Running head: AN INTEGRATIVE REVIEW 1

Skin-to-Skin in Cesarean Births

Brittney Ellett

Bon Secours Memorial College of Nursing

Nursing Research NUR 4122

April 25, 2017

I Pledge
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate the literature regarding the use of skin-to-

skin (SCC) at the delivery of a baby born by cesarean sections and the effects it has on the

newborn. SSC at birth in cesarean sections is not a common practice. There is a gap between

literature and evidenced-based practice to clinical implementation of SSC in cesarean section

births. The cesarean section rate is rising in the United States, therefore making SSC an issue.

This should be practiced during every birth that is free of complications and qualifies. The

research design is an integrative review. The search for literature was conducted using the

database EBSCO Discovery Service. The search yielded a total result of 325 articles and five

met the inclusion criteria. The results and findings of the five articles demonstrated support of

implementing SSC immediately at delivery of a cesarean birth. Findings showed a benefit to the

mothers and infants as well as a correlation between improved breastfeeding and use of SSC.

Studies also consistently showed a need for standardized protocols to be implemented for when

to include/exclude a mother-baby dyad from SSC at birth. Limitations to the review included the

nursing students lack of experience and knowledge, time to complete the assignment, and the

number of articles used for the review. Future research should include more wide based studies

implementing a standardized protocol at birth during a cesarean delivery to better implement this

institutionally long-term.
AN INTEGRATIVE REVIEW 3

Skin-to-Skin in Cesarean Births

The purpose of this integrative review is to conduct a search of the literature related to

immediate skin-to-skin (SSC) at the delivery of a baby born by cesarean section. SSC during the

birthing process has known benefits for both the mother and newborn. However, during

cesarean births, SSC is not the standard of care, and there is lack of practice and protocols for the

implementation of immediate SSC at delivery. Multiple organizations, including United Nations

Childrens Fund and the World Health Organization recommend SSC within one hour of birth

(Bavaro, Mendoza, McCarthy, Toledo, & Bauchat, 2016). The Baby Friendly Hospital Initiative

also recommends SSC starting immediately after birth and continuing for the first hour or until

the first breastfeed (Koopman, Callaghan-Koru, Alaofin, Argani & Farzin, 2016). This area

interests this researcher due to the growing number of cesarean births in the United States and

the lack of implementation of immediate SSC at delivery, which has known benefits for the

entire family. Therefore, the proposed PICO question by this researcher is as follows: In

women who undergo cesarean sections, what is the effect of immediate skin-to-skin at birth

compared to no skin-to-skin on the wellbeing of newborns?

Research Design, Search Methods, & Search Outcomes

The research design is an integrative review as a class assignment for an undergraduate

nursing program. This integrative review focuses on five research articles. These five articles

were found using the database EBSCO Discovery Service, which allowed narrowing the search

to articles that fit specific criteria set by the researcher. Key terms used to research these articles

included skin-to-skin cesarean, and skin-to-skin contact with cesarean section. These terms

yielded 65 and 260 articles on different searches within EBSCO Discovery Service, indicating a

plethora of literature in regards to this topic.

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To locate recent articles on the topic of choice, the search was limited to articles

published between 2012 and 2017. To narrow down the available results, filters were applied to

limit articles to English, peer reviewed, full text, academic articles. After applying the criteria,

five articles were chosen to be included, one quantitative study, three qualitative studies, and one

retrospective study that directly relate to the PICO question being researched, In women who

undergo cesarean sections, what is the effect of immediate skin-to-skin at birth compared to no

skin-to-skin on the wellbeing of newborns? Articles that did not meet criteria were excluded

from the review.

Findings/Results

The findings and results of the five research articles are consistent with the positive

benefits and outcomes between cesarean sections and SSC implementation at birth for both the

mother and newborn (Bavaro et al., 2016; Frederick, Busen, Engebreston, Hurst & Schneider,

2014; Koopman et al., 2016; Posthuma, Korteweg, Ploeg, Boer, Buiter, & Ham, 2016;

Zwedberg, Blomquist, & Sigerstad, 2014). A summary of the research articles can be found in

Appendix 1. The researcher summarized the findings using the following categories: protocols

and feeding.

