Skin-to-skin contact after birth: Developing a research and practice guideline.

AIM: Skin-to-skin contact immediately after birth is recognised as an evidence-based best practice and an acknowledged contributor to improved short- and long-term health outcomes including decreased infant mortality. However, the implementation and definition of skin-to-skin contact is inconsistent in both practice and research studies. This project utilised the World Health Organization guideline process to clarify best practice and improve the consistency of application. METHODS: The rigorous guideline development process combines a systematic review with acumen and judgement of experts with a wide range of credentials and experience. RESULTS: The developed guideline received a strong recommendation from the Expert Panel. The result concluded that there was a high level of confidence in the evidence and that the practice is not resource intensive. Research gaps were identified and areas for continued work were delineated. CONCLUSION: The World Health Organization guideline development process reached the conclusion immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 g with experienced staff if assistance is needed), after all modes of birth. Delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.

Exploring outcomes for women and neonates having skin-to-skin contact during caesarean birth: A quasi-experimental design and qualitative study.

PROBLEM: Women having an elective caesarean birth are often separated from their babies at birth with newborns transferred to a postnatal ward with the significant other. BACKGROUND: Two midwives were employed in 2019 to provide skin-to-skin contact for women who planned for elective caesarean births in a public hospital in metropolitan New South Wales with 4000 births per year and a 39% CB rate (57.8% of these births being elective). AIM: To compare the outcomes for women and their newborns on the effects of skin-to-skin contact at elective caesarean births within the first five minutes of birth to those who did not have skin-to-skin contact and to explore the lived experiences of women having skin-to-skin contact during their elective caesarean births. METHODS: A quasi-experimental design study with a qualitative component of in-depth interviews. Quantitative analyses included independent t-tests, chi square and logistic regression. Thematic analysis was used for the qualitative data. FINDINGS: In the quantitative results, there was a reduction in the time to the first feed (t(100) = -11.32, p < 0.001) (M = 38.9, SE = 20.7) (M = 124.9, SE = 50.1) and the first breastfeed (t(100) = -5.2, p < 0.001) (M = 53.2, SE = 82.5) (M = 277, SE = 295.8) with increased breastfeeding on discharge for women that had skin-to-skin contact at caesarean birth in comparison to those who did not receive skin-to-skin contact χ2(1) = 10.22, p < 0.05. In the qualitative results, women who had skin-to-skin contact during their caesarean birth had a positive experience with improved bonding and reported less anxiety and depression than their previous caesarean birth. CONCLUSION: This study provides evidence of the benefits of skin-to-skin contact during a caesarean birth.

Skin-to-skin contact and what women want in the first hours after a caesarean section.

OBJECTIVE: To explore women's experience of skin-to-skin contact and what women want in the first two hours after a caesarean. DESIGN: Audio recorded interviews were conducted with women as a part of a larger video ethnographic research study where video recordings, observations, field notes, focus groups and further in-depth interviews were conducted. SETTING: A metropolitan hospital in Sydney, Australia. PARTICIPANTS: Twenty-one women who had a caesarean section were involved in interviews around six weeks postpartum. ANALYSIS: The transcribed interviews were thematically analysed. FINDINGS: Women wanted their baby to stay with them and have skin-to-skin contact, even if they felt apprehensive about providing this care. An overarching theme was, 'I want our baby'. Several subthemes also emerged: 'I felt disconnected when I was separated from my baby', 'I want to explore my naked baby', 'I want my partner involved', and 'It felt right'. KEY CONCLUSIONS: Despite the challenges of providing skin-to-skin contact in the operating theatre and recovery, health professionals and institutions should recognise the importance of advocating for what women want including keeping women, their partners and babies together and encouraging continuous maternal and infant contact and skin-to-skin contact.

Who owns the baby? A video ethnography of skin-to-skin contact after a caesarean section.

PROBLEM: Providing skin-to-skin contact in the operating theatre and recovery is challenging. BACKGROUND: Barriers are reported in the provision of uninterrupted skin-to-skin contact following a caesarean section. AIM: To explore how health professionals' practice impacts the facilitation of skin-to-skin contact within the first 2h following a caesarean section. METHODS: Video ethnographic research was conducted utilising video recordings, observations, field notes, focus groups and interviews. FINDINGS: The maternal body was divided in the operating theatre and mothers were perceived as 'separate' from their baby in the operating theatre and recovery. Obstetricians' were viewed to 'own' the lower half of women; anaesthetists were viewed to 'own' the top half and midwives were viewed to 'own' the baby after birth. Midwives' responsibility for the baby either negatively or positively affected the mother's ability to 'own' her baby, because midwives controlled what maternal-infant contact occurred. Mothers desired closeness with their baby, including skin-to-skin contact, however they realised that 'owning' their baby in the surgical environment could be challenging. DISCUSSION: Health professionals' actions are influenced by their environment and institutional regulations. Further education can improve the provision of skin-to-skin contact after caesarean sections. Skin-to-skin contact can help women remain with their baby and obtain a sense of control after their caesarean section. CONCLUSION: Providing skin-to-skin contact in the first 2h after caesarean sections has challenges. Despite this, health professionals can meet the mother's desire to 'own' her baby by realising they are one entity, encouraging skin-to-skin contact and avoiding maternal and infant separation.

An implementation algorithm to improve skin-to-skin practice in the first hour after birth.

Evidence supporting the practice of skin-to-skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF "Ten Steps to Successful Breastfeeding" elaborated on the practice of skin-to-skin contact between the mother and her newly born baby indicating that the practice should be "immediate" and "without separation" unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin-to-skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self-attachment and suckling. However, the most recent Cochrane review of early skin-to-skin contact cites inconsistencies in the practice; the authors found "inadequate evidence with respect to details … such as timing of initiation and dose." This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin-to-skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin-to-skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.

