 percent (n = 320) had a repeat, elective (nonemergency) cesarean birth. This subset of 320 mothers constituted the potential study population for this QI project.
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Participants cesarean birth for a period of 20 minutes. The nurse used a semistructured interview format to gather the meaning of the lived experience of mothers using skin-to-skin contact immediately following cesarean birth, and to compare the most recent birth with a previous cesarean birth after which skin-to-skin contact did not occur. The nurse tape-recorded the interviews and an approved service transcribed them.
Setting The research setting for this project was a 408-bed Magnetdesignated community hospital in a suburb of New York City.
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English-speaking women ages 18 years or older who were having a repeat, elective (nonemergency) cesarean were eligible to participate. Women whose newborns required admission to the NICU or a transfer out of the hospital were excluded. The study sample consisted of six mothers between the ages of 27 and 40 years.
Planning of the Intervention The QI project included a purposive sample of six mothers who had at least one previous elective cesarean birth. Investigators used the operating room schedule and open chart review of patient medical records to identify potential
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participants. Investigators obtained Institutional Review Board (IRB) approval, and written approval to conduct the project from the hospital’s chief of obstetrics/gynecology. QI investigators deidentified the data, assigned each participant a pseudonym and stored the information in a locked file cabinet. Other than the need to ensure participant privacy, there were no ethical issues of concern with regard to protection of human subjects in this study.
Data Collection Each participant delivered a healthy newborn via scheduled cesarean between July and September 2011. Each participant had also delivered a healthy newborn via cesarean within the past 3 to 7 years. Participants were asked to compare the recent and past cesarean birthing experiences with regard to the performance of skin-to-skin contact with the newborn immediately following childbirth. Data were collected until saturation was reached. “Saturation” refers to the point where new data yields redundant information (Glaser & Strauss, 1967). Investigators achieved data verification through participant confirmation and interpretation of transcribed interviews; each participant received a copy of her transcript and had the opportunity to make changes.
Data Analysis
the interview data were identified inductively (Hsieh & Shannon, 2005). Nvivo 9 (QSR International, Perth, Australia) was used to store and organize the codes and data. The data analysis process involved three stages. First, an approved service transcribed each interview verbatim and the transcripts were imported into Nvivo 9. Second, the investigators coded all of the data using a line-by-line open coding technique (Glaser & Strauss, 1967); the investigators assigned one or more codes to each sentence of the interviews. Coding categories were inductively derived from the participants’ responses; their words were also used to establish the codes.
Photo © André Mansi / thinkstockphotos.com
Project lead staff analyzed the data using a conventional qualitative content analysis approach derived from grounded theory (Glaser & Strauss, 1967). Coding categories that emerged from
A MULTIDISCIPLINARY GROUP OF CLINICIANS SHOULD IDENTIFY AND ELIMINATE BARRIERS TO PERFORMING SKIN-TO-SKIN CONTACT IMMEDIATELY FOLLOWING CHILDBIRTH, REGARDLESS OF THE MODE OF BIRTH
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Next, using a constant comparison method (Glaser & Strauss, 1967), the investigators systematically compared each piece of text to the codes and assigned one or more codes to the text. As new ideas or meanings emerged from the data, the investigator added or modified codes as necessary. To assess coding consistency, the researcher checked and rechecked codes and code assignments. Third, the investigators compared the codes to each other to identify categories or emerging themes. To ensure the trustworthiness of the coding assignments, the investigators used negative case analysis (Lincoln & Guba, 1985) to check all of the codes against the themes and considered any alternative explanations for codes that did not fit into the themes. The investigators modified the themes if necessary to include any additional codes. They also checked the interpretations of the themes against the raw data (Lincoln & Guba, 1985).
Results The investigators identified two main themes arising from the analysis: (1) mothers’ relationships with their newborns, and (2) mothers’ experiences with breastfeeding.
Women’s Relationships With Their Newborns Overall, the women in this study reported a better experience with the most recent cesarean because of contact with the baby following birth, and noted that this improved the relationship with the baby. In previous cesarean experiences, participants’ husbands or partners were able to hold the baby, but the women had an extended wait before first contact with their children. One woman reported, “I just remember that my husband got to hold her right away but it was a very long time before I got to hold her.” The women disliked the separation and felt that waiting interfered with the ability to connect with the baby. One stated, “Well, the first one for me was like a nightmare, because I was in labor for so many hours and then I had to go on the table and get him taken out of me immediately, and he was just taken away from me. And it was like I was hit by a truck. When you have a C-section, you can’t hold them right away, and it’s like you kind of get robbed of that moment.” Women’s most recent cesarean experiences were improved by skin-to-skin contact with the newborn in the recovery room. Husbands or partners were able to join them. One woman noted, “It was nice to be alone with her and have her not be completely clean yet. That was something that was very different and it just felt very natural. The other part of it being that my husband was able to be in the room with us. It gave us something to share as a family before we were inundated with visitors.” Another woman stated, “I thought it was wonderful, my husband was there with me, the nurse that was in there was very helpful. She was very nice. She put a curtain behind her so if we had questions we could ask her, but she kind of left it as a more private moment. The room was very comfortable. It was peaceful. It was kind of dark, not dark pitch black but dark.”
