Wednesday, May 11, 2016

Skin-to-Skin Care After Cesarean

Image by Nicole Monet Photography
Although cesareans are generally over-used in most developed countries, sometimes they are truly needed. Thank goodness we have them as an option when they are needed.

But even a necessary cesarean can be difficult or even traumatic at times. Cesareans have also been found to negatively impact breastfeeding initiationduration, and formula supplementation rates.

One of the most consistent things heard from cesarean moms is how hard it is to be separated from her baby. Obviously, sometimes this is medically necessary, but babies have been routinely separated from their mothers even when there is no medical necessity. This separation can last for hours, sometimes even many hours. Research shows that this can negatively impact bonding and maternal interaction with the baby.

Many cesarean mothers say it feels like everyone gets to hold and take care of the baby before she does, which is difficult. Surgical birth can be a very passive experience for the mother, who may feel disconnected and distant from the baby afterwards.

In an effort to humanize and improve the cesarean experience, some doctors began experimenting with changing the care given during cesareans. The mother is prepped, and sometimes a clear drape is used so the parents can see the baby being delivered (if they wish). Often, the doctors wait a few minutes to cut the cord, letting the baby have the benefits of delayed cord clamping.

Then the baby is laid directly on the mother's bare chest, "skin to skin" as it were, which has been shown to have significant benefits. The mother's body warms the baby (along with blankets on top of both), the baby gets flora from the mother's skin, and the baby picks up the subtle cues that encourage early latching on for nursing. Thus, the baby is more gently transitioned to the outside world while the doctors finish stitching up the mother.

Some resources call this a "natural" cesarean, but this is a poor term, since surgery is anything but natural and the term tends to unrealistically minimize the realities of surgical birth. Many people feel that "gentle" cesarean or "family-friendly" cesarean are better alternative terms.

Women have been asking for many years for the drape to be lowered at the baby's delivery, and for the baby to go directly to them instead of to the nursery. For years, doctors have said that they couldn't do skin-to-skin in the operating room because it would delay treatment of the baby, might increase risk of infection for mother or baby, might increase hypothermia (low body temperature) of the newborn, and would interfere with the surgery.

But now, more and more hospitals are exploring this option because of consumer demand. The question is, how does this impact outcomes?

Skin-to-Skin After Cesarean Improves Outcomes

In a recent study, doctors looked at many of these questions in detail. Do mothers and babies who had skin-to-skin cesarean sections (SSCS) have worse outcomes?

The answer was that NO, mother-baby dyads having skin-to-skin care after cesareans did not have worse outcomes; they often had better outcomes instead.

For example, in the study, far fewer babies were admitted to intensive care after a SSCS than after a conventional cesarean (9.5% vs. 18%). Also, fewer had a suspected neonatal infection (2.0% vs. 7.3%).

There were slightly more surgical site infections in the SSCS group but the difference did not rise to statistical significance and could have been the result of chance. Surgical times were slightly longer (about 5 minutes longer on average) in the SSCS group but the recovery time was shorter by about 15 minutes on average.

This is not the only study to find positive results associated with skin-to-skin care after cesarean. A recent literature review found that a SSCS increased breastfeeding initiation rates, reduced time to first breastfeeding, decreased formula supplementation, reduced newborn stress, and improved maternal bonding.

Another recent study found that babies who experienced a SSCS did not experience more hypothermia than those born by conventional cesarean.

Basically, pretty much every objection traditionally used against skin-to-skin care after a cesarean has been debunked. So why isn't this routinely used in hospitals now? The answer is that medical culture can be difficult to change. The routines around surgical birth are firmly entrenched in most hospitals and it has been difficult to change the beliefs of many staff members, despite research showing the benefits of "gentle" cesareans.

The good news is that there is a growing cultural shift to humanize cesarean birth in many institutions. The bad news is that it is taking a long time to catch on in some areas. It is up to consumers and healthcare providers to keep pressuring for change in hospital culture.


Mammals have a strong biological need to see and hold their offspring immediately at birth; those that are separated from their offspring often reject their babies or take sub-optimal care of them.

Thankfully, humans have higher reasoning capacity and can overcome this; many cesarean mothers bond just fine with their babies. However, it is also not uncommon to have initial bonding issues; many cesarean mothers feel disconnected, like they really aren't sure this is their baby or that they are just a temporary caretaker of the baby. Or they may feel guilt at pictures of the baby alone in the NICU after the birth, like they had voluntarily abandoned their baby.

Research clearly shows that when mothers and babies do not have quick contact after birth, it can negatively affect bonding and breastfeeding behavior, sometimes even long-term. Cesareans can be inherently traumatic because the nature of the surgical procedure in most hospitals usually means a significant delay like this.

Skin-to-skin contact has a powerful role to play in helping cesarean mothers bond more easily with their child and improve breastfeeding rates. A Cochrane review of skin-to-skin contact after a normal vaginal birth found that skin-to-skin contact improved breastfeeding rates and duration, lowered cardio-respiratory stress in babies, and decreased crying. They found "no apparent short- or long-term negative effects" from skin-to-skin contact. In other words, skin-to-skin contact had NO real risks, only benefits.