Protocols

There was a mutual consensus among all five studies that some type of protocol needed

to be implemented for SSC during cesarean section deliveries (Bavaro et al., 2016; Frederick et

al., 2014; Koopman et al., 2016; Posthuma et al., 2016; & Zwedberg et al., 2014). The

quantitative study by Bavaro et al. used a prospective observational study to evaluate sedation

levels in women undergoing unscheduled and scheduled cesarean sections using neuraxial

anesthesia with validated sedation scales and assessed if the timing of SSC and breastfeeding
AN INTEGRATIVE REVIEW 5

were different between the two groups. The results showed that careful consideration is

important when assessing protocols for SSC in the operating room to account for increased

sedation in women undergoing unscheduled cesarean sections. Anesthesiologists should weigh

the risks and benefits of using potentially sedating medications in the operating room due to the

risk of safety implications in applying early SSC.

The qualitative study by Frederick et al., (2014) used a focused medical ethnographic

study to better understand the mothers experience of SSC immediately after cesarean delivery.

Use of SSC in surgical suites had a positive impact on the mothers, newborns, fathers, and staff

involved. Being in SSC proves to be the most optimal environment for adaptation of the neonate

to the extrauterine life. The neonate has better central nervous system control, a reduction in

stress, and maintenance of quiet sleep. The enforcement of protocols lies in the Advanced

Practice Nurses scope of practice within this study. Initiative needs to be taken to influence

policy-related practice for use of SSC during cesarean sections in all qualifying births on the

local and national levels.

Koopman et al., (2016) used an exploratory qualitative research design to study key

factors from a clinicians perspective regarding the influence of uninterrupted early SSC after

cesarean delivery of healthy full-term infants. There is a lack of a clear definition on clinical

eligibility for births, which causes reluctance among nurses to practice early SSC. Other barriers

within the medical field include other priorities during the delivery, inadequate staffing,

intravenous lines, cardiac leads, and a lack of education on the benefits of SSC. Suggestions on

implementation of SSC by the clinicians included that a clinical algorithm be established to

define medical conditions of the infant or the mother contraindicating use of SSC to exclude

mothers and babies at potential risk from early SSC. By having this protocol plan and flowchart
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in place, it may provide structure and make collaboration among interdisciplinary team members

more effective.

A single center retrospective cohort study conducted by Posthuma et al., (2016)

compared maternal and neonatal outcomes after conventional cesarean section versus a natural

or skin-to-skin cesarean section. P values of <0.05 were considered statistically significant. In

this study, there was a multidisciplinary SSC cesarean section protocol developed and

implemented as the new standard for cesarean sections in women who met the inclusion criteria.

The inclusion criteria identified is that the neonate must show no signs of distress. They keep the

newborn in SSC with the mother as long as possible during the cesarean and are assessed by a

pediatrician in the recovery ward within an hour after birth. Findings revealed that fewer

neonates born after SSC were admitted to the pediatric ward and fewer had a suspected neonatal

infection. Benefits for the mom included a shorter recovery time in the PACU, and a shorter

maternal hospital stay.

The qualitative study by Zwedberg et al., (2014) focused on midwives experiences and

perceptions of SSC with mothers and their healthy full-term infants immediately and during the

first day after cesarean sections. This study emphasizes the development of guidelines for each

health care organization enabling midwives and other professionals caring for the mother and her

newborn to describe and teach the importance of early SSC with the infant. The importance of

this evidence-based care routine cannot be established and successfully implemented until proper

education takes place on both the medical side and for the expecting mother.

Feeding

Four of the five research studies focused on breastfeeding success in newborns when SSC

is implemented during a cesarean section birth (Bavaro et al., 2016; Frederick et al., 2014;
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Koopman et al., 2016; Zwedberg et. al., 2014). Three qualitative and one quantitative study

addressed feeding. In the study by Bavaro et al., women who had initiated SSC in the operating

room were successfully breastfeeding within two hours of delivering. There were no significant

differences in the time between initiation of first breastfeeding between the scheduled and

unscheduled cesarean group. The mother also experienced less anxiety and had greater

satisfaction due to these outcomes.

In the qualitative study by Frederick et al., (2014) studying the mothers experience of

SSC, mothers were quick to have success with latching their newborn onto the nipple upon

returning to the recovery area with SSC being initiated in the surgical suite. This study notes that

while the newborn was lying on the mothers 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 (Frederick et al., 2014, p. 34). Another benefit for the

immediate initiation of SSC is that the mothers milk volume increases, thus bringing in her

supply quicker.