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In contrast to their previous experiences, these women were happy to have the opportunity to immediately bond with their newborn. They described this experience as “peaceful,” “good,” “important,” “pleasant,” “positive,” “wonderful,” “nice” or “great.” This opportunity helped women to feel closer to their babies from the beginning. One said, “I think it was very positive. I was able to bond with her sooner than I did with my other two.” Skin-to-skin contact was perceived as beneficial for recovery; it also allowed women to connect with their newborns. “And instantly they put her on me and she stopped crying immediately. I just felt it helped me recover and it helped me get just a sense of her immediately,” said one. Another wanted to confirm that her newborn was healthy: “You want to make sure of everything, 10 toes, 10 fingers. So it was nice to have that contact with her right away.” Women described feeling “natural” holding their newborn before the baby was completely clean. “The fact that they just get a little wash off, but her body was still in that state of...she was covered in the vernix, and it just made it feel more natural, more kind of removed from that medical feeling of giving birth in a hospital.” Women also felt that skin-to-skin contact following the birth helped them to connect with their newborns in a maternal way. “I felt like it gave me an opportunity to bond with her in a way that only a mother can but especially after the cesarean birth where you feel kind of removed from the birth with the physical presence of the sheet and you just feel almost alone and not an active part of it.” Another mother added, “I think the skin-to-skin, having this be my third cesarean, kind of added to that where I felt like, ‘Oh, this baby’s really, really mine.’ So having that skin-to-skin gave me that initial contact and takes away that awkwardness that sometimes I think a new mother may have towards a child.”
Women’s Experiences With Breastfeeding Women reported struggling with breastfeeding their previous children due to their lack of contact following the cesarean birth. One explained, “My first experience with breastfeeding in general was very tough. I didn’t feel like it went smoothly. I felt frustrated. I think it contributed to me having postpartum depression.” Another didn’t have a good experience with breastfeeding her two previous children, which prompted her negative perception of breastfeeding. “I think if I had gotten that experience with my first two I would have probably been more relaxed about nursing.” A third reported, “I found her to be very lethargic and didn’t nurse easily. She would fall asleep at the breast. She would suck once or twice and then pass out and so there was a lot of undressing and using the cold cloth and tickling and trying to get her just to stay with me so that we could kind of get into the rhythm of breastfeeding. And so I think we both found that difficult. She was frustrated. I was frustrated.”
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Results from this project indicate that women who had skinto-skin contact with their newborns following cesarean birth had better breastfeeding experiences, describing it as “good” or “wonderful.” They felt calmer and more relaxed, which facilitated the breastfeeding process. One said, “This experience of skin-to-skin contact, it’s having an easier nursing experience. It’s all so much better and relaxing than the first one.” Participants also reported that skin-to-skin contact helped the baby to latch better. One woman stated, “She latched right on and it was a nice, cozy setting, and I thought it was very good. I thought it worked out much better.” A second com-
WOMEN’S MOST RECENT CESAREAN EXPERIENCES WERE IMPROVED BY SKIN-TO-SKIN CONTACT WITH THE NEWBORN IN THE RECOVERY ROOM mented, “I think there was definitely a calming effect on both of us and I think that it just kind of lent itself naturally to her latching on.” A third agreed, stating, “I also felt like it helped her latch on so much faster because the breast being right there, she’s laying on me and it was just a quiet atmosphere and she just has, in retrospect, she’s been amazing with the breastfeeding and I have a feel that has to do with the skin to skin.”
Discussion This project confirms the value of the institution’s QI project. It’s consistent with earlier findings identifying bonding and breastfeeding benefits associated with immediate postpartum skin-to-skin contact between mothers and newborns following cesarean birth. Nurses working in labor and birth settings should promote the practice of skin-to-skin contact between women and their newborn infants immediately following birth, given the significant benefits associated with this experience. In particular, the moments right after birth represent the ideal timeframe for initiating breastfeeding, which generates important health benefits for the baby. A multidisciplinary group of clinicians should identify and eliminate barriers to performing skin-to-skin contact immediately following childbirth, regardless of the mode of birth. This is particularly important in situations requiring cesarean birth; research has shown that rising rates of cesarean birth have been accompanied by declines in breastfeeding rates (Prior et al., 2012; Zanardo et al., 2010).