Video ethnography during and after caesarean sections: methodological challenges.

AIMS AND OBJECTIVES: To describe the challenges of, and steps taken to successfully collect video ethnographic data during and after caesarean sections. BACKGROUND: Video ethnographic research uses real-time video footage to study a cultural group or phenomenon in the natural environment. It allows researchers to discover previously undocumented practices, which in-turn provides insight into strengths and weaknesses in practice. This knowledge can be used to translate evidence-based interventions into practice. DESIGN: Video ethnographic design. METHODS: A video ethnographic approach was used to observe the contact between mothers and babies immediately after elective caesarean sections in a tertiary hospital in Sydney, Australia. Women, their support people and staff participated in the study. Data were collected via video footage and field notes in the operating theatre, recovery and the postnatal ward. CONCLUSIONS: Challenges faced whilst conducting video ethnographic research included attaining ethics approval, recruiting vast numbers of staff members and 'vulnerable' pregnant women, and endeavouring to be a 'fly on the wall' and a 'complete observer'. There were disadvantages being an 'insider' whilst conducting the research because occasionally staff members requested help with clinical tasks whilst collecting data; however, it was an advantage as it enabled ease of access to the environment and staff members that were to be recruited. Despite the challenges, video ethnographic research enabled the provision of unique data that could not be attained by any other means. RELEVANCE TO CLINICAL PRACTICE: Video ethnographic data are beneficial as it provides exceptionally rich data for in-depth analysis of interactions between the environment, equipment and people in the hospital environment. The analysis of this type of data can then be used to inform improvements for future care.

A juxtaposition of birth and surgery: Providing skin-to-skin contact in the operating theatre and recovery.

OBJECTIVE: to provide insight into the facilitators and barriers of providing skin-to-skin contact in the operating theatre and recovery. DESIGN: ethnographic study utilising video recordings, field notes, focus groups and interviews. SETTING: a metropolitan public hospital in Sydney, Australia. PARTICIPANTS: 21 low-risk mothers having a repeat caesarean section, 26 support people, >125 staff members involved in their care and 43 staff members involved in focus groups/interviews. DATA COLLECTION AND ANALYSIS: collecting video footage and field notes for up two hours post caesarean section births, interviews at six weeks post partum and staff focus groups/interviews. Data was entered into NVivo10 and analysed using critical ethnographic techniques. FINDINGS: providing skin-to-skin contact in the operating theatre and recovery presents unique challenges due to the 'juxtaposition' of providing social and emotional care in an intrinsically medicalised setting. Staff members suggest that skin-to-skin contact in this environment can be improved by increasing staff and parent knowledge, writing and implementing a policy, addressing staffing issues, improving staff communication, addressing time constraints, adjusting the placement of equipment in the environment and making small changes to the way equipment is utilised. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: our findings show that skin-to-skin contact can be successfully implemented in the operating theatre and recovery room with staff members input into adjustments to existing care.

Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature.

The World Health Organization and the United Nations International Children's Emergency Fund recommends that mothers and newborns have skin-to-skin contact immediately after a vaginal birth, and as soon as the mother is alert and responsive after a Caesarean section. Skin-to-skin contact can be defined as placing a naked infant onto the bare chest of the mother. Caesarean birth is known to reduce initiation of breastfeeding, increase the length of time before the first breastfeed, reduce the incidence of exclusive breastfeeding, significantly delay the onset of lactation and increase the likelihood of supplementation. The aim of this review is to evaluate evidence on the facilitation of immediate (within minutes) or early (within 1 h) skin-to-skin contact following Caesarean section for healthy mothers and their healthy term newborns, and identify facilitators, barriers and associated maternal and newborn outcomes. A range of electronic databases were searched for papers reporting research findings published in English between January 2003 and October 2013. Seven papers met the criteria. This review has provided some evidence that with appropriate collaboration skin-to-skin contact during Caesarean surgery can be implemented. Further evidence was provided, albeit limited, that immediate or early skin-to-skin contact after a Caesarean section may increase breastfeeding initiation, decrease time to the first breastfeed, reduce formula supplementation in hospital, increase bonding and maternal satisfaction, maintain the temperature of newborns and reduce newborn stress.

Midwives' and doulas' perspectives of the role of the doula in Australia: a qualitative study.

OBJECTIVE: to explore midwives' and doulas' perspectives of the role of the doula in Australia. BACKGROUND: doulas are relatively new in Australia; nevertheless, demand for them is increasing. Research has not previously explored the role of a doula in Australia. This research aimed to answer the question: What are midwives' and doulas' perspectives of the role of a doula in Australia? DESIGN: qualitative study using focus groups that were digitally recorded, transcribed and the data analysed using thematic analysis. SETTING: New South Wales, Australia. PARTICIPANTS: 11 midwives and six doulas. FINDINGS: the key theme that emerged was that 'the broken maternity system' is failing women and midwives. The system is preventing midwives from providing woman- centred care. As a result, doulas are 'filling the gap' and midwives feel that doulas are 'taking our role'. Doulas fill the gap by providing continuity of care, advocating for women, protecting normal birth and by providing breast-feeding advice and emotional support in the community. Midwives are concerned that doulas are taking the caring part of their role from them and want the 'broken' maternity system fixed. Midwives described that doulas take their role from them by changing the relationship between themselves and labouring women, by reducing their role to obstetric nurses, by overstepping the doula role boundaries, and by holding the power at births. IMPLICATIONS FOR PRACTICE: despite the conflict reported between midwives and doulas, both groups identified that they see the potential for future collaboration. Taking into account the continued employment of doulas, it is important to improve collaboration between midwives and doulas for the sake of childbearing women.