ORIGINAL RESEARCH
Exploring the skin-to-skin contact experience during cesarean section Anitra C. Frederick, PhD, RN, (Assistant Professor)1 , Nancy H. Busen, PhD, FNP-BC (Margaret A. Barnett/PARTNERS Professorship and Assistant Dean/Department Chair of Family Health)1 , Joan C. Engebretson, DrPH, RN, AHN-BC, FAAN (Judy Fred Professorship in Nursing)1 , Nancy M. Hurst, PhD, RN, IBCLC (Director and Assistant Professor)2,3 , & Karen M. Schneider, MD (Practicing Physician and Associate Professor)4,5 1
University of Texas Health Science Center at Houston School of Nursing, Houston, Texas Women’s Support Services, Pavilion for Women, Texas Children’s Hospital, Houston, Texas 3 Pediatrics/Neonatology at Baylor College of Medicine, Houston, Texas 4 Texas Children’s Pavilion for Women, Houston, Texas 5 Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas 2
Keywords Qualitative; maternal experience; skin-to-skin contact; cesarean section. Correspondence Anitra C. Frederick, PhD, RN, University of Texas Health Science Center at Houston School of Nursing, Room 770, 6901 Bertner Avenue, Houston, TX 77030. Tel: 713-500-2097; Fax: 713-500-2073; E-mail: [email protected] Received: 27 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12229 Disclosure: All authors have seen and approved the manuscript. The authors report no conflict of interest or relevant financial relationships.
Abstract Purpose: To explore and describe the mother’s experience of holding her neonate in skin-to-skin contact (SSC) immediately after cesarean delivery during surgical closure and recovery. Data sources: Eleven women between the ages of 23 and 38 years, who had achieved 39.1–40.2 weeks gestational age, participated in an ethnographic study using observations and interviews with the mothers conducted at 24–48 h postdelivery. Interviews were transcribed verbatim and content analysis of both observational notes and transcripts were used to analyze the data. Conclusions: Findings from this study describe the mother’s experience of SSC during cesarean section. The primary theme that emerged was mutual caregiving: the mother–neonatal interaction and their shared and reciprocal relationship and benefits during SSC. Two contextual issues also were illuminated (a) the father’s influence on the SSC experience and (b) the cesarean environment. Implications for practice: With cesarean section the most common surgical procedure among American women, advanced practice nurses are in a unique position to encourage and educate women on the use of SSC for their benefit and that of their newborn. Advanced practice nurses are also empowered to influence institutional policy on SSC during cesarean deliveries at the local and national level.
Skin-to-skin contact (SSC) is the placement of the diaperclad neonate on the bare chest of the mother, upright, prone, and between her breasts (Johnson, 2005). SSC research has been reported in the healthcare literature for over 35 years, and a 2012 Cochrane Review reported SSC to be the most natural and humane method of care after birth and efficacious for both mother and neonate (Moore, Anderson, Bergman, & Dowswell, 2012). Previous research has primarily focused on SSC after vaginal deliveries. There is increasing interest by providers in extending the use of SSC in cesarean births to improve the physiological and emotional well-being of mother and baby. Cesarean section accounts for almost one-third (32.8%) Journal of the American Association of Nurse Practitioners 28 (2016) 31–38 C 2015 American Association of Nurse Practitioners
of all deliveries and affected 1.29 million women in 2012 (Hamilton, Martin, & Ventura, 2013). Accepted clinical practice is to separate mother and neonate immediately after birth for an average of 1–4 h with little opportunity for mutual interaction (Lobel & DeLuca, 2007). Rationale includes the need for surgical completion, patient monitoring, and post-op recovery frequently noted. However, these mothers often express disappointment, distress, and dissatisfaction with the birthing process (Chalmers et al., 2010; Lobel & DeLuca, 2007; Porter, Teijlingen, Ying Yip, & Bhattacharya, 2007). SSC provides the most optimal environment for neonatal adaptation to extrauterine life (Mikiel-Koystyra, Mazur, & Boltruszko, 2002) through better central 31
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nervous system control, reduction in stress, and maintenance of quiet sleep (Ferber & Makhoul, 2004). These infants achieve and maintain thermoregulation faster than those wrapped in blankets or placed in a crib (Bergstrom, Okong, Ransjo-Arvidson, 2007; Bystrova et al., 2003), experience less energy expenditure as evidenced by increased sleep times and decreased crying and activity level (Christensson et al., 1992; Ludington, 1990), and demonstrate decreased pain responses with uncomfortable procedures (Gray, Watt, & Blass, 2000; Johnston et al., 2010). The benefits of SSC extend to the mother as well. SSC plays a role in preventing and decreasing maternal depression (Bigelow, Power, MacLellan-Peters, Marion, & McDonald, 2012; Feldman, Eidleman, Sirota, & Weller, 2002), reduces cortisol levels and self-reported stress (Bigelow et al., 2012; Morelius, Theodorsson, & Nelson, 2005; Tallandini & Scalembra, 2006), encourages faster delivery of the placenta (Marin-Gabriel et al., 2010), increases breastmilk volume (Hurst, Valentine, Renfro, Burns, & Ferlic, 1997), and decreases time to initial breastfeeding (Hung & Berg, 2011). Mothers who practice SSC also score higher on measures of attachment to their neonate (Ahn, Lee, & Shin, 2010; Gathwala, Singh, & Balhara, 2008) and display increased maternal responsiveness and sensitivity (Bystrova et al., 2009; Feldman et al., 2002). The period immediately after birth, termed the “sensitive period,” is a very unique period for the creation of a strong maternal attachment to the neonate (Kennel, Trause, & Klaus, 1975; Klaus et al., 1972). Mothers who experience a cesarean are often denied access to their neonates during the “sensitive period” when hormonal and inherent behaviors come together to produce the most favorable outcomes. Given the efficacy of SSC after vaginal delivery, the purpose of this study was to explore and describe the mother’s experience of SSC immediately after cesarean delivery during the surgical closure and recovery period. Because little is known about how a mother interprets SSC with her neonate during cesarean closure, this study employed an ethnographic approach to better understand SSC during cesarean deliveries. Mothers’ responses are of great importance and knowledge gained through qualitative inquiry can be used to inform best practice in the future.
Methods Design setting and sample A focused medical ethnographic design was used to explore the SSC experience between a mother and her neonate after birth by a scheduled, cesarean section. Ethnography involves the study and description of human experiences based on field work that includes participant 32
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Table 1 Inclusion/exclusion criteria for mothers scheduled for a cesarean section Inclusion criteria
Exclusion criteria
Carrying a live, singleton fetus with no preexisting special needs Achieved between 39 and 42 weeks postmenstrual age (PMA) by obstetrical dates and who have maintained prenatal carea Will obtain regional anesthesia during surgery Ability to speak and read English Delivery of newborn with APGARb scores > 7 at 1 min and >8 at 5 min postbirth
Maternal complications with surgery Neonatal problem requiring immediate separation from the mother for medical care or NICU admittance
a
The American College of Obstetricians and Gynecologists (ACOG) recommends that scheduled elective cesareans should only be carried out after achieving 39 weeks PMA. b The APGAR score was used as a measure of neonatal stability. It is used to evaluate the infant’s condition and adjustment to extrauterine life. A rating of 0, 1, or 2, is given for each of five characteristics: heart rate, respiratory effort, muscle tone, reflex ability, and color.