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Lessons Learned QI project adopters can expect some minor to moderate challenges in implementing a skin-to-skin contact program at their institutions. First, clinicians working in the labor and birth setting may be reluctant to change established care processes. Labor and birth units are very busy care settings; to maximize efficiency, most clinicians prefer to transport newborns to the nursery to conduct assessments and administer injections. To obtain clinician support for immediate skin-to-skin contact between women and their infants, improved patient outcomes should be emphasized as an important counterweight to the brief delay in infant assessment. Even with clinician support, designing and implementing a new work process can constitute a second challenge, as existing work processes must accommodate reasonable delays associated with building skin-to-skin contact into postpartum activities. Another challenge to QI project adoption might include the reluctance of some women to hold their babies for an extended period immediately following birth, due to pain or upset associated with birth. Thus, processes should accommodate patient preferences and medical circumstances; for example, processes to allow skin-to-skin contact might include a lactation consultant visit so that breastfeeding education can occur as part of the contact period. Notably, this institution’s experience indicates that these challenges are minor and easily overcome.
Strengths and Limitations One of the QI project’s most important strengths was its qualitative evaluation of the intervention. Women’s perspectives, perceptions and experiences, conveyed in their own words, provided a compelling justification to institutional leaders for the QI project. In this case, investigators considered creating a formal survey instrument so that mothers could rate different aspects of their postpartum experience, but decided that interviews would provide a more nuanced and powerful evaluation of the QI project’s impact. Because the QI project included only participants who underwent two cesarean births—one with postpartum skin-to-skin contact and one without—subjects were able to draw comparisons between their two postpartum experiences. Although this resulted in a potential limitation, since only a small number of women met study criteria, data saturation (from a qualitative methodology standpoint) was achieved. The authors do not believe that including a larger number of participants would have altered the results.
A Second Project Staff at this hospital are planning a second project that will involve a more diverse sample and include Spanish-speaking mothers. This will evaluate differences in the experiences of English- versus Spanish-speaking women with regard to their perception of benefits associated with performing skin-to-skin
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contact with their newborn infants immediately following cesarean birth.
Conclusion This QI project studied women’s perceptions of skin-to-skin contact after cesarean birth, in contrast to these same women’s earlier experiences of cesarean birth without the implementation of skin-to-skin contact. The women described many benefits of experiencing skin-to-skin contact after cesarean. This type of project is applicable to labor and birth units across all types of institutions and could enhance the postpartum experience for many women and babies, as well as provide opportunities for additional studies that can further explore, define and confirm the positive impact of skin-to-skin contact on patient satisfaction and on breastfeeding rates. NWH
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Ferber, S. G., & Makhoul, I. R. (2004). The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: A randomized, controlled trial. Pediatrics, 113(4), 858–865.
Zanardo, V., Svegliado, G., Cavallin, F., Giustardi, A., Cosmi, E., Litta, P., & Trevisanuto, D. (2010). Elective cesarean delivery: Does it have a negative effect on breastfeeding? Birth, 37(4), 275–279. doi:10.1111/j.1523-536X.2010.00421.x
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Piscataway, NJ: Aldine.
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THERE ARE MANY BENEFITS associated with skin-to-skin contact between mothers and newborn infants immediately after birth (Dalbye, Calais, & Berg, 2011; Gregson & Blacke, 2011; Hung & Berg, 2011; Price & Johnson, 2005). Despite evidence of its benefit from the literature, clinical application of skin-to-skin contact after cesarean birth may not occur in the labor and delivery (L&D) room (Nolan & Lawrence, 2009). Additionally, the perceptions of new mothers regarding the benefits associated with skin-to-skin contact immediately following cesarean birth have rarely been studied. Abstract: A quality improvement (QI) project was designed to identify women’s perceptions of the benefits of skin-to-skin contact with newborns immediately following cesarean birth. Women reported positive experiences associated with skin-to-skin contact with their newborns. A major theme that emerged was that women who had cesarean birth felt that this QI project resulted in a birthing experience comparable to that of mothers who had vaginal deliveries.Participants also experienced decreased anxiety regarding the health and welfare of their newborns, as compared to a previous cesarean birth experience in which they did not have skin-to-skin contact. DOI: 10.1111/1751-486X.12135 Keywords: breastfeeding | cesarean birth | quality improvement | skin-to-skin contact
