Kangaroo care is defined as the way of “holding a preterm or full term infant so that there is skin-to-skin contact between the infant and the person holding it. The baby, wearing only a diaper, is held against the parent’s bare chest. Kangaroo Care (also Kangaroo Maternal [Mother] Care or Skin-to-Skin Contact and Breastfeeding) is a method used to restore the unique mother-infant bond following the sudden separation during the birth experience particularly in premature births”( www.med.umich.edu/nicu/pdf/C.3KangarooCare.pdf, 2010). Mothers are more likely to be able to practice skin to skin contact or kangaroo care following a vaginal delivery versus a cesarean which is seen as a medical procedure and not a delivery.
Infants born to mothers via cesarean are usually whisked away to a nursery and are separated from their mother for as long as two hours. Infants most alert period is the first one to two hours after delivery and most babies born via cesarean spend this time in the nursery away from their mothers and once they are reunited with their mothers they are now in a deeper sleep state and tend to not breastfeed as well as babies that are born vaginally and allowed skin to skin contact immediately. This paper focuses on the need to change the way we take care of mothers and infants that give birth via cesarean and allow them the same bonding experience as mothers that give birth to their infants vaginally.
Step 1: Assess the Need for Change in Hospital Practice
How can nurses promote change in the OR with the OB physician, Pediatric team, Anesthesiologist, and nursing staff? The best way to promote change in a healthcare facility is to show how it will benefit the patients and improve the way they view the hospitals. Healthcare is becoming a competitive business and how a mother views her birth experiences will reflect on her survey score, which could potentially affect reimbursement amounts in the future if a hospital has a low score. Nurses should look into the benefits to both mother and baby in regards to their health when they receive time to do skin to skin contact in the OR. Evaluate what potential obstacles would hinder the surgical procedure by doing skin to skin contact and come up with potential solutions so that skin to skin contact in the OR does not interfere with the surgical procedure.
Step 2: Link the Problem, Interventions, and Outcomes
The problem with skin to skin contact in the OR is that for many years physicians have performed Cesarean sections in a certain way and therefore are difficult when it comes to changing the way they practice this procedure. Hospital procedures are written and followed for many years and physicians can be very reluctant to change the way they practice medicine. The first step is to show both the OB and Pediatric doctors the benefits to mother and baby if they are allowed to do skin to skin contact.
Some of the benefits to mother and baby are the following “stabilize the preterm infant’s heartbeat, temperature, and breathing. Preterm infants often have difficulty coordinating their breathing and heart rate. Researchers also have found that mothers who use kangaroo care often have more success with breastfeeding and improve their milk supply. Further, researchers have found that preterm infants who experience kangaroo care have longer periods of sleep, gain more weight, decrease their crying, have longer periods of alertness, and earlier hospital discharge” (www.med.umich.edu/nicu/pdf/C.3KangarooCare.pdf, 2010). This would apply to all babies allowed to do skin to skin contact and not just premature babies.
The benefits to mom are “enhanced maternal-infant attachment & bonding increased maternal self-confidence, increased maternal affectionate behavior, enhanced relaxation and experience less anxiety, less breast engorgement, and more rapid involution (uterus returning to pre-pregnant size)” (www.preciousimagecreations.com/presentations/kangaroocare.pdf, 2006). These benefits could be shown to the OB and Pediatric providers during their monthly meeting and also how improving a mother’s birth experience could raise hospital scores which can improve reimbursement rates in the future. For the nursing staff in the OR and the Anesthesiology team it is a matter of showing them that they can still do their jobs without the skin to skin contact causing major disruptions. The best way to do this is to come up with a protocol and discuss in staff meeting and then have a “mock cesarean surgery” to show how it would work if the protocol was to be implemented. This allows the nurses and doctors a way to see it in action and how it would impact their job duties while in the OR.