observation and in-depth interviews (Denzin & Lincoln, 2011). Medical ethnography is situated within the healthcare context and speaks to how patients interpret their experiences within the system (Engebretson, 2011). The ethnographic approach provides a thick description and a rich understanding of life experiences to better understand clinical phenomena where findings can be applied to practice (Dewalt & Dewalt, 2002; Thorne, Kirkham, & O’Flynn-Magee, 2004). The ethnographic design was employed to find a “lens” into a mother’s experience of SSC immediately after delivery. Observation of the SSC interaction occurred during the cesarean until the first feeding and an in-depth, loosely structured interview was conducted with the mother between 24 and 48 h postpartum. The study was conducted at a large hospital in the Texas Medical Center. Institutional Review Board (IRB) approval was obtained from two independent institutions and written informed consent was required of participants. The sample included 14 women who were scheduled as cesarean deliveries, had an assenting obstetrician and anesthesiologist, and agreed to participate in SSC immediately after birth during surgical closure and recovery. Table 1 illustrates inclusion and exclusion criteria used for the study. Eligible women scheduled for a cesarean birth were initially identified, and then a purposive sampling strategy was employed, which allowed for the deliberate choice of information-rich cases in order to achieve a complete description and analysis of the phenomena of
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interest (Sandelowski, 1998). For example, women with a variety of previous birth experiences and ethnicities were recruited during the presurgical appointment by the pre-op staff nurse and the investigator. Sampling continued until data saturation and redundancy were achieved with a full understanding of the phenomena (Richards & Morse, 2007).
Data collection and analysis Data collection included observation with field notes and individual interviews. Observation of the SSC interaction was conducted during the cesarean procedure, concluding with the first feeding. Observations focused on the interactions between the mother and neonate, and included the mother’s support person in the room and the healthcare staff involved in SSC and patient care. After a review of field notes, observations of interest were included in the maternal interview for clarification and a deeper understanding. An in-depth, loosely structured interview with the mother was conducted at a convenient time prior to discharge. Following Spradley’s (1979) recommendations, an interview guide was used to spur discussion and assist the mother in recall of the SSC experience, observations of interest to the investigator, and the mother’s overall impressions. The interview started with the grand-tour question, “Tell me about the SSC experience you shared with your newborn after the cesarean section.” Mothers were able to direct the interview by discussing what was important to them. Additional probes included such questions as: “how did you feel during SCC with your newborn, what could have improved the SSC experience for you, and how did this experience compare with your expectations?” Data interpretation was validated by clarifying observations and statements with the informants. Data collection and analysis were iterative and recursive and began after the first cesarean was observed. As the dataset grew, the field notes were used to aid the investigator in making comparisons, summarizing patterns, and drawing conclusions. During later interviews, participants verified or clarified the meaning behind emerging patterns and investigator conclusions. All interviews were digitally voice-recorded and transcribed by the investigator. Qualitative content analysis was used to analyze the interview data and develop themes (Saldana, 2009). Transcripts and field notes were reviewed and initial codes were categorized, classified, and synthesized to aid in conceptualizing the data. These codes and categories were used to support the overarching theme and contextual issues from the data. To improve rigor within the data analysis, raw data, coding schema, and thematic fit were frequently reviewed
with seasoned nurse researchers until consensus in coding and thematic analysis was achieved. A peer debriefing session was held where the themes were discussed to ensure findings were clearly anchored to the data.
Results Eleven (n = 11) women, aged 23–38, who were between 39.1 and 40.2 weeks gestational age participated in the study. Eight were scheduled for repeat cesareans, two were primiparous women who required a cesarean for medical issues (a contracted pelvis and a retinal hole that made vaginal deliveries potentially unsafe), and one multiparous woman had a breech presentation. Two women delivered prior to their scheduled cesarean date and one neonate was admitted to the neonatal intensive care unit (NICU) after birth because of respiratory distress and was not available for SCC. There were 11 neonates (four female, seven male), with an average weight of 3619 g. They took from 5 to 18 min to achieve SSC with their mothers; the duration of SSC was from 12 to 62 min with an average of 33 min. See Table 2 for a complete description of clinical information and SSC data regarding study participants. The main theme that emerged from the data was the Mutual Caregiving shared between mother and neonate. The term Mutual Caregiving was first introduced by G. C. Anderson (1977, 1989), who created a framework for the maintenance of mother and infant in close contact after birth. Two important contextual issues were also illuminated by the data findings: the Father’s Influence and the Cesarean Environment. The desire to hold the neonate and know their condition firsthand was on the forefront of the mothers’ mind both before and during the cesarean procedure. The initial SSC, the introduction of mother and neonate for the first time in the extrauterine environment, was a profound moment for the mother. When placed together in SSC, the dyad became immediately interactive with and responsive to one other, using all their senses as a means of communication. The two appeared to settle into one another, as if they were in an insulated, emotional cocoon. Most mothers noted the desire and ability to tune out the surrounding operating room (OR) environment and concentrate solely on their newborn. “I didn’t care about anything else. I was just concentrating on him.” All the mothers commented on the calming nature of the SSC, both for themselves and for their neonate. The mothers stated the act of having the neonate against their skin quieted and relaxed the baby. In addition, they noted a peace that came over them when holding. This sense of calm and reassurance was reciprocal for the dyad, each reinforcing the other. “ . . . and instantly, the minute he got 33
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Table 2 Maternal demographics, birth, and SSC data Dyad 1 2 3 5 6 7 8 10 12 13 14
Maternal age (years) 32 38 27 35 36 31a,b 23 37 29 33b 36b
Gestation/para
Race
Neonatal weight (g)
Gender
Birth to SSC (min)
Duration of SSC (min)
2/2 3/2 4/3 2/2 2/2 4/2 3/2 6/2 3/2 1/1 1/1
C C AA C H H H C AA H H
3120 3805 3440 3440 4140 3290 4025 3630 4170 3630 3120
F M M F M M M F M F M
6 6 18 5 5 11 5 18 6 7 8
30 53 25 49 62 32 12 41c 12 24c 23c
AA, African American; C, Caucasian; F, female; H, Hispanic; M, male. a First child delivered vaginally. b Primary cesarean section. c SSC continued after observation period.
on me, he got quiet and that just made me feel good . . . he was just so happy to be with mom.” “I noticed that as soon as they put him on my chest he got quiet and stopped crying and he seemed comfortable and that made me feel comfortable, too.” Because of the nature of the SSC, mothers and neonates were able to share comforting touch. The mothers frequently commented on the ability to experience the neonate through touch which was reassuring and meaningful. The ability to feel, see, and interact with the neonate immediately, and on such an intimate level, put the mother at ease. “Those thoughts are just running through your head. Are there ten fingers? Are there ten toes? Is she pink? Is she blue? You know . . . is she breathing okay? Is her heart rate okay? Whereas, with her on your chest, I mean you just, you experience it firsthand. Being able to immediately know that and see it is a very powerful experience.” Having the neonate so close allowed the mother to verbally interact with her baby. Most mothers spoke quietly to their neonate during the holding session. Many commented on the belief that their voice was soothing to the newborn and was something only she could provide. The mothers also commented on their ability to provide warmth to the neonate. These first shared moments gave the mother a sense of empowerment and many mothers commented on the strong bond they felt toward their baby. “When I started talking to him he would calm down.” “My voice was soothing to him. So, I helped him a lot.” “Because it was traumatizing for him, with everything going on, and I think that immediate bond helped him a lot.” “Actually, it was a wonderful experience. Because, with my prior cesarean, I didn’t have any contact with the baby. This time, I was able to actually bond with my baby.” 34
Even in the midst of the cesarean closure, the SSC experience felt natural for most of the mothers. “I love that . . . they didn’t even finish cleaning him and they gave him to me.” “It just felt natural” were the most common reactions. With the neonate lying on the mother’s chest, the progression toward breastfeeding was readily observed: quiet rest, salivating, licking, lip smacking, kneading of the hands, and movement of the head toward the nipple. Some mothers attempted breastfeeding while lying flat on the OR table, but none were successful in latching the baby onto the nipple during the procedure. Many attributed the inability of the neonate to latch onto the breast as a result of the cesarean procedure in progress. “I thought it was going to be possible but then, I realized no way.” “Because he was taking more space over there and they were working over there. But, he wanted it. He was ready. He was really sucking. And I was thinking, if we had a nice position, he would have.” All mothers who breastfed had rapid success in latching the neonate onto the nipple after returning to the recovery area. Observation of the dyad revealed that neonates in this study latched onto the nipple within 2–7 min of arrival to the recovery room. “It was just really nice to be in the recovery room and to have her take to me as quickly as she did. That wasn’t the experience with my son.”