Background Research conducted over the past 30 years has described numerous benefits associated with skin-to-skin contact between mothers and their newborn infants (Bergman, 2005; Dalbye et al., 2011; Hung & Berg, 2011; Walters, Boggs, Ludington-Hoe, Price, & Morrison, 2007; Witt, 2008). However, recent studies identify a disparity based on type of birth (Gouchon et al., 2010; Moore, Anderson, Bergman, & Dowswell, 2012); women who give birth via cesarean have less opportunity for this practice immediately postpartum (Bergman, 2005; Dalbye et al., 2011; Elliott-Carter & Harper, 2012). Direct care nurses working in the mother/baby area of a Magnet-designated hospital observed this disparity and sought to change current practice. They collaborated with physicians and other staff to eliminate barriers and create an environment that enabled mothers to have skin-to-skin contact with their newborns immediately following cesarean birth. A subsequent qualitative evaluation examined the perceived benefits mothers associated with performing skin-to-skin contact with their newborn infants. At one time, newborns remained with their mothers almost exclusively after birth (Moore et al., 2012). Although many hospitals today have implemented “Baby-Friendly” practices, newborns are often taken away from their mothers shortly after birth for routine interventions, including weighing, measuring, eye treatments, injections and bathing (Bergman, 2005; Dalbye et al., 2011; Elliott-Carter & Harper, 2012; Moore et al., 2012). Current research has revealed that the benefits of skinto-skin contact are significant (Bergman, 2005; Dalbye et al.,
Judith Ann Moran-Peters, DNSc, RN, NE-BC, BC, is an assistant vice president for nursing-critical care services and coordinator of nursing research/evidence-based practice at Huntington Hospital in Huntington, NY. Cheryl Robyn Zauderer, PhD, CNM, NPP, IBCLC, is an assistant professor at the New York Institute of Technology in Old Westbury, NY, and has a private practice in Garden City, NY. Susan Goldman, MSN, BC, RN, is the clinical nurse specialist and coordinator for student affiliations, and the maternal child clinical nurse specialist for the Department of Nursing, at Huntington Hospital in Huntington, NY. Jennifer Baierlein, MS, RNC-OB, is a staff nurse in labor and delivery and teaches prenatal classes to expectant parents at Huntington Hospital in Huntington, NY. April Eve Smith, MS, BS, RNC-OB, C-EFM, is a staff nurse in labor and delivery and teaches prenatal classes to expectant parents at Huntington Hospital in Huntington, NY; she is also an adjunct clinical professor for Stony Brook University. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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2011; Hung & Berg, 2011; Walters et al., 2007; Witt, 2008). The American Academy of Pediatrics (AAP, 2012) and the World Health Organization (WHO): Maternal and Newborn Health/ Safe Motherhood Unit (1998) advocate for skin-to-skin contact for mothers and their healthy newborns. They believe that contact should occur as soon as possible after birth, including after cesarean (AAP, 2012; WHO: Maternal and Newborn Health/ Safe Motherhood Unit, 1998). Studies indicate that parents prefer to have this experience with their newborns (Bergman, 2005; Gregson & Blacke, 2011). Dabrowski (2007) reported on a community hospital that instituted skin-to-skin contact. Staff nurses standardized it as an evidenced-based practice to promote the health and wellness of mother and baby. Many benefits were associated with this practice, such as increased breastfeeding rates, improved bonding experiences and overall satisfaction of the mothers regarding their hospital childbirth experience. Dalbye et al. (2011) conducted a qualitative study of 20 postpartum women who practiced skin-to-skin contact, and described the positive response of newborns as “affinity.” Mothers also responded positively, and expressed the desire to continue skin-to-skin contact to bond with their infants. A randomized trial conducted by Ferber and Makhoul (2004) found that newborns who were allowed skin-to-skin contact slept better and for longer periods, and seemed less jittery than newborns in the control group. Skin-to-skin contact immediately following delivery could support the newborn in adapting to the extrauterine environment. Gouchon et al. (2010) were concerned that newborns who were exposed to skin-to-skin contact, especially after a cesarean birth, could suffer from hypothermia. They conducted a study with 34 pairs of mothers and newborns after elective cesarean and compared them to newborns who were provided with routine, non-skin-to-skin contact. The results indicated that newborns who received skin-to-skin contact were not at increased risk for hypothermia, and the authors concluded that skin-to-skin contact could be implemented safely after cesarean birth (Gouchon et al., 2010). Skin-to-skin contact may be particularly important given the breastfeeding difficulties experienced by many women. Baxter (2006) conducted a study on newborn feeding with 422 women who had given birth via cesarean, and asked whether they were still breastfeeding after 18 weeks. The women who had discontinued breastfeeding did so because of pain, a difficult time with attachment, lack of support or insufficient milk. Women who gave birth by cesarean had a more difficult time with breastfeeding and bonding because they were recovering from major surgery as well as caring for a newborn. This study highlights the importance of supporting the new mother to promote breastfeeding and bonding; skin-to-skin contact with the newborn might be an effective intervention (Baxter, 2006; Ferber & Makhoul, 2004).
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Opening photo © Marie Griffin / petitenfantbaby.com
A quality improvement (QI) project was conducted to evaluate the implications of the unavailability of skin-to-skin contact following a cesarean birth and to identify perceptions of women who performed skin-to-skin contact after their second cesarean birth, particularly related to facilitation of breastfeeding, in order to compare cesarean birthing experiences in which skin-to-skin contact was and was not present.