Cesarean born infants receiving early SSC have more success breastfeeding than infants

who do not experience early SSC care, as noted in the qualitative study by Zwedberg et al.,

(2014). They include that SSC should be shared between the mother and infant as much as

possible for successful breastfeeding. Practicing early SSC increases the mothers level of

oxytocin, causing it to rise from the babys massage-like movements on the breast during the

pre-suckling phase. This helps the milk supply to come in faster.

Early SSC is particularly critical in the first hour as the infant completes a sequence of

inborn behavioral patterns that lead to the first breastfeed (Koopman et al., 2016, p. 1368).

Koopman et al. discusses more benefits for the mother and infant in regards to immediate SSC
AN INTEGRATIVE REVIEW 8

and breastfeeding success rates during a cesarean section birth. Positive effects on the baby of

early SSC for feeding include longer breastfeeding duration, higher breastfeeding rates at one to

four months post birth, and increased total duration of breastfeeding.

Discussion/Implications

The findings of the integrative review address the many effects that SSC during cesarean

section has on the mothers and the babys bond and successful long-term outcomes. Therefore,

the review findings support the researchers PICO question. The PICO question specifically asks

about the effect of immediate skin-to-skin at birth compared to no skin-to-skin on the wellbeing

of newborns in cesarean sections. All studies indicate the need for a standardized protocol of

implementation of SSC at birth of a cesarean section baby (Bavaro et al., 2016; Frederick et al.,

2014; Koopman et al., 2016; Posthuma et al., 2016; & Zwedberg et al., 2014). Furthermore, four

out of the five studies researched addressed the positive benefits in relation to breastfeeding and

immediate SSC at birth (Bavaro et al., 2016; Frederick et al., 2014; Koopman et al., 2016; &

Zwedberg et. al., 2014). All of these studies, whether addressing perspectives from midwives,

clinicians, or parents themselves, advocate for a change in current practice to have improved

long-term outcomes for the newborn and family dynamics. Researching the multidisciplinary

protocol developed by Posthuma et al. on a larger scale could bring light to this problem and

develop new considerations for the implications of standardized SSC at cesarean births.

The implications of these findings suggest the potential to positively impact a large

number of mothers with the implementation of SSC protocols during a cesarean birth. This

research shows that larger samples of participants could be a valuable resource to the practices of

SSC at cesarean births. The implementation of these practices will provide a fulfillment to the

gap currently seen in practice with the lack of SSC initiated within cesarean births.
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Limitations

The researcher acknowledges multiple limitations that influenced this integrative review.

The researcher is a novice researcher which makes researching difficult. This review is a class

assignment which is conducted individually with minimal experience in completing an

integrative review. Due to limited time and other obligations, there were constraints for this

assignment. The research was limited to five nursing journal articles dated within the last five

years which put limits on searching literature.

Conclusion

Findings discussed in this integrative review highlight the importance of implementing

SSC immediately following cesarean sections in order to improve maternal-newborn bonding

and outcomes. Depending on the duration of SSC at birth, the mother and infants bonding and

feeding can be disrupted. At birth, the mother and newborn should have an uninterrupted sacred

hour of bonding. Each hospital and state operate protocols differently, but a universal standard

can help to alleviate this problem and ensure the best care for mothers delivering via cesarean.

Several studies demonstrated the prolonged effects SSC can provide for the entire family. This

may help integrate knowledge into evidence-based practice protocols. Nurses are at the forefront

to address this issue and serve as an advocate to better the outcomes of families being served on

labor and delivery units nationwide.

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References

Bavaro, B. J., Mendoa, L. J., McCarthy, J. R., Toledo, P., & Bauchat, R. J. (2016). Maternal

sedation during scheduled versus unscheduled cesarean delivery: Implications for skin-

to-skin contact. International Journal of Obstetric Anesthesia, 27, 17-24. doi:

http://dx.doi.org/10.1016/j.ijoa.2016.06.003

Frederick, C. A., Busen, H. N., Engerbreston, C. J., Hurst, M. N., & Schneider, M. K. (2014).