Father’s influence All the mothers participating in this study had the father of the baby present as their support person during the cesarean procedure. The mother’s attention was primarily focused on her neonate during SSC, yet the father’s presence and participation was important to the mother. Mothers acknowledged these first shared moments with their newborn and the father as the formation of the
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Table 3 Take-home points for APRNs and their patients Benefits of SSC for both mother and neonate Mother
Neonate
• Decreases postpartum depressive symptoms • Achieve and maintain thermoregulation more rapidly • Increases responsiveness to neonate • Better central nervous system control • Enhances attachment to neonate • Promotes soothing, decreases crying • Reduces stress • Success in breastfeeding • Increases milk volume • Decreased pain response Cesarean section is not a contraindication for immediate SSC (Crenshaw et al., 2012; Smith, Plaat, & Fisk, 2008). Mothers should no longer be denied access to SSC during cesarean The use of SSC during cesarean is achievable and desirable. Findings included • Sense of maternal empowerment • Enhanced maternal confidence • Ability to calm the neonate easily with touch and voice • Rapid breastfeeding success in recovery • Father’s presence provided a buffer to the OR environment • OR environment was stressful and SSC calmed the mother and neonate APRNs should develop and encourage practice guidelines supporting the use of SSC during cesarean. Step 4 of the Baby Friendly Hospital Initiative encourages continuous, uninterrupted SSC for stable, cesarean mother–neonate dyads (WHO/UNICEF, 2009) Prenatal teaching points for improving the experience of SSC during cesarean • OR monitoring and equipment expectations: • Cycling BP cuff, an intravenous catheter (IV), an oxygen saturation monitor, and EKG leads present • Prone position, pressure/movement felt below the sterile drape during the surgery, staff continually circulating in the OR • Neonatal responses to SSC: • General movement, crying or silence normal, and advances toward the breast • React to the mother’s voice and touch • Encourage mothers to speak up. Ask for help, as needed
family unit. “It was nice for the three of us to be there together. I mean, we both got a little weepy seeing our little boy there.” “It was a bonding of the three of us, definitely.” Many fathers did what they could to support the mother by assisting her and the neonate during SSC. While some fathers were uncertain of their place in the OR setting and distanced themselves, most fathers sat close throughout the SSC session providing support through quiet speech with mother and neonate, repositioning the neonate as needed, and asking staff for assistance on behalf of the mother. Observation revealed the father provided a buffer to the outside environment. Mothers commented that if they were not holding the neonate in SSC, they would prefer for the father to be holding and interacting with the neonate instead of the neonate being observed on the warmer.
Cesarean environment The experience of SSC shortly after birth occurred within the context of the surgical environment. Being rolled into the bright OR, full of surgical equipment, and staff clothed in gowns and masks is a foreign experience to most mothers. “I mean, cesareans are so impersonal.” Knowing about the epidural procedure and subsequently being separated from the lower half of their body with no control over the
birth process was anxiety provoking for the mothers in the study. These feelings were somewhat alleviated by the SSC shared with their neonate: “It was very unique in the sense that I was totally numb. I had no control over anything. I felt helpless. And then when I saw him, it was just super emotional and then having him made it all worth . . . (cries). I had no feeling with my legs totally numb. I had zero control being dependent on all the people there. I was . . . It was very difficult. I threw up. I had to be helped and everything. And then, when you put him on top of me and I was able to hold him I just forgot about how helpless I was and how uncomfortable.” While the SSC relieved some of the anxiety associated with the cesarean procedure, the surgery in progress was not lost to the mothers. Mothers noted feeling as if the baby was in the way of the surgical procedure. They also noted their discomfort, the surgical monitoring equipment, and the impersonal nature of the cesarean process. No matter how focused the mother was on her neonate she was frequently reminded of her surroundings. “I would move my arms down and then the doctor would say, reposition.” “It was not as intimate as I thought because there were so many people around doing so many things.” “They (doctors) were working and they don’t know what we’re doing over here. That’s priority, you know. I’m open, so they need to work on that.” 35
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The mothers also commented on their desire to see more of the baby, but they were unable to do so while laying supine on the OR table. They reflected on the frequent need to reposition the baby. During SSC, the neonate was placed atop the breast tissue in a transverse lie as opposed to upright so that the obstetrician could have room to work. At times, the positioning of the dyad caused the neonate to slowly move toward the mother’s upper chest and neck. The mother’s supine position made visualization of the neonate difficult and required vigilant attention and repositioning by the nursing staff. “I was too uncomfortable, because I was a little bit upside down, I guess.” “ . . . so, I was like, I want to grab her and be in a comfortable position. That would be great. But, because it’s a C-section, you can’t do it.” “The only thing I didn’t really like about it was that I felt like I couldn’t really see her because of my position.” The use of monitoring equipment for the mother undergoing the cesarean procedure is necessary throughout cesarean closure. The mothers commented that their first bonding moments were “constantly interrupted” by the peripheral surgical equipment. While the SSC was preferred over the alternative of not holding so soon after birth, the equipment interfered with the mothers’ ability to focus solely on the neonate. “It was interrupting my bonding—the taking of the blood pressure. I had to stretch my arm out and I was holding him with the other, so I was kind of interrupted a little.” “I thought . . . I would really be able to just hold him. But, I realized they would still have to have the blood pressure monitoring. So, because that was still there, it didn’t really ruin my experience, but it wasn’t just me and the baby.” All the mothers commented that holding their neonate against their skin so soon after birth was a special moment they would not have wanted to miss. However, four mothers chose to shorten their SSC session, or delay it, because of various circumstances. For example, two mothers felt overwhelmed by the cesarean birth environment and the stimuli around them. They were anxious, concerned for their neonate, and both relinquished the neonate to staff before the cesarean closure was complete. One mother felt tingling in her arm and chose to cease holding while prone. At the completion of closure, she continued with SSC. Another mother was having a lot of pain during the procedure and delayed holding until her pain subsided. Then, she held the neonate in SSC and continued to hold until after the first breastfeeding session was complete in recovery.