Photo © Kati Molin / thinkstockphotos.com
STUDIES INDICATE THAT PARENTS PREFER TO HAVE THIS EXPERIENCE WITH THEIR NEWBORNS McGrath and Phillips (2009) conducted a qualitative phenomenological study involving 20 women who had given birth via cesarean to explore the issue of newborn feeding after a second cesarean birth. Several themes, some conflicting, emerged from the data; these included a very strong desire to breastfeed, a decision to not breastfeed, a prompt switch to bottle-feeding when obstacles occurred and, for some, a view that bottlefeeding was easier and more convenient. Obstacles associated with a cesarean birth included a postponement of newborn contact with the breast, separation from the newborn, lack of skin‐to‐skin contact, the troubled state of the newborn after the birth and the baby receiving a bottle in the nursery before being presented to the mother. One mother also stated that she developed engorgement resulting from the delay in contact, which made breastfeeding more difficult.
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Benefits of Skin-to-Skin Contact Skin-to-skin contact (first called “Kangaroo Care”) was first studied in the early 1980s in Bogota, Colombia (Anderson, 1999). At that time, the mortality rate among premature Colombian babies was 70 percent owing to factors such as infections, respiratory problems and a lack of bonding with a parent (Anderson, 1999). Kangaroo Care evolved in the absence of medical care; of necessity, mothers of premature infants held their babies 24 hours a day, even sleeping with infants tucked under their clothing, as if in a kangaroo’s pouch. Researchers investigating Kangaroo Care noticed a precipitous drop in mortality; in fact, premature babies experiencing Kangaroo Care were thriving. As a result, Lundington introduced the practice of Kangaroo Care to hospitals in the United States in the early 1990s (Anderson, 1999). The benefits associated with Kangaroo Care, mostly studied in neonatal intensive care units (NICU), include a stable heart rate (fewer bradycardic episodes), improvement in regular breathing (75 percent decrease in apneic episodes) and improved oxygen saturation. Additional benefits that have been demonstrated include less cold stress, longer periods of sleep, improved weight gain, better brain development, a reduction in “purposeless” activity, decreased crying, longer periods of alertness, enhanced breastfeeding and earlier hospital discharge (Chia, Sellick, & Gan, 2006; Feldman, 2004; Feldman,
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Eidelman, Sirota, & Weller, 2002; Mercer, 2004). Benefits to parents include earlier bonding with their infants and improved self-confidence in newborn care (Chia et al., 2006; Feldman, 2004; Feldman et al., 2002; Hung & Berg, 2011). According to the WHO (2013), breastfeeding is one of the best ways to ensure newborn (and child) health and survival. Breast milk is safe, contains antibodies that help protect infants from common childhood illnesses, and is readily available and inexpensive, which can help guarantee that infants receive ample nourishment. The WHO strongly suggests exclusive breastfeeding for the first 6 months of life and advises that breastfeeding should begin within an hour of birth. This can be encouraged as a part of skin-to-skin contact with newborns.
Impetus for Quality Improvement Despite the evidence linking skin-to-skin contact with improved outcomes, many hospitals fail to integrate this practice into daily use because of barriers in obstetric settings. These barriers are more common for new mothers undergoing cesarean birth (Elliott-Carter & Harper, 2012; Ferber & Makhoul, 2004; Gouchon et al., 2010). Spurred by the “Ten Steps to Successful Breastfeeding,” QI project jointly sponsored by the WHO and UNICEF, the L&D unit at our community hospital introduced skin-to-skin contact in April 2009 as an evidence-based nursing practice with new mothers immediately post-delivery, but only for vaginal births. Feedback from patients and nurses indicated high
satisfaction and other positive outcomes; subsequently, L&D nurses were determined to provide this experience after cesarean birth as well. The first step was to identify barriers to skin-to-skin contact immediately following cesarean birth. A collaborative group, including obstetric nurses, obstetricians and anesthesiologists identified key barriers and proposed solutions (see Box 1). To be able to assess the effects of this QI project, investigators conducted a qualitative evaluation in which mothers were asked the following questions: (1) What are your perceptions of the benefits of performing skin-to-skin contact with your newborn infant immediately following delivery? and (2) What differences do you note between your current cesarean birth experience, where immediate skin-to-skin contact was performed, and your previous elective cesarean birth experience when performing skin-to-skin contact was not the standard of care?
Conceptual Framework The investigators selected Mercer’s Maternal Role Attainment Theory as the conceptual framework for this study; Mercer recommends replacing the term “maternal role attainment” with “becoming a mother”(Mercer, 2004). According to Mercer (2004) renaming the process recognizes the larger life-transforming experience women go through when they become mothers, and that women continue to grow as mothers throughout their children’s lives. Mercer’s work is an appropriate conceptual fit for this study because it describes the process by which new mothers gather information and seek new expert
BOX 1
Barriers and Solutions to Implementing Skin-to-Skin Contact After Cesarean
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Barriers Major surgery with sterile draping decreases ability to provide skin-to-skin contact.
