Skin-to-skin contact (SSC), defined as the early placement of the naked infant in a prone position onto its mother's bare chest (Srivastava, Gupta, Bhatnagar, & Dutta, 2014), has become a standard of care in labor and birth suites across the United States. Evidence suggests numerous benefits of SSC including improved infant physiological regulation (e.g., thermoregulation, metabolism) (Beiranvand, Valizadeh, Hosseinabadi, & Pournia, 2014 ; Steinhauer & Clarke, 2015), earlier breastfeeding initiation (Beiranvand et al.; Hung & Berg, 2011), and increased maternal perception of bonding with their babies (Frederick, Busen, Engebretson, Hurst, & Schneider, 2016). Given the many benefits of SSC, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2016) developed clinical recommendations in support of SSC for all stable newborns, born at ≥37 weeks gestation, by either vaginal or cesarean birth. Based on AWHONN's recommendations, together with growing evidence suggesting SSC leads to improved maternal–infant well-being outcomes, our hospital has successfully instituted SSC as a standard of care for all women and their infants after vaginal birth.
We recognized that a significant number of mother–infant dyads were not recipients of the many benefits of SSC in part due to the hospital's 30% cesarean rate. Although well accepted for women after vaginal births, the nurses voiced concern about intraoperative SSC and risk of neonatal hypothermia due to the cooler and draftier operating room (OR) environment. To investigate the feasibility of offering SSC among women after cesarean births at our institution, a feasibility study was conducted to assess the change in infant temperature before and after SSC.
Infant Temperature and Skin-to-Skin Contact after Cesarean Birth
Several researchers have examined infant temperature with SSC initiated after cesarean birth. In a randomized controlled trial (RCT), Beiranvand et al. (2014) compared temperatures in two groups of infants born via cesarean section in Iran. Temperatures were assessed using an infrared thermometer to the forehead and compared in infants receiving SSC (n = 46) versus infants in a routine care group (n = 44). No significant differences in mean newborn temperature were noted between the two groups at any of three time points, 30 minutes after the initiation of SSC, half an hour after, or 1 hour after (p = 0.86, 0.31, 0.52), respectively. In another RCT, Kollmann et al. (2017) assigned women to an intraoperative SSC group (n = 17) or a postoperative SSC group (n = 18) to identify differences in neonatal transition (Apgar score, temperature). No significant differences were noted in Apgar scores or rectal temperature between the two groups.
Given the many well-documented benefits of SSC and the limited research to date regarding early intraoperative SSC for infants after cesarean births, the purpose of this feasibility study was to answer the following research question: What is the change in temperature pre and post SSC among infants born via elective cesarean section?
Study Design and Methods
At a 189-bed private community hospital in Northern California, with approximately 1,400 births per year, postcesarean intraoperative SSC was offered to all medically stable mothers and their newborns in the hospital's birth center. The SSC procedure was explained to all mothers prior to their cesarean section surgery and mothers were informed of their right to accept or decline the opportunity to participate.
Full-term singleton infants of women over age 18 years who had given birth via elective cesarean section ≥38 weeks to ≤42 weeks gestation were the focus population of this study. Babies with known or suspected complications such as congenital defects requiring complex care, those who required resuscitation efforts at birth, or those with a 5-minute Apgar of <7, indicating a need for a higher level of intervention were excluded. Although the American College of Obstetricians and Gynecologists (2013) recommends elective cesareans should not be performed before a gestational age of 39 weeks, women were included if they were ≥38 weeks per study hospital current practice. Focused examination of the study hospital's standard of elective cesarean deliveries was an attempt to control for a potential suboptimal intraoperative SSC experience following an emergent cesarean birth.
Design and Data Collection Plan
We used a quantitative, descriptive, retrospective design to analyze newborn axillary temperatures before and after intraoperative SSC. A deidentified data set was created from the electronic medical records (EMR) of all eligible mothers and their newborns who participated in intraoperative SSC in the study setting from January 1 through December 31, 2016. Institutional review board and hospital approvals were obtained prior to data collection.
Intraoperative SSC at the study hospital is defined as the period of time an infant, wearing a prewarmed hat and diaper, is placed into direct contact with mother's bare chest in the OR after cesarean birth. See Table 1 for complete study hospital intraoperative SSC protocol. Intraoperative SSC at the hospital is initiated after the 5-minute Apgar score is assigned and concludes as cesarean surgical skin closure begins. Skin-to-skin contact may end sooner upon maternal request or any destabilization in the mother or infant. Mothers may decline to participate in intraoperative SSC at any time.