Discussion The use of SSC for dyads undergoing cesarean section is a new model of care. During this study, the use of SSC 36
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in the surgical setting had a positive impact on the mothers, fathers, and staff involved. No adverse events were observed before, during, or after the cesarean. The mothers in this study commented on their overall satisfaction and appreciation for the opportunity to hold their neonates within minutes of delivery. Some mothers commented on their discomfort and gave suggestions for improving SSC during cesarean. Requests were made to lengthen the blood pressure (BP) monitoring cycle and to raise the head of the OR bed slightly during SSC. Every participant who had undergone a previous cesarean spoke more favorably upon the SSC experience compared to previous cesareans when routine separation was practiced. The use of SSC within minutes of birth enabled the mothers to know their neonates firsthand, to interact with them immediately, and to begin the bonding process. These findings reinforce previous reports in the literature noting enhanced feelings of attachment to the newborn (Ahn et al., 2010; Gathwala et al., 2008) and immediate feelings of bonding with their baby (Finigan & Davies, 2004). An important finding from this study was the ability of SSC to empower the mother, bolstering maternal role confidence even during the cesarean birth experience. The mothers were actively engaged and involved with their neonate from the moment the baby was placed in SSC on their chest. The mother’s touch and sound of her voice calmed the baby and neonates latched on to the breast quickly. The use of intraoperative SSC gave the mother a sense of early accomplishment and power in her maternal role. Other studies investigating the use of SSC after cesarean also report positive outcomes (Gouchon, 2010; Hung & Berg, 2011). Similar findings were supported in this study. Breastfeeding mothers in this study commented on the ease of the initial breastfeeding session and were pleased by how readily their neonates “took” to them in the recovery room. Mothers reported that SSC made breastfeeding easier and continued to use SSC in the first 24–48 h after their delivery. Consistent with other studies (Velandia, Matthisen, Uvnas-Moberg, & Nissen, 2010), mothers in this study referred to their desire and ability to interact with the neonate verbally, calming and soothing them with their voice. Unique to this study were the mothers’ comments concerning the father’s role and the support he provided during the intraoperative SSC. While mothers were primarily focused on the neonate, they appreciated the support provided by the father during the SSC and acknowledged his role in the formation of the family unit during the first moments of SSC. In addition to the paternal role, fathers were able to act as a buffer between mothers and surgical environment. Fathers comforted their wife
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and asked for assistance from staff when their wife was unable, or unwilling, to ask for herself. For those mothers who were able to compare this birth to a previous cesarean, the use of SSC changed her perspective on the cesarean environment. Mothers in this study described circumstances surrounding a previous cesarean, and the subsequent separation from their neonate, with disappointment and feelings of loss. These sentiments reinforce previous finding from other studies (Chalmers et al., 2010; Lobel & DeLuca, 2007; Porter et al., 2007). In contrast, this study found that the use of SSC during the cesarean allowed the mother to engage with her neonate as early as possible. She was able to experience an early and intimate moment with the neonate and formation of the family unit could commence.
Implications for practice The use of SSC during cesarean closure is making its way into hospitals in the United States as a result of decisive research, reporting the benefits of SSC. This study found the use of SSC after cesarean birth highly desirable for mothers and neonates. Advanced practice nurses and staff nurses will play a major role in supporting the use of SSC during cesarean deliveries. Advanced practice nurses are in an ideal position to educate patients and other healthcare providers on the use and advantages associated with SSC during and immediately after a cesarean birth. Mothers in this study suggested teaching points for those desiring this practice in the future (see Table 3). In addition to education, advanced practice nurses will have an opportunity to influence policy-related practice to the use of SSC during cesarean. There is a need to develop practice guidelines for its use. Advanced practice nurses in roles of administration and hospital leadership will be on the forefront of change in this arena. Mothers in this study felt great appreciation toward staff and others for the opportunity to hold and bond with their babies immediately during the cesarean procedure and believed other mothers should have the same opportunity. “It should be standard practice” was a response reiterated time and again. Nurses can assist new families by educating them and offering and supporting this method of care during cesarean section.
References Ahn, H. Y., Lee, J., & Shin, H.-J. (2010). Kangaroo care on premature infant growth and maternal attachment and post-partum depression in South Korea. Journal of Tropical Pediatrics, 56(5), 342–344. Anderson, G. C. (1977). The mother and her newborn: Mutual caregivers. Journal of Obstetric, Gynecologic and Neonatal Nursing, 6(5), 50–57. Anderson, G. C. (1989). Risk in mother-infant separation postbirth. Image: The Journal of Nursing Scholarship, 21(4), 196–199.
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Bergstrom, A., Okong, P., & Ransjo-Arvidson, A. B. (2007). Immediate maternal thermal response to skin-to-skin care of newborn. Acta Paediatrica, 96(5), 655–658. Bigelow, A., Power, M., MacLellan-Peters, J., Marion, A., & McDonald, C. (2012). Effect of mother/infant skin-to-skin contact on postpartum depressive symptoms and maternal physiological distress. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(3), 369–382. doi:10.1111/j.1552-6909.2012.01350.x Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Mukhamedrakhimov, R., . . . Widstrom, A. M. (2009). Early contact versus separation: Effects on mother-infant interaction one year later. Birth, 36(2), 97–109. Bystrova, K., Widstrom, A. M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Welles-Nystrom, B., Wassberg, C., & Uvnas-Moberg, K. (2003). Skin-to-skin contact may reduce negative consequences of “the stress of being born”: A study on temperature in newborn infants subjected to different ward routines in St. Petersberg. Acta Paediatric, 92(3), 320–326. Chalmers, B., Kaczorowski, J., Darling, E., Heaman, M., Fell, D. B., O’Brien, B., & Lee, L. (2010). Cesarean and vaginal birth in Canadian women: A comparison of experiences. Birth, 37, 44–49. Christensson, K., Siles, C., Moreno, L., Belaustequi, A., De La Fuente, P., Lagercrantz, H., . . . Winberg, J. (1992). Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatrica, 81(6), 488–493. Crenshaw, J. T., Cadwell, K., Brimdyr, K., Widstrom, A. M., Svennson, K., Champion, J. D., . . . Winslow, E. H. (2012). Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates. Breastfeeding Medicine, 7(2), 69–78. doi:10.1089/bfm.2011.0400 Denzin, N. K., & Lincoln, Y. S. (Eds.). (2011). The Sage handbook of qualitative research. (4th ed.). Thousand Oaks, CA: Sage Publications, Incorporated. Dewalt, K. M., & Dewalt, B. R. (2002). Participant observation: A guide for fieldworkers. New York: AltaMira Press. Engebretson, J. (2011). Clinically applied medical ethnography: Relevance to cultural competence in patient care. Nursing Clinics of North America, 46(2), 145–154. doi:10.1016/j.cnur.2011.02.002 Feldman, R., Eidleman, A. I., Sirota, L., & Weller, A. (2002). Comparison of skin-to-skin (kangaroo) and traditional care: Parenting outcomes and preterm infant development. Pediatrics, 110(1), 16–26. Ferber, S. R., & 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. Finigan, V., & Davies, S. (2004). “I just wanted to love, hold him forever”: Women’s lived experience of skin-to-skin care with their baby immediately after birth. Evidence Based Midwifery, 2(2), 59–65. Gathwala, G., Singh, B., & Balhara, B. (2008). KMC facilitates mother baby attachment in low birth weight infants. Indian Journal of Pediatrics, 75, 43–47. Gouchon, S., Gregori, D., Picotto, G., Nageroni, M., & Giulio, P. (2010). Skin-skin contact after cesarean delivery. Nursing Research, 59(2), 78–84. Gray, L., Watt, L., & Blass, E. M. (2000). Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 105(1), e14–e24. Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2013). Births: Preliminary data for 2012. National Vital Statistics Reports, 62(3). Hyattsville, MD: National Centers for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62˙03.pdf Hung, K., & Berg, O. (2011). Early skin-to-skin after cesarean to improve breastfeeding. American Journal of Maternal Child Nursing, 36(5), 318–324. doi:10.1097/NMC.0b013e3182266314. Hurst, N. M., Valentine, C. J., Renfro, L., Burns, P., & Ferlic, L. (1997). Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. Journal of Perinatology, 17(3), 213–217. Johnson, A. N. (2005). Kangaroo holding beyond the NICU. Pediatric Nursing, 31(10), 53–56. Johnston, C., Campbell-Yeo, M., Fernandes, A., Inglis, D., Streiner, D., & Zee, R. (2010). Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews, (3). doi:10.1002/14651858.CD008435
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Kennel, J. H., Trause, M. A., & Klaus, M. H. (1975). Evidence for a sensitive period in the human mother. Ciba Foundation Symposium Journal, 33, 87–101. Klaus, M. H., Jerauld, B. S., Kreger, N. C., McAlpine, W., Steffa, M., & Kennell, J. H. (1972). Maternal attachment: Importance of the first post-partum days. New England Journal of Medicine, 286(9), 460–463. Lobel, M., & DeLuca, R. S. (2007). Psychosocial sequelae of cesarean delivery: Review and analysis of their causes and implications. Social Science & Medicine, 64(11), 2272–2284. Ludington, S. (1990). Energy conservation during skin to skin contact between premature infants and their mothers. Heart and Lung, 19(5), 445–451. Marin-Gabriel, M. A., Llana Martin, I., Lopez Escobar, A., Fernandez Villalba, E., Romero Blanco, I., & Touza Pol, P. (2010). Randomized controlled trial of early skin-to-skin contact: Effects on the mother and the newborn. Acta Paediatrica, 99(11), 1630–1634. doi:10.1111/j.1651-2227.2009.01597.x. Mikiel-Kostyra, K., Mazur, J., & Boltruszko, I. (2002). Effect of early skin-to-skin contact after delivery on duration of breastfeeding: A prospective cohort study. Acta Paediatric, 91, 1301– 1306. Moore, E. R., Anderson, G. C., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (5). doi:10.1002/14651858.CD003519.pub3. Morelius, E., Theodorsson, E., & Nelson, N. (2005). Salivary cortisol and mood and pain profiles during skin-to-skin care for an unselected group of mothers and infants in neonatal intensive care. Pediatrics, 116, 1105–1113. doi:10.1542/peds.2004-2440.
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Porter, M., Teijlingen, E., Ying Yip, L. C., & Bhattacharya, S. (2007). Satisfaction with cesarean section: Qualitative analysis of open-ended questions in a large postal survey. Birth, 34, 148–154. Richards, L., & Morse, J. M. (2007). Read me first user’s guide to qualitative methods (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc. Saldana, J. (2009). The coding manual for qualitative researchers. Thousand Oaks, CA: Sage. Sandalowski, M. (1998). Focus on qualitative methods: Time and qualitative research. Research in Nursing and Health, 22, 79–87. Smith, J., Plaat, F., & Fisk, N. M. (2008). The natural cesarean: A woman-centered technique. BJOG: An International Journal of Obstetrics and Gynaecology, 115(8), 1037–1042. doi:10.1111/j.1471-0528.1008.01777.x Spradley, J. (1979). The ethnographic interview. Belmont, CA: Wadsworth. Tallandini, M. A., & Scalembra, C. (2006). Kangaroo mother care and mother-premature infant dyadic interaction. Infant Mental Health, 27(3), 251–275. doi:10.1002/imhj.20091. Thorne, S., Kirkham, S. R., & O’Flynn-Magee, K. (2004). The analytic challenge in interpretive description. International Journal of Qualitative Methods, 3(1), 1–11. Velandia, M., Matthisen, A. S., Uvnas-Moberg, K., & Nissen, E. (2010). Onset of vocal interaction between parents and newborns in skin-to-skin contact immediately after elective cesarean section. Birth, 37(3), 192–201. doi:10.1111/j.1523-536x.2010.00406.x World Health Organization & United Nations Children’s Fund (WHO/UNICEF). (2009). Baby-friendly hospital initiative: Revised, updated, and expanded for integrated care.
Exploring the skin-to-skin contact experience during cesarean section Anitra C. Frederick, PhD, RN, (Assistant Professor)1 , Nancy H. Busen, PhD, FNP-BC (Margaret A. Barnett/PARTNERS Professorship and Assistant Dean/Department Chair of Family Health)1 , Joan C. Engebretson, DrPH, RN, AHN-BC, FAAN (Judy Fred Professorship in Nursing)1 , Nancy M. Hurst, PhD, RN, IBCLC (Director and Assistant Professor)2,3 , & Karen M. Schneider, MD (Practicing Physician and Associate Professor)4,5 1
University of Texas Health Science Center at Houston School of Nursing, Houston, Texas Women’s Support Services, Pavilion for Women, Texas Children’s Hospital, Houston, Texas 3 Pediatrics/Neonatology at Baylor College of Medicine, Houston, Texas 4 Texas Children’s Pavilion for Women, Houston, Texas 5 Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas 2
Keywords Qualitative; maternal experience; skin-to-skin contact; cesarean section. Correspondence Anitra C. Frederick, PhD, RN, University of Texas Health Science Center at Houston School of Nursing, Room 770, 6901 Bertner Avenue, Houston, TX 77030. Tel: 713-500-2097; Fax: 713-500-2073; E-mail: [email protected] Received: 27 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12229 Disclosure: All authors have seen and approved the manuscript. The authors report no conflict of interest or relevant financial relationships.
Abstract Purpose: To explore and describe the mother’s experience of holding her neonate in skin-to-skin contact (SSC) immediately after cesarean delivery during surgical closure and recovery. Data sources: Eleven women between the ages of 23 and 38 years, who had achieved 39.1–40.2 weeks gestational age, participated in an ethnographic study using observations and interviews with the mothers conducted at 24–48 h postdelivery. Interviews were transcribed verbatim and content analysis of both observational notes and transcripts were used to analyze the data. Conclusions: Findings from this study describe the mother’s experience of SSC during cesarean section. The primary theme that emerged was mutual caregiving: the mother–neonatal interaction and their shared and reciprocal relationship and benefits during SSC. Two contextual issues also were illuminated (a) the father’s influence on the SSC experience and (b) the cesarean environment. Implications for practice: With cesarean section the most common surgical procedure among American women, advanced practice nurses are in a unique position to encourage and educate women on the use of SSC for their benefit and that of their newborn. Advanced practice nurses are also empowered to influence institutional policy on SSC during cesarean deliveries at the local and national level.