Solutions Skin-to-skin contact was initiated within 2 hours of birth.
Pain and sedation medications used during cesarean alters a mother’s mental status, and, therefore, the ability to safely hold her newborn.
Anesthesiologists were asked to not automatically sedate mothers after surgery, due to the benefits of skin-to-skin and breastfeeding.
Standard practice specified transporting babies born via cesarean immediately to the nursery for admission assessment, a process that required several hours.
Delayed bathing the infants upon arrival from the operating room so that their temperatures would remain stable. This act would facilitate a quicker reunion in the L&D recovery room and enable skinto-skin contact and breastfeeding.
After transport to the nursery, newborns were not returned to the L&D area. Babies born via cesarean joined their mothers for the first time in a regular room on the postpartum unit, after a significant amount of time had passed.
Through effective communication, collaboration of all members and education allowed for positive outcomes regarding this change in practice.
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models. Providing opportunities for mothers to engage in skinto-skin contact immediately following cesarean birth is an evidence-based nursing practice that represents a new expert model of patient care for mothers and their newborn infants (Dalbye et al., 2011).
Methods Written consent was obtained from participants, and on the third postpartum day a direct-care nurse from the L&D unit interviewed English-speaking mothers who had experienced
ADDITIONAL BENEFITS THAT HAVE BEEN DEMONSTRATED INCLUDE LESS COLD STRESS, LONGER PERIODS OF SLEEP, IMPROVED WEIGHT GAIN, BETTER BRAIN DEVELOPMENT, A REDUCTION IN “PURPOSELESS” ACTIVITY, DECREASED CRYING, LONGER PERIODS OF ALERTNESS, ENHANCED BREASTFEEDING AND EARLIER HOSPITAL DISCHARGE
Magnet status, achieved by less than 10 percent of all U.S. hospitals, is a prestigious award granted by the American Nurses’ Credentialing Center for excellence in nursing services. In 2009, this hospital had 1,547 births with an overall cesarean birth rate of 42 percent (n = 649). Among the mothers having cesarean birth, approximately 50 percent (n = 320) had a repeat, elective (nonemergency) cesarean birth. This subset of 320 mothers constituted the potential study population for this QI project.
Photo © stanfram / thinkstockphotos.com
Participants cesarean birth for a period of 20 minutes. The nurse used a semistructured interview format to gather the meaning of the lived experience of mothers using skin-to-skin contact immediately following cesarean birth, and to compare the most recent birth with a previous cesarean birth after which skin-to-skin contact did not occur. The nurse tape-recorded the interviews and an approved service transcribed them.
Setting The research setting for this project was a 408-bed Magnetdesignated community hospital in a suburb of New York City.
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English-speaking women ages 18 years or older who were having a repeat, elective (nonemergency) cesarean were eligible to participate. Women whose newborns required admission to the NICU or a transfer out of the hospital were excluded. The study sample consisted of six mothers between the ages of 27 and 40 years.
Planning of the Intervention The QI project included a purposive sample of six mothers who had at least one previous elective cesarean birth. Investigators used the operating room schedule and open chart review of patient medical records to identify potential
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participants. Investigators obtained Institutional Review Board (IRB) approval, and written approval to conduct the project from the hospital’s chief of obstetrics/gynecology. QI investigators deidentified the data, assigned each participant a pseudonym and stored the information in a locked file cabinet. Other than the need to ensure participant privacy, there were no ethical issues of concern with regard to protection of human subjects in this study.
Data Collection Each participant delivered a healthy newborn via scheduled cesarean between July and September 2011. Each participant had also delivered a healthy newborn via cesarean within the past 3 to 7 years. Participants were asked to compare the recent and past cesarean birthing experiences with regard to the performance of skin-to-skin contact with the newborn immediately following childbirth. Data were collected until saturation was reached. “Saturation” refers to the point where new data yields redundant information (Glaser & Strauss, 1967). Investigators achieved data verification through participant confirmation and interpretation of transcribed interviews; each participant received a copy of her transcript and had the opportunity to make changes.
Data Analysis
the interview data were identified inductively (Hsieh & Shannon, 2005). Nvivo 9 (QSR International, Perth, Australia) was used to store and organize the codes and data. The data analysis process involved three stages. First, an approved service transcribed each interview verbatim and the transcripts were imported into Nvivo 9. Second, the investigators coded all of the data using a line-by-line open coding technique (Glaser & Strauss, 1967); the investigators assigned one or more codes to each sentence of the interviews. Coding categories were inductively derived from the participants’ responses; their words were also used to establish the codes.