Exploring the skin-to-skin contact experience during cesarean section. Journal of the

American Association of Nurse Practitioners, 28, 31-38. doi: 10.1002/2327-6924.12229

Koopman, I., Callaghan-Koru, A. J., Alaofin, O., Argani, H. C., & Farzin, A. (2016). Early skin-

to-skin contact for healthy full-term infants after vaginal and caesarean delivery: A

qualitative study on clinican perspectives. Journal of Clinical Nursing, 25, 1367-1376.

doi: 10.1111/jocn.13227

Posthuma, S., Kortweg, J. F., Ploeg, M. J., Boer, D. H., Buiter, D. H., & Ham, P. D. (2016).

Risks and benefits of the skin-to-skin cesarean section a retrospective cohort study. The

Journal of Maternal-Fetal & Neonatal Medicine, 30(2), 159-163. doi:

10.3109/14767058.2016.1163683

Zwedberg, S., Blomquist, J., & Sigerstad, E. (2014). Midwives experiences with mother-infant

skin-to-skin contact after a caesarean section: Fighting an uphill battle. Midwifery,

31(1), 215-220. doi: http://doi.org/10.1016/j.midw.2014.08.014

 AN INTEGRATIVE REVIEW: SKIN-TO-SKIN IN CESAREAN BIRTHS 11

Appendix 1: Qualitative & Quantitative

(Table of Evidence)