Skin-to-skin contact (SSC) is the placement of the diaperclad neonate on the bare chest of the mother, upright, prone, and between her breasts (Johnson, 2005). SSC research has been reported in the healthcare literature for over 35 years, and a 2012 Cochrane Review reported SSC to be the most natural and humane method of care after birth and efficacious for both mother and neonate (Moore, Anderson, Bergman, & Dowswell, 2012). Previous research has primarily focused on SSC after vaginal deliveries. There is increasing interest by providers in extending the use of SSC in cesarean births to improve the physiological and emotional well-being of mother and baby. Cesarean section accounts for almost one-third (32.8%) Journal of the American Association of Nurse Practitioners 28 (2016) 31–38 C 2015 American Association of Nurse Practitioners
of all deliveries and affected 1.29 million women in 2012 (Hamilton, Martin, & Ventura, 2013). Accepted clinical practice is to separate mother and neonate immediately after birth for an average of 1–4 h with little opportunity for mutual interaction (Lobel & DeLuca, 2007). Rationale includes the need for surgical completion, patient monitoring, and post-op recovery frequently noted. However, these mothers often express disappointment, distress, and dissatisfaction with the birthing process (Chalmers et al., 2010; Lobel & DeLuca, 2007; Porter, Teijlingen, Ying Yip, & Bhattacharya, 2007). SSC provides the most optimal environment for neonatal adaptation to extrauterine life (Mikiel-Koystyra, Mazur, & Boltruszko, 2002) through better central 31
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nervous system control, reduction in stress, and maintenance of quiet sleep (Ferber & Makhoul, 2004). These infants achieve and maintain thermoregulation faster than those wrapped in blankets or placed in a crib (Bergstrom, Okong, Ransjo-Arvidson, 2007; Bystrova et al., 2003), experience less energy expenditure as evidenced by increased sleep times and decreased crying and activity level (Christensson et al., 1992; Ludington, 1990), and demonstrate decreased pain responses with uncomfortable procedures (Gray, Watt, & Blass, 2000; Johnston et al., 2010). The benefits of SSC extend to the mother as well. SSC plays a role in preventing and decreasing maternal depression (Bigelow, Power, MacLellan-Peters, Marion, & McDonald, 2012; Feldman, Eidleman, Sirota, & Weller, 2002), reduces cortisol levels and self-reported stress (Bigelow et al., 2012; Morelius, Theodorsson, & Nelson, 2005; Tallandini & Scalembra, 2006), encourages faster delivery of the placenta (Marin-Gabriel et al., 2010), increases breastmilk volume (Hurst, Valentine, Renfro, Burns, & Ferlic, 1997), and decreases time to initial breastfeeding (Hung & Berg, 2011). Mothers who practice SSC also score higher on measures of attachment to their neonate (Ahn, Lee, & Shin, 2010; Gathwala, Singh, & Balhara, 2008) and display increased maternal responsiveness and sensitivity (Bystrova et al., 2009; Feldman et al., 2002). The period immediately after birth, termed the “sensitive period,” is a very unique period for the creation of a strong maternal attachment to the neonate (Kennel, Trause, & Klaus, 1975; Klaus et al., 1972). Mothers who experience a cesarean are often denied access to their neonates during the “sensitive period” when hormonal and inherent behaviors come together to produce the most favorable outcomes. Given the efficacy of SSC after vaginal delivery, the purpose of this study was to explore and describe the mother’s experience of SSC immediately after cesarean delivery during the surgical closure and recovery period. Because little is known about how a mother interprets SSC with her neonate during cesarean closure, this study employed an ethnographic approach to better understand SSC during cesarean deliveries. Mothers’ responses are of great importance and knowledge gained through qualitative inquiry can be used to inform best practice in the future.
Methods Design setting and sample A focused medical ethnographic design was used to explore the SSC experience between a mother and her neonate after birth by a scheduled, cesarean section. Ethnography involves the study and description of human experiences based on field work that includes participant 32
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Table 1 Inclusion/exclusion criteria for mothers scheduled for a cesarean section Inclusion criteria
Exclusion criteria
Carrying a live, singleton fetus with no preexisting special needs Achieved between 39 and 42 weeks postmenstrual age (PMA) by obstetrical dates and who have maintained prenatal carea Will obtain regional anesthesia during surgery Ability to speak and read English Delivery of newborn with APGARb scores > 7 at 1 min and >8 at 5 min postbirth
Maternal complications with surgery Neonatal problem requiring immediate separation from the mother for medical care or NICU admittance
a
The American College of Obstetricians and Gynecologists (ACOG) recommends that scheduled elective cesareans should only be carried out after achieving 39 weeks PMA. b The APGAR score was used as a measure of neonatal stability. It is used to evaluate the infant’s condition and adjustment to extrauterine life. A rating of 0, 1, or 2, is given for each of five characteristics: heart rate, respiratory effort, muscle tone, reflex ability, and color.
observation and in-depth interviews (Denzin & Lincoln, 2011). Medical ethnography is situated within the healthcare context and speaks to how patients interpret their experiences within the system (Engebretson, 2011). The ethnographic approach provides a thick description and a rich understanding of life experiences to better understand clinical phenomena where findings can be applied to practice (Dewalt & Dewalt, 2002; Thorne, Kirkham, & O’Flynn-Magee, 2004). The ethnographic design was employed to find a “lens” into a mother’s experience of SSC immediately after delivery. Observation of the SSC interaction occurred during the cesarean until the first feeding and an in-depth, loosely structured interview was conducted with the mother between 24 and 48 h postpartum. The study was conducted at a large hospital in the Texas Medical Center. Institutional Review Board (IRB) approval was obtained from two independent institutions and written informed consent was required of participants. The sample included 14 women who were scheduled as cesarean deliveries, had an assenting obstetrician and anesthesiologist, and agreed to participate in SSC immediately after birth during surgical closure and recovery. Table 1 illustrates inclusion and exclusion criteria used for the study. Eligible women scheduled for a cesarean birth were initially identified, and then a purposive sampling strategy was employed, which allowed for the deliberate choice of information-rich cases in order to achieve a complete description and analysis of the phenomena of
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interest (Sandelowski, 1998). For example, women with a variety of previous birth experiences and ethnicities were recruited during the presurgical appointment by the pre-op staff nurse and the investigator. Sampling continued until data saturation and redundancy were achieved with a full understanding of the phenomena (Richards & Morse, 2007).
Data collection and analysis Data collection included observation with field notes and individual interviews. Observation of the SSC interaction was conducted during the cesarean procedure, concluding with the first feeding. Observations focused on the interactions between the mother and neonate, and included the mother’s support person in the room and the healthcare staff involved in SSC and patient care. After a review of field notes, observations of interest were included in the maternal interview for clarification and a deeper understanding. An in-depth, loosely structured interview with the mother was conducted at a convenient time prior to discharge. Following Spradley’s (1979) recommendations, an interview guide was used to spur discussion and assist the mother in recall of the SSC experience, observations of interest to the investigator, and the mother’s overall impressions. The interview started with the grand-tour question, “Tell me about the SSC experience you shared with your newborn after the cesarean section.” Mothers were able to direct the interview by discussing what was important to them. Additional probes included such questions as: “how did you feel during SCC with your newborn, what could have improved the SSC experience for you, and how did this experience compare with your expectations?” Data interpretation was validated by clarifying observations and statements with the informants. Data collection and analysis were iterative and recursive and began after the first cesarean was observed. As the dataset grew, the field notes were used to aid the investigator in making comparisons, summarizing patterns, and drawing conclusions. During later interviews, participants verified or clarified the meaning behind emerging patterns and investigator conclusions. All interviews were digitally voice-recorded and transcribed by the investigator. Qualitative content analysis was used to analyze the interview data and develop themes (Saldana, 2009). Transcripts and field notes were reviewed and initial codes were categorized, classified, and synthesized to aid in conceptualizing the data. These codes and categories were used to support the overarching theme and contextual issues from the data. To improve rigor within the data analysis, raw data, coding schema, and thematic fit were frequently reviewed
with seasoned nurse researchers until consensus in coding and thematic analysis was achieved. A peer debriefing session was held where the themes were discussed to ensure findings were clearly anchored to the data.
