“Stuck on You” Skin to Skin as a Standard of Care for Newborns in the OR/PACU

Introduction

References

Implementation

Conclusion

Acknowledgements

Methods & Materials

Model of Care Committee Sub-Group OR/PACU

Dr John Wimmer, Neonatology

Dana Bryant,RN, MBA, Director OR/PACU

Cleo Montpellier, RN, BSN,MHA,CPAN, Assistant Director PACU

Amy Skrinjar, MSN, Director Birthing Suites

Myra Kelly,CRNA, Director of Anesthesia

Helen Sneed RN,MSN Maternity Admissions,

Camilla Wood RN, BSN PACU Assistant Director

Wynn Fussell, CRNA,MSN, ANP

Nancy Kazmar, RN PACU

Miranda Hill, RN Mother-Baby

Beth Olson RN, OR

Beverly Daly, RN,BSN, IBCLC

Donna Wear, RNC,BSN ,Mother-Baby Unit

Christie Wicker RNC ,Birthing Suites

Laura Stines, RN, MSN Infection Prevention

Kathleen Kohut, RN MSN Infection Prevention

After a successful pilot of 310 vaginal deliveries in January of 2012 resulted in a

change to skin to skin (S2S) care for all our vaginally delivered babies and we had a 100% success

rate in maintaining optimal axillary temperatures even after being bathed in the mother’s room, we

wanted to venture into the same practice following cesarean sections.

Parents with planned and unplanned cesarean deliveries heard about what was going on with

the S2S care after vaginal deliveries so they began to expect S2S care for their cesarean birth

experience. They communicated this request often through “birth plans” presented to staff upon

arrival.

Our goals at Women’s Hospital were:

S2S contact as a transitional method for all stable newborns following a cesarean section

Axillary temperatures and vital signs to remain stable through the transitional period

Increase our breastfeeding rate

Parent participants in the pilot were interviewed the day after the birth of their baby. They were

asked about their experience of S2S contact immediately after birth. We asked them to

rate their experience on a Likert scale of one to five: “1” being that they “did not like it” and “5”

that they “loved it”. Results: 100% participants rated their experience as a “5”. Three parents

rated it as a “10”!

Data collected for the PDSA was shared with the OR/PACU Sub Committee. There were no

negative outcomes for the 10 couples participating in the pilot. Lengthy and detailed discussions

were held about how this could be accomplished as the standard of care for all newborns at Cone

Health Women’s Hospital.

The OR/PACU subcommittee of the Model of Care committee, consisted of staff from Birthing

Suites, Postpartum, Nursery, OR, PACU, Infection Prevention and NICU and included RN’s,

CRNA’s, and physicians. September of 2012 this committee began the work to Plan, Do, Study,

Act (PDSA). Every question and reason to not change was addressed and answered from fears

of contaminating the OR to having enough room for the extra nurse at the “table-side” in the OR.

A PDSA-based pilot was planned for providing S2S in the OR and PACU for 10 scheduled

cesareans over 2 weeks. Guidelines were written and communicated extensively. Participants

were randomly selected from the OR schedule and asked if they would like to participate. Every

mother/support person asked was very willing to participate in S2S contact and have a nursery

nurse stay with them.

S2S contact was initiated in the OR after the 5 minute Apgar score. Baby remained S2S

during the entire surgery. Baby was removed from the mother only for the brief transport of the

mother to the PACU bed. Then the baby was returned to the mother’s chest in the PACU bed

and transported to the PACU. Families were allowed to see the new baby on the mother’s chest

briefly outside the PACU. The goal was for the baby to remain S2S for at least one hour and until

the first feeding was accomplished. All routine care of the newborn was performed at the bedside

and continuing S2S if able. One nurse was chosen by a senior leader to provide care for all 10

deliveries.

Staff resistance to change was addressed. Staff was educated about the process through

multiple meetings. They were encouraged to express concerns at unit meetings about the

change in our model of care. As more staff witnessed the benefits for families and newborns,

resistance was resolved.