We analyzed infant temperatures measured immediately before (T1) and after (T2) intraoperative SSC. To minimize the risk of rectal perforation (Frederick et al., 2016) and associated bradycardia from rectal temperature measurement, nurses assessed axillary temperatures using Medline® Premier Oral Digital thermometers. Maternal demographic data (age, race, estimated weeks gestation), infant data (gender, weight, 1- and 5-minute Apgar scores, estimated gestational age), and total intraoperative SSC time in minutes were extracted from EMR.
Descriptive statistics, including frequencies, means, and other measures of central tendency were used to analyze maternal–infant characteristics and temperature.
Of the 1,437 births occurring in the study setting between January 1 and December 31, 2016, less than one third (n = 398) were cesarean births. Data analysis of 91 mother–infant dyads is presented. See Figure 1 for complete participant EMR inclusion process.
Women in the sample ranged between 23 and 49 years of age (M = 35 years, SD= 4.2 years), were an average of 39 weeks, 4 days gestation, with 55% (n = 50) self-identifying as Caucasian. Fifty-eight percent (n = 53) of the infants were male with birthweight ranging from 2,720 g to 4,670 g (M = 3,566 g, SD = 401.83 g) (Table 2 for complete participant characteristics). Intraoperative SSC care participation time for each mother–infant dyad ranged from 3 to 25 minutes (M = 13.5, SD= 5.44).
Infant temperature. Infant temperature from T1 to T2 remained the same in 19 (21%) of the sample and increased at T2 for 32 (35%). Temperature decreased in 40 (44%) infants between T1 and T2. Of the 40 infants with lower T2 temperatures, 4 (10%) had an axillary temperature <36 °C.
There are limited data on intraoperative SSC and infant temperature among mother–baby dyads where the baby remains in the OR. When the intraoperative SSC plan of care was developed, the overarching concern of the clinical team was supporting infant thermoregulation and prevention of hypothermia-induced morbidities. In response to this concern, a feasibility study was implemented to test an intraoperative SSC plan that included standardized thermoprotective measures. Lack of consensus about temperature measurement methods (site, type of thermometer) made evidence evaluation and translation to practice challenging. With this knowledge in mind, this feasibility study supported the existing practice of measuring axillary temperatures with a digital thermometer and followed the study hospital's existing hypothermia protocol stating any infant with an axillary temperature <36 °C requires further intervention beyond SSC.
Findings of this study demonstrate over half of the infants experienced either no change or an increase in their T2 temperature with 40 infants experiencing a decrease in their T2 temperature. Of these 40 infants, 4 (10%) had axillary temperatures <36 °C. Given the retrospective design, it is unknown if any of the four infants with T2 axillary temperatures <36 °C experienced hypothermia-related morbidities; however, we were able to ascertain that none were admitted to the neonatal intensive care unit.
The findings of this study are limited due to the retrospective design, which relied on EMR entries. Although all clinicians at the facility received EMR and data entry training, 50% of eligible participants were excluded due to missing EMR T2 infant axillary temperature entries. Limitations provide opportunities for evaluation of workflow and EMR platform to further understand reasons for missing data. Nurses' knowledge and comfort level in performing intraoperative SSC should be assessed.
Given concerns about neonatal hypothermia during intraoperative SSC, findings of this feasibility study demonstrate that the majority of infant's T1 temperature was either maintained or increased providing further support for continuing intraoperative SSC at the hospital. Using evidence to support a proposed change of practice can serve to improve nurse and healthcare provider confidence in the new practice, which promotes use of SSC for all women with stable infants after cesarean births. All nurses and other healthcare providers caring for women during the childbearing period should be knowledgeable about SSC. Clinicians should know their institution's policy on acceptable gestational age for elective cesarean births as well as definition, policy, and procedure for hypothermia. To promote higher rates of intraoperative SSC among mother–baby dyads after cesarean births, clinical leaders must develop SSC guidelines and plans for ongoing evaluation. To increase overall rates of SSC at the time of birth, education including benefits to the mother and infant should be discussed throughout pregnancy (Zwedberg, Blomquist, & Sigerstad, 2015). Our findings may serve to lend support to other hospitals considering making a practice change to offer SSC in the OR.
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