Results Eleven (n = 11) women, aged 23–38, who were between 39.1 and 40.2 weeks gestational age participated in the study. Eight were scheduled for repeat cesareans, two were primiparous women who required a cesarean for medical issues (a contracted pelvis and a retinal hole that made vaginal deliveries potentially unsafe), and one multiparous woman had a breech presentation. Two women delivered prior to their scheduled cesarean date and one neonate was admitted to the neonatal intensive care unit (NICU) after birth because of respiratory distress and was not available for SCC. There were 11 neonates (four female, seven male), with an average weight of 3619 g. They took from 5 to 18 min to achieve SSC with their mothers; the duration of SSC was from 12 to 62 min with an average of 33 min. See Table 2 for a complete description of clinical information and SSC data regarding study participants. The main theme that emerged from the data was the Mutual Caregiving shared between mother and neonate. The term Mutual Caregiving was first introduced by G. C. Anderson (1977, 1989), who created a framework for the maintenance of mother and infant in close contact after birth. Two important contextual issues were also illuminated by the data findings: the Father’s Influence and the Cesarean Environment. The desire to hold the neonate and know their condition firsthand was on the forefront of the mothers’ mind both before and during the cesarean procedure. The initial SSC, the introduction of mother and neonate for the first time in the extrauterine environment, was a profound moment for the mother. When placed together in SSC, the dyad became immediately interactive with and responsive to one other, using all their senses as a means of communication. The two appeared to settle into one another, as if they were in an insulated, emotional cocoon. Most mothers noted the desire and ability to tune out the surrounding operating room (OR) environment and concentrate solely on their newborn. “I didn’t care about anything else. I was just concentrating on him.” All the mothers commented on the calming nature of the SSC, both for themselves and for their neonate. The mothers stated the act of having the neonate against their skin quieted and relaxed the baby. In addition, they noted a peace that came over them when holding. This sense of calm and reassurance was reciprocal for the dyad, each reinforcing the other. “ . . . and instantly, the minute he got 33
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Table 2 Maternal demographics, birth, and SSC data Dyad 1 2 3 5 6 7 8 10 12 13 14
Maternal age (years) 32 38 27 35 36 31a,b 23 37 29 33b 36b
Gestation/para
Race
Neonatal weight (g)
Gender
Birth to SSC (min)
Duration of SSC (min)
2/2 3/2 4/3 2/2 2/2 4/2 3/2 6/2 3/2 1/1 1/1
C C AA C H H H C AA H H
3120 3805 3440 3440 4140 3290 4025 3630 4170 3630 3120
F M M F M M M F M F M
6 6 18 5 5 11 5 18 6 7 8
30 53 25 49 62 32 12 41c 12 24c 23c
AA, African American; C, Caucasian; F, female; H, Hispanic; M, male. a First child delivered vaginally. b Primary cesarean section. c SSC continued after observation period.
on me, he got quiet and that just made me feel good . . . he was just so happy to be with mom.” “I noticed that as soon as they put him on my chest he got quiet and stopped crying and he seemed comfortable and that made me feel comfortable, too.” Because of the nature of the SSC, mothers and neonates were able to share comforting touch. The mothers frequently commented on the ability to experience the neonate through touch which was reassuring and meaningful. The ability to feel, see, and interact with the neonate immediately, and on such an intimate level, put the mother at ease. “Those thoughts are just running through your head. Are there ten fingers? Are there ten toes? Is she pink? Is she blue? You know . . . is she breathing okay? Is her heart rate okay? Whereas, with her on your chest, I mean you just, you experience it firsthand. Being able to immediately know that and see it is a very powerful experience.” Having the neonate so close allowed the mother to verbally interact with her baby. Most mothers spoke quietly to their neonate during the holding session. Many commented on the belief that their voice was soothing to the newborn and was something only she could provide. The mothers also commented on their ability to provide warmth to the neonate. These first shared moments gave the mother a sense of empowerment and many mothers commented on the strong bond they felt toward their baby. “When I started talking to him he would calm down.” “My voice was soothing to him. So, I helped him a lot.” “Because it was traumatizing for him, with everything going on, and I think that immediate bond helped him a lot.” “Actually, it was a wonderful experience. Because, with my prior cesarean, I didn’t have any contact with the baby. This time, I was able to actually bond with my baby.” 34
Even in the midst of the cesarean closure, the SSC experience felt natural for most of the mothers. “I love that . . . they didn’t even finish cleaning him and they gave him to me.” “It just felt natural” were the most common reactions. With the neonate lying on the mother’s chest, the progression toward breastfeeding was readily observed: quiet rest, salivating, licking, lip smacking, kneading of the hands, and movement of the head toward the nipple. Some mothers attempted breastfeeding while lying flat on the OR table, but none were successful in latching the baby onto the nipple during the procedure. Many attributed the inability of the neonate to latch onto the breast as a result of the cesarean procedure in progress. “I thought it was going to be possible but then, I realized no way.” “Because he was taking more space over there and they were working over there. But, he wanted it. He was ready. He was really sucking. And I was thinking, if we had a nice position, he would have.” All mothers who breastfed had rapid success in latching the neonate onto the nipple after returning to the recovery area. Observation of the dyad revealed that neonates in this study latched onto the nipple within 2–7 min of arrival to the recovery room. “It was just really nice to be in the recovery room and to have her take to me as quickly as she did. That wasn’t the experience with my son.”
Father’s influence All the mothers participating in this study had the father of the baby present as their support person during the cesarean procedure. The mother’s attention was primarily focused on her neonate during SSC, yet the father’s presence and participation was important to the mother. Mothers acknowledged these first shared moments with their newborn and the father as the formation of the
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Table 3 Take-home points for APRNs and their patients Benefits of SSC for both mother and neonate Mother
Neonate
• Decreases postpartum depressive symptoms • Achieve and maintain thermoregulation more rapidly • Increases responsiveness to neonate • Better central nervous system control • Enhances attachment to neonate • Promotes soothing, decreases crying • Reduces stress • Success in breastfeeding • Increases milk volume • Decreased pain response Cesarean section is not a contraindication for immediate SSC (Crenshaw et al., 2012; Smith, Plaat, & Fisk, 2008). Mothers should no longer be denied access to SSC during cesarean The use of SSC during cesarean is achievable and desirable. Findings included • Sense of maternal empowerment • Enhanced maternal confidence • Ability to calm the neonate easily with touch and voice • Rapid breastfeeding success in recovery • Father’s presence provided a buffer to the OR environment • OR environment was stressful and SSC calmed the mother and neonate APRNs should develop and encourage practice guidelines supporting the use of SSC during cesarean. Step 4 of the Baby Friendly Hospital Initiative encourages continuous, uninterrupted SSC for stable, cesarean mother–neonate dyads (WHO/UNICEF, 2009) Prenatal teaching points for improving the experience of SSC during cesarean • OR monitoring and equipment expectations: • Cycling BP cuff, an intravenous catheter (IV), an oxygen saturation monitor, and EKG leads present • Prone position, pressure/movement felt below the sterile drape during the surgery, staff continually circulating in the OR • Neonatal responses to SSC: • General movement, crying or silence normal, and advances toward the breast • React to the mother’s voice and touch • Encourage mothers to speak up. Ask for help, as needed
family unit. “It was nice for the three of us to be there together. I mean, we both got a little weepy seeing our little boy there.” “It was a bonding of the three of us, definitely.” Many fathers did what they could to support the mother by assisting her and the neonate during SSC. While some fathers were uncertain of their place in the OR setting and distanced themselves, most fathers sat close throughout the SSC session providing support through quiet speech with mother and neonate, repositioning the neonate as needed, and asking staff for assistance on behalf of the mother. Observation revealed the father provided a buffer to the outside environment. Mothers commented that if they were not holding the neonate in SSC, they would prefer for the father to be holding and interacting with the neonate instead of the neonate being observed on the warmer.