Photo © André Mansi / thinkstockphotos.com
Project lead staff analyzed the data using a conventional qualitative content analysis approach derived from grounded theory (Glaser & Strauss, 1967). Coding categories that emerged from
A MULTIDISCIPLINARY GROUP OF CLINICIANS SHOULD IDENTIFY AND ELIMINATE BARRIERS TO PERFORMING SKIN-TO-SKIN CONTACT IMMEDIATELY FOLLOWING CHILDBIRTH, REGARDLESS OF THE MODE OF BIRTH
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Next, using a constant comparison method (Glaser & Strauss, 1967), the investigators systematically compared each piece of text to the codes and assigned one or more codes to the text. As new ideas or meanings emerged from the data, the investigator added or modified codes as necessary. To assess coding consistency, the researcher checked and rechecked codes and code assignments. Third, the investigators compared the codes to each other to identify categories or emerging themes. To ensure the trustworthiness of the coding assignments, the investigators used negative case analysis (Lincoln & Guba, 1985) to check all of the codes against the themes and considered any alternative explanations for codes that did not fit into the themes. The investigators modified the themes if necessary to include any additional codes. They also checked the interpretations of the themes against the raw data (Lincoln & Guba, 1985).
Results The investigators identified two main themes arising from the analysis: (1) mothers’ relationships with their newborns, and (2) mothers’ experiences with breastfeeding.
Women’s Relationships With Their Newborns Overall, the women in this study reported a better experience with the most recent cesarean because of contact with the baby following birth, and noted that this improved the relationship with the baby. In previous cesarean experiences, participants’ husbands or partners were able to hold the baby, but the women had an extended wait before first contact with their children. One woman reported, “I just remember that my husband got to hold her right away but it was a very long time before I got to hold her.” The women disliked the separation and felt that waiting interfered with the ability to connect with the baby. One stated, “Well, the first one for me was like a nightmare, because I was in labor for so many hours and then I had to go on the table and get him taken out of me immediately, and he was just taken away from me. And it was like I was hit by a truck. When you have a C-section, you can’t hold them right away, and it’s like you kind of get robbed of that moment.” Women’s most recent cesarean experiences were improved by skin-to-skin contact with the newborn in the recovery room. Husbands or partners were able to join them. One woman noted, “It was nice to be alone with her and have her not be completely clean yet. That was something that was very different and it just felt very natural. The other part of it being that my husband was able to be in the room with us. It gave us something to share as a family before we were inundated with visitors.” Another woman stated, “I thought it was wonderful, my husband was there with me, the nurse that was in there was very helpful. She was very nice. She put a curtain behind her so if we had questions we could ask her, but she kind of left it as a more private moment. The room was very comfortable. It was peaceful. It was kind of dark, not dark pitch black but dark.”
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In contrast to their previous experiences, these women were happy to have the opportunity to immediately bond with their newborn. They described this experience as “peaceful,” “good,” “important,” “pleasant,” “positive,” “wonderful,” “nice” or “great.” This opportunity helped women to feel closer to their babies from the beginning. One said, “I think it was very positive. I was able to bond with her sooner than I did with my other two.” Skin-to-skin contact was perceived as beneficial for recovery; it also allowed women to connect with their newborns. “And instantly they put her on me and she stopped crying immediately. I just felt it helped me recover and it helped me get just a sense of her immediately,” said one. Another wanted to confirm that her newborn was healthy: “You want to make sure of everything, 10 toes, 10 fingers. So it was nice to have that contact with her right away.” Women described feeling “natural” holding their newborn before the baby was completely clean. “The fact that they just get a little wash off, but her body was still in that state of...she was covered in the vernix, and it just made it feel more natural, more kind of removed from that medical feeling of giving birth in a hospital.” Women also felt that skin-to-skin contact following the birth helped them to connect with their newborns in a maternal way. “I felt like it gave me an opportunity to bond with her in a way that only a mother can but especially after the cesarean birth where you feel kind of removed from the birth with the physical presence of the sheet and you just feel almost alone and not an active part of it.” Another mother added, “I think the skin-to-skin, having this be my third cesarean, kind of added to that where I felt like, ‘Oh, this baby’s really, really mine.’ So having that skin-to-skin gave me that initial contact and takes away that awkwardness that sometimes I think a new mother may have towards a child.”
Women’s Experiences With Breastfeeding Women reported struggling with breastfeeding their previous children due to their lack of contact following the cesarean birth. One explained, “My first experience with breastfeeding in general was very tough. I didn’t feel like it went smoothly. I felt frustrated. I think it contributed to me having postpartum depression.” Another didn’t have a good experience with breastfeeding her two previous children, which prompted her negative perception of breastfeeding. “I think if I had gotten that experience with my first two I would have probably been more relaxed about nursing.” A third reported, “I found her to be very lethargic and didn’t nurse easily. She would fall asleep at the breast. She would suck once or twice and then pass out and so there was a lot of undressing and using the cold cloth and tickling and trying to get her just to stay with me so that we could kind of get into the rhythm of breastfeeding. And so I think we both found that difficult. She was frustrated. I was frustrated.”