First Author Bavaro, J.B. 2016 All authors are from the Department of Anesthesiology and Toledo also is associated with the
(Year)/Qualifications Center for Healthcare Studies at the Northwestern University Feinberg School of Medicine in Chicago, IL.
Background/Problem -Compared patient-reported and observer-assessed levels of sedation during unscheduled and scheduled cesarean
Statement deliveries.
-Maternal sedation during cesarean delivery could have safety implications for early skin-to-skin contact in the
operating room.
Conceptual/theoretical -Prospective Observational Study
Framework -Quantitative
Design/ -Laboring women undergoing unscheduled cesarean delivery with epidural anesthesia, and scheduled cesarean
Method/Philosophical delivery with spinal anesthesia were enrolled.
Underpinnings -Sedation levels were measured using patient reported and observer-assessed scales being evaluated at baseline and
15, 30, 45, and 60 minutes following a T4 sensory level.
Sample/ -Approved by the Institutional Review Board at Northwestern University
Setting/Ethical -Conducted at Prentice Womens Hospital between September 2014 and May 2015.
Considerations -All participants gave written informed consent before transfer to the OR
-Excluded obese, chronically exposed to opioids or anxiolytics, or received intrapartum magnesium.
-Enrolled on the day of surgery for women who met the criteria.
-48 women agreed to participate and provide informed consent.
-24 women who underwent SCD and 24 who underwent UCD were analyzed.
Major Variables -Evaluate and compare sedation levels in women undergoing unscheduled and SCD with neuraxial anesthesia using
Studied (and their validated sedation scales and assess whether timing of SCC and breastfeeding differed between these 2 groups.
definition), if
appropriate
Measurement -Collected by a physician member of the research staff not involved in the patients; clinical care.
Tool/Data Collection -Assessed using 2 sedation scales: visual analog scale for sedation and the observers assessment of alertness and
Method sedation scale.
Data Analysis -Mann-Whitney U-test compared the VAS sedation score at 45 minutes between groups.
-Mean Standard Deviation score at 45min following spinal anesthesia was 4 +/- 2.
Findings/Discussion -Patient-reported levels of sedation were greater at 45 min in laboring women undergoing unscheduled versus
scheduled cesarean deliveries, but observer assessed sedation was not different between groups.
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-Women undergoing unscheduled cesarean deliveries are more sedated than women undergoing scheduled cesarean
deliveries.
-SCC protocols for cesarean deliveries must consider maternal sedation and anesthesiologists should use sedating
medications carefully.
-Women undergoing UCD with epidural anesthesia self-reported greater levels of sedation at baseline and for up to
60min after attaining T4 surgical anesthetic level than women undergoing SCD with spinal anesthesia.
-Sedation burden or aggregate sedation over time values, were significantly greater by both self-reporting and
observer assessment in women undergoing UCD. -Observer assessments of sedation were not significantly
different at any single time point.
-Single observer assessment may be inadequate to assess the degree of maternal sedation before skin-to-skin
contact.
Appraisal/Worth to -Despite the difference in sedation, there was no difference in the time to initiation of Skin-to-skin contact or the
practice first breastfeeding.
-Protocols to initiate skin-to-skin contact in the operating room may need modification to account for increased
sedation in women undergoing UCD and anesthesiologists should carefully weigh the benefits of using potentially
sedating medications during SSC.
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First Author -Frederick, C. A. 2014 All are some sort of professor in a Nursing program. 2 hold PhDs, 1 is a MD, 4
(Year)/Qualifications are RNs, 1 is a Family Nurse Practitioner, and 1 is a Doctor of Public Health, all holding valid credentials.
Background/Problem -Explore and describe mothers experience of holding her neonate in skin-to-skin contact immediately after
Statement cesarean delivery during surgical closure and recovery.
-SSC provides the most optimal environment for neonatal adaptation to extrauterine life through better central
nervous system control, reduction in stress, and maintenance of quiet sleep.
Conceptual/theoretical -Qualitative content analysis
Framework -Focused Medical Ethnographic Design
Design/Method/Philosophical -Ethnographic study using observations and interviews conducted with the mothers at 24-48 hours post-
Underpinnings delivery.
-Study conducted at a large hospital in the Texas Medical Center
Sample/ Setting/Ethical -11 women between the ages of 23-38 years old who had achieved 39.1-40.2 weeks gestational age.
Considerations -Ethnographic study
-Institutional Review Board approval was obtained from 2 independent institution
-Written informed consent was required of participants.
Major Variables Studied -Main theme = Mutual caregiving: the mother-neonatal interaction and their shared and reciprocal
(and their definition), if relationship and the benefits during SCC.
appropriate -Fathers influence on SCC experience acknowledged his role in the formation of the family unit during the
first moments of SSC.
-Cesarean environment.
Measurement Tool/Data -Interviews were transcribed verbatim and content analysis of both observational notes and transcripts were
Collection Method used to analyze the data.
-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 24-48 hours postpartum.
-Observation with field notes & individual interviews.
Data Analysis -Data interpretation was validated by clarifying observations and statements with the informants.
-Interviews were digitally voice-recorded and transcribed by the investigator
-Qualitative content analysis used to analyze the interview data and develop themes.
Findings/Discussion -Use of SCC 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.
-Mothers were satisfied and appreciative for the opportunity to hold their neonates within minutes of delivery.
 AN INTEGRATIVE REVIEW
Appraisal/Worth to practice
14
-Enabled mothers to know their neonates firsthand, to interact with them immediately, and to being the
bonding process.
-Early accomplishment and power in her maternal role by the use on intraoperative SSC
-Ease of initial breastfeeding session and were pleased by how readily their neonates took to them in the
recovery room.
-Encourage and educate women on the use of SSC for their benefit and that of their newborn.
-Empowered to influence institutional policy on SSC during cesarean deliveries at the local and national
level.
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First Author (Year)/ Koopman, I. 2016 Associated with Johns Hopkins University. All hold degrees ranging from BSC, PhD,
Qualifications MHS, MS, CNM, Nurse Midwife, and most are assistant professors at Johns Hopkins.
Background/ Problem -Aimed to understand the perceptions on early SSC for healthy full-term infants.
Statement -Lack of a clear definition on clinical eligibility accounts for reluctance among nurses to practice early SCC.
-Despite the numerous benefits of early SCC, difficulties in implementation impede its universal use as standard
of care.
-Study aims to provide insight into clinician perspectives on uninterrupted early SSC and its facilitating factors
and barriers after delivery of healthy full-term infants. -Adoption of early SCC is low in many settings and the
barriers that hinder universal use are not well understood.
Conceptual /theoretical -Thematic analysis approach
Framework -Coding framework developed and subthemes emerged. -Semi-structured interviews
Design/Method/ -Exploratory qualitative research design following a pragmatic approach to address specific programmatic
Philosophical challenges.
Underpinnings -Interviews conducted at the Obstetrics & Gynecology unit of a university-affiliated community hospital in the
United States and its associated level-IIIb NICU.
Sample/ Setting/Ethical -11 participants and interviews were conducted of 5 RNs from the OB/GYN unit, 4 RNs from the NICU and 2
Considerations doctors (one from each unit) (Small sample size!!) - Study approved by the John Hopkins University School of
Medicine Institutional Review Board.
-Only 2 had received SSC training prior to this research. -Unhealthy babies and mothers were not included in
this study.
-Any identifying information was omitted
Major Variables Studied -The current practice of early SCC at the hospital -Experience with early SSC -Opinion on early SSC
(and their definition), if -Factors that influence the practice of early SSC facilitating factors and barriers to early SSC
appropriate -Early SCC implementation feasibility of early SSC, if parents were interested and if a clinical algorithm is
necessary to implement early SSC.
-Institutional, familial-level, and implementation factors & subthemes logistics, education of clinicians, parental
education and motivation.
Measurement Tool/Data -Educational sessions for nurses on transitioning to mother-baby couplet care taught by a lactation consultant
Collection Method comprising on the benefits of early SSC immediately after vaginal or caesarean delivery.
-Took place of September October 2014.
-Semi-structured interviews on early SSC lasting for 10-30 minutes conducted in a private room during work
hours.
Data Analysis -Thematic analysis conducted to analyze the data. -Recorded interviews were transcribed into verbatim data.
 AN INTEGRATIVE REVIEW 16