This project represents innovation:

First hospital in North Carolina (and one of very few hospitals in the nation) that is a high-

volume referral center that practicing S2S after both vaginal and cesarean deliveries as a

standard of care for all patients

Maintain S2S contact through the first feeding and transfer of the mother/baby to the

postpartum room.

Our bottom line became: “What is best for the patient?”. Many more practice changes have

taken place since the skin to skin set the ground work and changed our culture of care.

We were able to achieve this goal without additional staff. It was just a matter of moving

current staff and equipment to the bedside and being willing to not only think but practice

“outside the box”.

Concerns about implementation of this model of care included staffing. The nursery nurse stayed

with each couple for an average of 3 hours and 20 minutes. Because we firmly felt this was

evidenced based best practice, we decided to implement this in phases, “baby steps in the OR”.

In Phase One, we would commit to providing S2S for all stable infants born by cesarean in the

OR for 30 minutes. The baby and support person would then go to the nursery and resume routine

care. The baby did return to the mother in the PACU for feeding and bonding.

In Phase Two the baby remained S2S in the OR during the entire procedure and remained with

the mother in the PACU until the first feeding was accomplished and then the baby would be

transferred to the nursery until the mother was brought to her postpartum room.

In Phase Three the baby stayed with the mother during the entire OR, PACU and transfer to the

postpartum room. This phase 3 was accomplished by having supervision help with the recovering

couplet by involving PACU RN’s and Lactation assistance in the PACU. The support person is

encouraged to remain with the mother and baby to help with the transition to the postpartum room.

Phase three began March 4,2013.

Smith, Pat Bohling, MS,RNC, Moore, Karen, MSN, RNC, IBCLC, Peters, Liz, BSN, RNC, CLC (July/August

2012) Implementing Baby –Friendly Practices: Strategies for Success, Maternal Child Nursing, Vol 37,No 4,

pp228-233.

Berg, Ocean, MSN, RN, CNS, Hung, MS, RN, CNS (September/October 2011) Early Skin to Skin After

Cesarean to Improve Breastfeeding, Maternal Child Nursing ,Vol 36,No 5, pp 318-324.

Spradlin, Ludmila R. RN,BSN,MS,CNOR (March,2009)Implementation of a Couplet Care Program for

Families After a Cesarean Birth, AORN Journal, Vol 89,No3,pp 553-562.

After analyzing the data, it became clear that there was an immediate overall

improvement of infant health. Admissions to NICU for hypoglycemia and infant

readmissions for hyperbilirubinemia dropped to half the numbers seen under the

old model of care.

Pilot Results Long Term Outcomes

One year after the process change 10 couples were randomly chosen and interviewed once again

about the process of S2S in the OR and keeping the baby with the mother during the entire

recovery time. The same question was asked about their experience of S2S contact immediately

after birth. We asked them to rate their experience on the same Likert scale that was used during

the pilot. Again,100% of the participants gave us a ”5”. Parent comments included the baby being

calmer and the parents feeling less anxious. Frequently in both the pilot and now a year later,

parents who had a previous delivery that did not include S2S speak openly about how meaningful

the experience was for them and how they wish they had the opportunity with their previous

birth(s). Lactation consultants and parents note improvements in breastfeeding outcomes

regarding ease of the first latch-on and the frequency and length of breastfeeding while in the

hospital. No adverse outcomes of S2S in the OR/ PACU have been demonstrated.

Newborns now stay with their parents in the OR and in the PACU. All routine care takes place at

the bedside. Babies are allowed to be transported to the PACU on their mother’s chest and briefly

greet the visitors before entering the PACU. This process change is a huge satisfier for patients

and families. In the old model the mother was not able to participate in the family ‘s first view of the

new baby.

An unexpected result has been PACU staff has commented that mothers complain of

pain and itching less frequently when the baby remains S2S.

0%

10%

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100%

2012 2013 2014

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