Step 3: Synthesize the Best Evidence There has been some research to look at skin to skin contact after cesarean birth. One study found “the effectiveness of skin-to-skin contact (SSC) after vaginal delivery has been shown. After cesarean births, SSC is not done for practical and medical safety reasons because it is believed that infants may suffer mild hypothermia. The aim of this study was to compare mothers’ and newborns’ temperatures after cesarean delivery when SSC was practiced (naked baby except for a small diaper, covered with a blanket, prone on the mother’s chest) with those when routine care was practiced (dressed, in the bassinet or in the mother’s bed) in the 2 hours beginning when the mother returned from the operating room. An experimental, no inferiority adaptive trial was designed with four levels of analysis: 34 pairs of mothers and newborns, after elective cesarean delivery, were randomized to SSC (n = 17) or routine care (n = 17). Temporal artery temperature was taken with an infrared ray thermometer at half-hour intervals.
Results of the study: compared with newborns who received routine care, SSC cesarean-delivered newborns were not at risk for hypothermia. The mean temperatures of both groups were almost identical: after 30 min, 36.1 degrees C for both groups (+/-0.4 degrees C for SSCs and +/-0.5 degrees C for the controls), and after 120 min, 36.2 degrees C +/- 0.3 degrees C for SSCs versus 36.4 degrees C +/- 0.7 degrees C for the controls (no significant differences). Time from delivery to the mothers’ return to their room was 51 +/- 10 min. The SSC newborns attached to the breast earlier (nine SSC newborns and four controls after 30 min) were breast-fed (exclusively or prevalently) at discharge (13 SSCs and 11 controls) and at 3 months (11 SSCs and 8 controls), and the SSC mothers expressed high levels of satisfaction with the intervention.” (Gouchon, 2010). This study showed that the skin to skin contact for the infants born via cesarean is not a potential risk for hyperthermia in the OR while doing skin to skin contact with their mother which was one of the theories that most doctors use as to why they feel skin to skin contact should not be allowed in the OR. However, by using the information obtained in this study it is clear that there is potential risk to infant if they remain in the OR and allowed to do skin to skin contact with their mother.
This next study “found that mother–infant separation during the first two hours after birth is associated with less infant self-regulation, and decreased maternal sensitivity and attachment that is not compensated by rooming-in. A critical role for nurses is to advocate for patients and families in situations where breastfeeding practices are not evidence-based, such as after cesarean births. Although research suggests that early STS contact is key to successful breastfeeding initiation, its use immediately after healthy cesarean birth is rare. Our experience shows that it is feasible to improve the quality of care after cesarean birth in a relatively short period. Nurses can be leaders in changing practice to incorporate early STS contact into regular cesarean care for mothers and infants by ensuring that the routine care after cesarean births is family-centered and research-based” (Berg, 2011).
This research shows how nurses need to advocate for their patients and show how skin to skin contact early on even in the OR can have long term positive effects for both mothers and babies. Also it increases a mother’s satisfaction which means she is more likely to recommend a hospital to others due to her positive birth experience as well as come back for any future births for herself. If hospitals allow mothers to do skin to skin contact after any birth method, they can impact the bond between mother and infant in a positive way without having to invest any costly resources. It is just a matter of letting a mother hold her infant close to her body and letting Mother Nature take its course. This can make such a positive difference on a mother’s birth experience which can impact the way a hospital is viewed in the community. Having a positive reputation in the birthing experience can be an invaluable marketing tool for a hospital to use in their quest to attract business to their hospital. Sometimes the first experience a person has with hospital is when they come in to give birth, if they have a positive experience then they will come back for other births as well as other medical reasons.
Another study pointed out that if a mother is unable to do skin to skin contact with the infant after cesarean, then the father can do the kangaroo care and still have positive effects on the infant. The goal of this study was to equate the effects of skin-to-skin contact on crying and pre-feeding behavior in healthy, full-term infants born by elective cesarean birth that received their skin-to-skin contact from their fathers versus the standard care during the first 2 hours after birth. Twenty-nine father-infant pairs partook in a randomized controlled trial, in which infants were randomly selected to be either in the skin-to-skin contact group with their father or the standard care group.