-Coding framework developed after familiarization with the data and open coding by the researcher.
-Used Atlas Ti 7 to facilitate qualitative analysis.
Findings/Discussion -For caesarean deliveries, SCC was seldom practiced.
-Competing priorities for the attending staff and inadequate staffing were barriers found as well as intravenous
lines and cardiac leads on the mothers chest.
-Need for education and emphasis on the benefits of early SSC to have the entire team on board with the practice
of early SCC.
Appraisal/Worth to -Suggestions to put a clinical algorithm in place to define medical conditions of the infant or mother that
practice contraindicate SCC.
-Understanding the facilitating factors & barriers on uninterrupted early SSC from a clinicians perspective
provides a better insight into the practice of early SCC.
-Factors should be considered & Addressed before successful implementation of early SCC can be established.
-Provide a better understanding of clinician perspectives on early SCC and help guide its implementation as
standard of care for healthy full-term infants.
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First Author Posthuma, S. Authors are qualified for this research and come from the departments of obstetrics & gynecology,
(Year)/Qualifications anesthesiology and pain medicine and pediatrics in the Martini Hospital in the Netherlands. - 2016
Background/Problem -Although birth is a major life event for parents, parental involvement during cesarean sections is often not a focus.
Statement -Developed a multidisciplinary SSCS protocol for their hospital. If the neonate showed no signs of distress at birth, it
stays in skin-to-skin contact with its mother as long as possible, preferably during the whole cesarean.
Conceptual -Quantitative
/theoretical -No specific theoretical framework mentioned
Framework
Design/Method/ -Single center retrospective cohort study conducted in the department of Obstetrics & Gynecology of the Martini
Philosophical Hospital in Gronigen, The Netherlands.
Underpinnings
Sample/ -Analyzed 650 women - 285 women in the skin-to-skin cesarean section and 365 in the conventional cesarean group
Setting/Ethical (August 2011-August 2012 and January 2013-December 2013). -Approval received by the Medical Ethical
Considerations Committee of the Martini Hospital.
-Informed consent was not needed. patient files were retained retrospectively & stored anonymously.
Major Variables -Excluded cesarean before 37 weeks, general anesthesia used, and fetal distresses cases.
Studied (and their -Main maternal outcome measured was surgical site infection, also looked at fever treatment with antibiotics,
definition), if maternal sepsis, excessive blood loss, and maternal death.
appropriate -Outcome Measures Maternal outcomes & Neonatal Outcomes in table 2 &3.
-Neonatal outcomes = birth weight, Apgar score <7 at 5 min, umbilical artery pH <7.0 at birth, neonatal admission to
the maternal ward, pediatric ward, or transfer to a tertiary NICU, hyperbilirubinemia, hypoglycemia, hypothermia,
suspected infection, and neonatal sepsis.
-Surgical outcomes = total mean operating time, surgery time, and recovery time.
Measurement -Retrospective cohort of women who underwent a skin-to-skin cesarean section compared to conventional cesarean
Tool/Data Collection sections. -Data taken from electronic hospital patient files and paper hospital charts. -Data stored anonymously &
Method de-identified in a separate file for evaluation.
Data Analysis -No significant differences in surgical infection site or other maternal outcomes.
-Fewer neonates born after SSCS were admitted to the pediatric ward and fewer had a suspected neonatal infection,
no differences were observed for other outcomes.
-Analysis performed using SPSS 20. -Differences between groups were a mean with standard deviation or mean
difference.
-Mean operation time was 3m2s longer in the SSCS group compared to the conventional CS group & the mean
recovery time was 14m46s shorter.
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-Dichotomous/categorical outcomes presented as numbers and percentages with relative risks