But for too long, those benefits remained out of reach for women who had cesareans. For years, doctors said skin-to-skin contact was too "risky" or logistically difficult to do during a cesarean. Some staff began advocating skin-to-skin care for fathers during a cesarean, which is better than nothing, but still left the mother out of the picture.

Happily, now that we know that skin-to-skin contact is safe and practical, more hospitals are starting to offer skin-to-skin contact for the mother during a cesarean in order to promote a more family-friendly experience. In one hospital, the rate of skin-to-skin contact at cesarean has increased from 20% to 60% in healthy term infants.

There is one caution, however. Many cesarean activists are concerned that some hospitals are trying to blunt criticism of excessive cesarean rates by making them more palatable to the public through these promotions. Some institutions may even try to sell parents on planned cesareans by promoting them as a "natural" alternative, implying they are just as safe as a vaginal birth. One recent study addresses this concern, stating:
It must be mentioned that a patient-centered approach to cesarean delivery should not be used to promote elective cesarean birth. We agree that vaginal birth is generally the safest mode of delivery, and each cesarean birth increases maternal risk during subsequent pregnancies.Yet when cesarean delivery is medically necessary, gentle cesarean may provide a positive birth experience for a family, rather than a surgery to be endured. Furthermore immediate skin-to-skin contact promotes early and successful breastfeeding, which may be adversely affected by cesarean birth compared with vaginal birth.
Let's be clear. The best way to increase breastfeeding rates and improve bonding is to lower the rate of non-indicated cesareans. However, when a cesarean becomes a reality, techniques like immediate skin-to-skin contact can help the experience become more family-friendly and humane.

Sadly, immediate skin-to-skin contact during a cesarean is still all too rare in hospitals, but the rate is increasing. It's long past time for this low-risk intervention to become the standard of care when a cesarean is done.


J Matern Fetal Neonatal Med. 2016 Mar 9:1-21. [Epub ahead of print] Risks and benefits of the skin-to-skin cesarean section - a retrospective cohort study. Posthuma S1, Korteweg FJ1, van der Ploeg JM1, de Boer HD2, Buiter HD3, van der Ham DP1. PMID: 26955857
OBJECTIVE: Comparing maternal and neonatal outcomes after conventional cesarean section (CS) versus a "natural" or "skin-to-skin"cesarean section (SSCS). METHODS: Retrospective cohort of women who underwent a SSCS (01-2013 until 12-2013) compared to conventional CS (08-2011 until 08-2012). CS before 37 weeks, under general anesthesia and in case of fetal distress were excluded. Main outcome measures were maternal blood loss, post-operative infection and admission; neonatal infection and admission; procedural outcomes. RESULTS: We analyzed 285 (44%) women in the SSCS-group and 365 (56%) in the conventional CS-group. There were no significant differences in surgical site infection (2.1% vs. 1.6%; RR 1.1; 95%CI 0.64-2.0), or other maternal outcomes. Fewer neonates born after SSCS were admitted to the pediatric ward (9.5% vs. 18%; RR 0.58; 95%CI 0.41-0.80) and fewer neonates had a suspected neonatal infection (2.0% vs. 7.3%; RR 0.40; 95%CI 0.19-0.83). No differences were observed for other outcomes. Mean operation time was 4m42s longer in the SSCS-group compared to the conventional CS-group (58m vs. 53m; 95%CI 2m44s to 6m40s). Mean recovery time was 14m46s shorter (114m vs. 129m; 95%CI 3m20s to 26m). CONCLUSION: Adverse maternal and neonatal outcomes were not increased after skin-to-skin cesarean compared to conventional cesarean delivery.
J Am Board Fam Med. 2014 Sep-Oct;27(5):690-3. doi: 10.3122/jabfm.2014.05.140014. Promotion of family-centered birth with gentle cesarean delivery. Magee SR1, Battle C2, Morton J2, Nothnagle M2. PMID: 25201938
PURPOSE: In this commentary we describe our experience developing a "gentle cesarean" program at a community hospital housing a family medicine residency program. The gentle cesarean technique has been popularized in recent obstetrics literature as a viable option to enhance the experience and outcomes of women and families undergoing cesarean delivery. METHODS: Skin-to-skin placement of the infant in the operating room with no separation of mother and infant, reduction of extraneous noise, and initiation of breastfeeding in the operating room distinguish this technique from traditional cesarean delivery. Collaboration among family physicians, obstetricians, midwives, pediatricians, neonatologists, anesthesiologists, nurses, and operating room personnel facilitated the provision of gentle cesarean delivery to families requiring an operative birth. RESULTS: Among 144 gentle cesarean births performed from 2009 to 2012, complication rates were similar to or lower than those for traditional cesarean births. Gentle cesarean delivery is now standard of care at our institution. CONCLUSION: By sharing our experience, we hope to help other hospitals develop gentle cesarean programs. Family physicians should play an integral role in this process.