The data was collected from both groups via a tape-recording crying time for the infants and by naturalistic observations that evaluated the infants’ behavioral response which was recorded every 15 minutes centered on the scoring criteria described in the Neonatal Behavioral Assessment Scale (NBAS). This research information is helpful because it looks at how skin to skin contact can be done just as easily by the father and how it positively impacts the newborn and helps to calm the infant and facilitate a drowsy state for the infant sooner than the infants that received the standard care. (Erlandsson, 2007). This information can be used to show that if a mother has to have an emergency cesarean under general anesthesia that the father can take over the role and do skin to skin contact which is just as good for the infant and can be written into the protocol so that even cesarean under general anesthesia are still allowed to provide the best care to their newborn which is skin to skin care.
Step 4: Design Practice Change
Hospital policies need to be re-evaluated when there is evidence based research that supports change in the way healthcare is practiced. Taking babies away from the mother after cesarean birth is a long held practice and now research shows that this is not beneficial to mother or baby. It also could potentially do damage to the maternal-infant bond and hindered breastfeeding habits. Nurses need to be the ones to advocate for their patients and show the research to the physicians as well as hospital administration in order to get the ball rolling and change the way we care for cesarean mothers and infants.
Step 5: Implement and Evaluate the Change in Practice Policy reviewed by a committee and re-written so that skin to skin contact between mother and infant or father and infant is allowed immediately after cesarean in the OR unless there is a life threatening issue to mom or baby which would override the skin to skin contact. In-services to all staff including physicians to the policy change and the benefits that skin to skin contact for mothers and infants. Keep a log of cesarean deliveries, whether skin to skin contact was implemented, at what point in the delivery was the skin to skin contact initiated and for how long, any issues, and any comments from the parents on how this affected their birth experience. This information should be over a six month study period.
Step 6: Integrate and Maintain Change The information obtained should help show the benefits of skin to skin contact to all mothers and babies whether they deliver vaginally or cesarean. Hospital policy should be re-written so that all mothers are able to do skin to skin contact no matter how they deliver and only if there is a life threatening issue to mom or baby would this override the kangaroo care after delivery. Once the policy is rewritten then all staff including physicians will adhere to the policy in order to provide the best possible care to all mothers and their newborn infants.
Summary Skin to skin contact or kangaroo care has only been used for vaginal mothers and infants. However, now research has shown that an infant can do skin to skin contact with its mother or father in the OR without any potential issue to the mother or baby. In fact the research shows that it is very beneficial to the mother and infant if they do skin to skin contact immediately after delivery. The only setback is getting the practice of whisking away a baby from the OR to the nursery changed and shifting the way physicians and staff handled a cesarean procedure. If they are shown the evidence based research on how skin to skin immediately after cesarean can benefit both mother and infant can improve the birth experience, then they will be more likely to initiate the change in policy and practice.
Berg, O., & Hung, K. J. (2011). Early Skin-to-Skin to Improve Breastfeeding After Cesarean Birth. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 40S18-9. doi:10.1111/j.1552-6909.2011.01242_24.
Erlandsson, K., Dsilna, A., Fagerberg, I., & Christensson, K. (2007). Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth: Issues In Perinatal Care, 34(2), 105-114.
Gouchon, Silvia; Gregori, Dario; Picotto, Amabile; Patrucco, Giovanna; Nangeroni, Marco; Di Giulio, Paola(2010) Skin-to-Skin Contact After Cesarean Delivery: An Experimental Study. Nursing Research, 59(2) 78-84
Morrison, B. (2006) Kangaroo Care: Natures Best for our Little Ones www.preciousimagecreations.com/presentations/kangaroocare.pdf
University of Michigan, Holden Newborn Intensive Care website. Kangaroo Care www.med.umich.edu/nicu/pdf/C.3KangarooCare.pdf