-Continuous data tested with a students t-test or a non-parametric mean-Whitney U test & P values of <0.05
considered statistically significant -Categorical data analyzed with Chi-square test and presented as confidence
intervals and p value.
Findings/Discussion -Adverse maternal and neonatal outcomes were not increased after skin-to-skin cesarean compared to conventional
cesarean delivery. -Found other benefits of SSCS compared to conventional CS = shorter recovery time in the
PACU, shorter maternal hospital stay, and fewer neonates admitted to the pediatric ward for suspected infection.
Appraisal/Worth to -Large sample size and single center design eliminating bias due to differences in procedural approach of the SSCS.
practice -Limitations limited information, prone to information bias, but not likely to influence comparisons, outcome
conclusions were drawn by physicians rather than by pre-specified definitions.
-Significant decrease in neonatal admissions to the pediatric ward and the decrease in antibiotic treatment for
suspected infections in neonates in the SSCS-group. -SSCS is a safe alternative for a conventional CS with
respect to surgical, maternal, and neonatal outcomes.
-A family centered approach providing parents an optimal birth experience, for planned as well as unplanned CS.
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First Author
(Year)/Qualifications
Background/ Problem
Statement
Conceptual/
theoretical Framework
Design/Method/ Philosophical
Underpinnings
Sample/ Setting/ Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/ Data
Collection Method
Data Analysis
Findings/Discussion
19
Zwedberg, S. 2014 - All authors are registered nurse midwives (RNM) and one has a PhD
-Explore midwives experiences and perceptions of skin-to-skin contact with mothers and their healthy full-
term infants immediately and during the first day after caesarean sections.
-It is particularly difficult to create the conditions needed for continuous skin-to-skin contact with the
newborn infant after a cesarean birth.
-Difficulties involved in introducing a new evidence-based care routine such as skin-to-skin care.
-Qualitative
-No specific theoretical framework listed
-Qualitative interviews with semi-structured questions.
-Individual interview study
-Eight midwives from 3 different hospitals in Stockholm (sufficient sample size as this was a pilot study for a
larger research study).
-Interviews took place in an undisturbed room near each midwives workplace.
-Study was approved by the Research Ethics Committee of Karolinska Institutent.
-Exploring midwives conceptions of skin-to-skin contact between mother and infant after caesarean birth
-Study yielded seven subcategories with 3 main categories being obstacles, promoting more skin-to-skin
contact, and challenges that midwives faced.
-Subcategories included mothers condition, collaboration, time, and resources, knowledge and cultural
differences, something natural, strategies, dismissed and disappointed and parents decision.
-Individual interview study
-Interviews had open-ended question about skin-to-skin care and then described their caring processes for
mother, father and infant as well as their approach to skin-to-skin care immediately after caesarean birth and
during the following day.
-Interviews were recorded on audiotape and lasted from 26-54 minutes.
-Transcribed material analyzed and interpreted using qualitative content analysis.
-Theme from analysis = fighting an uphill battle.
-There are many obstacles that correlate with implementing skin-to-skin such as lack of knowledge, the
mothers condition post C-section, lack of time and collaboration with other professionals.
-skin-to-skin is not prioritized because many health care practitioners are unaware of its positive benefits.
-Need for education for both health care and parents.
-Midwives advocate a proven beneficial and cost-effective intervention to parents who are unwilling and do
not understand its benefits, and within health care organizations unaccustomed to providing this type of care.
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Appraisal/Worth to practice
20
-Need for education of all of those involved in the care of mothers and infants following C-Sections.
-Should develop guidelines for each health care organization that enables midwives and other professionals
caring for the mother and her newborn to emphasize, describe and teach the important of early skin-to-skin
contact with the infant.
-Not often prioritized due to a lack of awareness among health care practitioners regarding its positive effects.
-Need for education for all health care practitioners involved in caesarean procedures regarding the care of
mothers and infants as well as this education for the parents about the benefits of SCC.