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Results from this project indicate that women who had skinto-skin contact with their newborns following cesarean birth had better breastfeeding experiences, describing it as “good” or “wonderful.” They felt calmer and more relaxed, which facilitated the breastfeeding process. One said, “This experience of skin-to-skin contact, it’s having an easier nursing experience. It’s all so much better and relaxing than the first one.” Participants also reported that skin-to-skin contact helped the baby to latch better. One woman stated, “She latched right on and it was a nice, cozy setting, and I thought it was very good. I thought it worked out much better.” A second com-
WOMEN’S MOST RECENT CESAREAN EXPERIENCES WERE IMPROVED BY SKIN-TO-SKIN CONTACT WITH THE NEWBORN IN THE RECOVERY ROOM mented, “I think there was definitely a calming effect on both of us and I think that it just kind of lent itself naturally to her latching on.” A third agreed, stating, “I also felt like it helped her latch on so much faster because the breast being right there, she’s laying on me and it was just a quiet atmosphere and she just has, in retrospect, she’s been amazing with the breastfeeding and I have a feel that has to do with the skin to skin.”
Discussion This project confirms the value of the institution’s QI project. It’s consistent with earlier findings identifying bonding and breastfeeding benefits associated with immediate postpartum skin-to-skin contact between mothers and newborns following cesarean birth. Nurses working in labor and birth settings should promote the practice of skin-to-skin contact between women and their newborn infants immediately following birth, given the significant benefits associated with this experience. In particular, the moments right after birth represent the ideal timeframe for initiating breastfeeding, which generates important health benefits for the baby. A multidisciplinary group of clinicians should identify and eliminate barriers to performing skin-to-skin contact immediately following childbirth, regardless of the mode of birth. This is particularly important in situations requiring cesarean birth; research has shown that rising rates of cesarean birth have been accompanied by declines in breastfeeding rates (Prior et al., 2012; Zanardo et al., 2010).
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Lessons Learned QI project adopters can expect some minor to moderate challenges in implementing a skin-to-skin contact program at their institutions. First, clinicians working in the labor and birth setting may be reluctant to change established care processes. Labor and birth units are very busy care settings; to maximize efficiency, most clinicians prefer to transport newborns to the nursery to conduct assessments and administer injections. To obtain clinician support for immediate skin-to-skin contact between women and their infants, improved patient outcomes should be emphasized as an important counterweight to the brief delay in infant assessment. Even with clinician support, designing and implementing a new work process can constitute a second challenge, as existing work processes must accommodate reasonable delays associated with building skin-to-skin contact into postpartum activities. Another challenge to QI project adoption might include the reluctance of some women to hold their babies for an extended period immediately following birth, due to pain or upset associated with birth. Thus, processes should accommodate patient preferences and medical circumstances; for example, processes to allow skin-to-skin contact might include a lactation consultant visit so that breastfeeding education can occur as part of the contact period. Notably, this institution’s experience indicates that these challenges are minor and easily overcome.
Strengths and Limitations One of the QI project’s most important strengths was its qualitative evaluation of the intervention. Women’s perspectives, perceptions and experiences, conveyed in their own words, provided a compelling justification to institutional leaders for the QI project. In this case, investigators considered creating a formal survey instrument so that mothers could rate different aspects of their postpartum experience, but decided that interviews would provide a more nuanced and powerful evaluation of the QI project’s impact. Because the QI project included only participants who underwent two cesarean births—one with postpartum skin-to-skin contact and one without—subjects were able to draw comparisons between their two postpartum experiences. Although this resulted in a potential limitation, since only a small number of women met study criteria, data saturation (from a qualitative methodology standpoint) was achieved. The authors do not believe that including a larger number of participants would have altered the results.
A Second Project Staff at this hospital are planning a second project that will involve a more diverse sample and include Spanish-speaking mothers. This will evaluate differences in the experiences of English- versus Spanish-speaking women with regard to their perception of benefits associated with performing skin-to-skin
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contact with their newborn infants immediately following cesarean birth.
Conclusion This QI project studied women’s perceptions of skin-to-skin contact after cesarean birth, in contrast to these same women’s earlier experiences of cesarean birth without the implementation of skin-to-skin contact. The women described many benefits of experiencing skin-to-skin contact after cesarean. This type of project is applicable to labor and birth units across all types of institutions and could enhance the postpartum experience for many women and babies, as well as provide opportunities for additional studies that can further explore, define and confirm the positive impact of skin-to-skin contact on patient satisfaction and on breastfeeding rates. NWH
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