Cesarean environment The experience of SSC shortly after birth occurred within the context of the surgical environment. Being rolled into the bright OR, full of surgical equipment, and staff clothed in gowns and masks is a foreign experience to most mothers. “I mean, cesareans are so impersonal.” Knowing about the epidural procedure and subsequently being separated from the lower half of their body with no control over the
birth process was anxiety provoking for the mothers in the study. These feelings were somewhat alleviated by the SSC shared with their neonate: “It was very unique in the sense that I was totally numb. I had no control over anything. I felt helpless. And then when I saw him, it was just super emotional and then having him made it all worth . . . (cries). I had no feeling with my legs totally numb. I had zero control being dependent on all the people there. I was . . . It was very difficult. I threw up. I had to be helped and everything. And then, when you put him on top of me and I was able to hold him I just forgot about how helpless I was and how uncomfortable.” While the SSC relieved some of the anxiety associated with the cesarean procedure, the surgery in progress was not lost to the mothers. Mothers noted feeling as if the baby was in the way of the surgical procedure. They also noted their discomfort, the surgical monitoring equipment, and the impersonal nature of the cesarean process. No matter how focused the mother was on her neonate she was frequently reminded of her surroundings. “I would move my arms down and then the doctor would say, reposition.” “It was not as intimate as I thought because there were so many people around doing so many things.” “They (doctors) were working and they don’t know what we’re doing over here. That’s priority, you know. I’m open, so they need to work on that.” 35
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The mothers also commented on their desire to see more of the baby, but they were unable to do so while laying supine on the OR table. They reflected on the frequent need to reposition the baby. During SSC, the neonate was placed atop the breast tissue in a transverse lie as opposed to upright so that the obstetrician could have room to work. At times, the positioning of the dyad caused the neonate to slowly move toward the mother’s upper chest and neck. The mother’s supine position made visualization of the neonate difficult and required vigilant attention and repositioning by the nursing staff. “I was too uncomfortable, because I was a little bit upside down, I guess.” “ . . . so, I was like, I want to grab her and be in a comfortable position. That would be great. But, because it’s a C-section, you can’t do it.” “The only thing I didn’t really like about it was that I felt like I couldn’t really see her because of my position.” The use of monitoring equipment for the mother undergoing the cesarean procedure is necessary throughout cesarean closure. The mothers commented that their first bonding moments were “constantly interrupted” by the peripheral surgical equipment. While the SSC was preferred over the alternative of not holding so soon after birth, the equipment interfered with the mothers’ ability to focus solely on the neonate. “It was interrupting my bonding—the taking of the blood pressure. I had to stretch my arm out and I was holding him with the other, so I was kind of interrupted a little.” “I thought . . . I would really be able to just hold him. But, I realized they would still have to have the blood pressure monitoring. So, because that was still there, it didn’t really ruin my experience, but it wasn’t just me and the baby.” All the mothers commented that holding their neonate against their skin so soon after birth was a special moment they would not have wanted to miss. However, four mothers chose to shorten their SSC session, or delay it, because of various circumstances. For example, two mothers felt overwhelmed by the cesarean birth environment and the stimuli around them. They were anxious, concerned for their neonate, and both relinquished the neonate to staff before the cesarean closure was complete. One mother felt tingling in her arm and chose to cease holding while prone. At the completion of closure, she continued with SSC. Another mother was having a lot of pain during the procedure and delayed holding until her pain subsided. Then, she held the neonate in SSC and continued to hold until after the first breastfeeding session was complete in recovery.
Discussion The use of SSC for dyads undergoing cesarean section is a new model of care. During this study, the use of SSC 36
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in the surgical setting had a positive impact on the mothers, fathers, and staff involved. No adverse events were observed before, during, or after the cesarean. The mothers in this study commented on their overall satisfaction and appreciation for the opportunity to hold their neonates within minutes of delivery. Some mothers commented on their discomfort and gave suggestions for improving SSC during cesarean. Requests were made to lengthen the blood pressure (BP) monitoring cycle and to raise the head of the OR bed slightly during SSC. Every participant who had undergone a previous cesarean spoke more favorably upon the SSC experience compared to previous cesareans when routine separation was practiced. The use of SSC within minutes of birth enabled the mothers to know their neonates firsthand, to interact with them immediately, and to begin the bonding process. These findings reinforce previous reports in the literature noting enhanced feelings of attachment to the newborn (Ahn et al., 2010; Gathwala et al., 2008) and immediate feelings of bonding with their baby (Finigan & Davies, 2004). An important finding from this study was the ability of SSC to empower the mother, bolstering maternal role confidence even during the cesarean birth experience. The mothers were actively engaged and involved with their neonate from the moment the baby was placed in SSC on their chest. The mother’s touch and sound of her voice calmed the baby and neonates latched on to the breast quickly. The use of intraoperative SSC gave the mother a sense of early accomplishment and power in her maternal role. Other studies investigating the use of SSC after cesarean also report positive outcomes (Gouchon, 2010; Hung & Berg, 2011). Similar findings were supported in this study. Breastfeeding mothers in this study commented on the ease of the initial breastfeeding session and were pleased by how readily their neonates “took” to them in the recovery room. Mothers reported that SSC made breastfeeding easier and continued to use SSC in the first 24–48 h after their delivery. Consistent with other studies (Velandia, Matthisen, Uvnas-Moberg, & Nissen, 2010), mothers in this study referred to their desire and ability to interact with the neonate verbally, calming and soothing them with their voice. Unique to this study were the mothers’ comments concerning the father’s role and the support he provided during the intraoperative SSC. While mothers were primarily focused on the neonate, they appreciated the support provided by the father during the SSC and acknowledged his role in the formation of the family unit during the first moments of SSC. In addition to the paternal role, fathers were able to act as a buffer between mothers and surgical environment. Fathers comforted their wife
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and asked for assistance from staff when their wife was unable, or unwilling, to ask for herself. For those mothers who were able to compare this birth to a previous cesarean, the use of SSC changed her perspective on the cesarean environment. Mothers in this study described circumstances surrounding a previous cesarean, and the subsequent separation from their neonate, with disappointment and feelings of loss. These sentiments reinforce previous finding from other studies (Chalmers et al., 2010; Lobel & DeLuca, 2007; Porter et al., 2007). In contrast, this study found that the use of SSC during the cesarean allowed the mother to engage with her neonate as early as possible. She was able to experience an early and intimate moment with the neonate and formation of the family unit could commence.
Implications for practice The use of SSC during cesarean closure is making its way into hospitals in the United States as a result of decisive research, reporting the benefits of SSC. This study found the use of SSC after cesarean birth highly desirable for mothers and neonates. Advanced practice nurses and staff nurses will play a major role in supporting the use of SSC during cesarean deliveries. Advanced practice nurses are in an ideal position to educate patients and other healthcare providers on the use and advantages associated with SSC during and immediately after a cesarean birth. Mothers in this study suggested teaching points for those desiring this practice in the future (see Table 3). In addition to education, advanced practice nurses will have an opportunity to influence policy-related practice to the use of SSC during cesarean. There is a need to develop practice guidelines for its use. Advanced practice nurses in roles of administration and hospital leadership will be on the forefront of change in this arena. Mothers in this study felt great appreciation toward staff and others for the opportunity to hold and bond with their babies immediately during the cesarean procedure and believed other mothers should have the same opportunity. “It should be standard practice” was a response reiterated time and again. Nurses can assist new families by educating them and offering and supporting this method of care during cesarean section.
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