DOI: 10.1097/JPN.
0000000000000322
EXPERT OPINION
Erin Cleary, MD; Mike Cohen, MD; Elisabeth D. Howard, PhD, CNM, FACNM
A Cry for Equity in the Operating Room
Standardizing Skin-to-Skin Practices
Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit—Life!
Emily Dickinson1
arly skin-to-skin contact (SSC) following birth is
E associated with successful breastfeeding and im-
proved newborn transition to extrauterine life.2
Hospital practices such as keeping a mother and infant
together for at least the first hour postbirth leads to im-
proved initiation and duration of breastfeeding.2,3 These
practices are strong predictors of exclusive breastfeed-
ing rates at discharge, which is a core perinatal quality
measure.4 Baby-friendly hospital protocols such as stan-
dardized SSC after vaginal delivery assist in the estab-
lishment of exclusive breastfeeding.2–5 However, recent
cesarean rates of 32%6 of all infants born in the United
States put a substantial population at risk for delayed or
unsuccessful breastfeeding.3 Cesarean births adversely
affect breastfeeding initiation, milk supply, and infant
receptivity compared with vaginal delivery.3 To include
and standardize the benefits of SSC in this group of pa-
tients, operating room (OR) culture must be addressed.
This necessitates multidisciplinary collaboration and
process improvement to identify and employ best work-
flow practices to ensure all eligible dyads participate
in SSC after birth.5 Perinatal nurses are uniquely posi-
tioned to drive quality and optimize patient- and family-
centered care of the mother and the infant as their role
bridges the labor, birth, and OR environments.4
SKIN-TO-SKIN CONTACT: THE BASICS
At the time of birth, a myriad of physiologic adap-
tions facilitate fetal transition to the extrauterine en-
vironment. Abrupt changes in circulation and initia-
tion of the respiratory system take place in order for
Disclosure: The authors have disclosed that they have no significant
relationships with, or financial interest in, any commercial companies
pertaining to this article.
The Journal of Perinatal & Neonatal Nursing
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E PERINATAL
the neonate to survive. Studies illustrate the dynamic
neurohormonal interactions between the mother and
the child that promote this transition, with emphasis
on the initiation of lactogenesis for the mother and
a healthy stress response in the neonate.2–5 Early SSC
is associated with increased rates of exclusive breast-
feeding at the time of discharge from hospital, with a
dose-dependent increase observed (2 hours vs 1 hour).7
Skin-to-skin contact further increases exclusive breast-
feeding at discharge.2,3 The trend continues with both
increased exclusive breastfeeding rates and duration of
breastfeeding. In addition to more successful breast-
feeding, there is higher neonatal temperature and blood
sugar levels, lower respiratory and heart rates, and
fewer episodes of crying observed in dyads with SSC.2
The maternal benefits observed in early SSC include
less state anxiety, increased attachment to the infant,
and higher satisfaction with the birth experience.2,3,5
The long-term maternal benefits of breastfeeding in-
clude decreased risk of cardiovascular disease, includ-
ing metabolic syndrome and myocardial infarction, de-
creased breast and ovarian cancer risks, decreased risk
of type 2 diabetes, increased bonding with the infant,
and decreased rates of postpartum depression.3,6 Sub-
optimally, breastfed infants are at risk for diarrhea,
respiratory infections, sudden infant death syndrome
(SIDS), type 1 and 2 diabetes, and leukemia.3,6
The public health ramifications of such a simple prac-
tice are profound. The anticipated effect of even a 5%
increase in the rate of breastfeeding in the United States
projects a statistically significant difference in childhood
infectious morbidity, specifically otitis media and gas-
trointestinal infections.7 The cost savings of this mod-
erately increased rate is estimated at more than $40
million.7
SSC APPLICATIONS IN CESAREAN BIRTHS
Historically, the literature on SSC included only dyads
following vaginal births. However, mounting evidence
now exists to suggest that term and even late-term
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 EXPERT OPINION E PERINATAL
infants born via cesarean delivery can experience SSC
and demonstrate higher rates of exclusive breastfeed-
ing, among other positive postoperative milestones,
compared with routine care after cesarean birth.2,3,5
This is particularly important as women who birth by
cesarean delivery are less successful reaching breast-
feeding goals2 and have lower satisfaction with birth
experience than those who have a vaginal delivery.2,3
Recent evidence on SSC in the OR following cesarean
delivery indicates that mothers who experienced direct
SSC had decreased need for additional pain medica-
tions in the OR (47% in the SSC group vs 57% in the
no-SSC group).8 These data support direct SSC immedi-
ately following delivery as a beneficial nonpharmaco-
logic adjunct to postoperative pain control.8 Both OR
temperature and concern for neonatal temperature in-
stability are often cited as reasons to avoid SSC in the
OR. However, in a study of 100 women randomized to
SSC versus routine care, there were no statistically sig-
nificant differences between neonatal temperature in
the OR and that on arrival to the nursery unit.9 Inter-
estingly, there were also no significant differences be-
tween the temperature of the OR, temperature of the
nursery unit, and temperature of the mother’s room.9
LOGISTICS OF ROUTINE SSC
Prior to implementation of any hospital policies on SSC
in the OR, identification of key stakeholders to ensure
success of process improvement efforts is essential.5 At
minimum, this will include members from the anesthe-
sia, obstetrics, pediatric teams, and the nursing staff.
Based on the unique design of any obstetrical OR en-
vironment, this may include perioperative nurses, OR
circulating nurses, labor and delivery nurses, and pe-
diatric nurses, each with specific roles in the care of
the mother and the infant.5 Additional key players to
consider are scrub technicians, doulas, nurse-midwives,
patients, family members, and personnel dedicated to
quality improvement in the hospital. Communication
with and education of the staff at the offices where pa-
tients receive prenatal care are crucial, as they enable
a consistent message to patients regarding expectations
at the time of cesarean delivery.
Preoperatively
Well before time in the OR, education and counseling
on the anticipated SSC goals occur. Implementing an
opt-out approach over an opt-in approach encourages
the patient to consider and discuss SSC with her
support person. In the event she is not a candidate, it
is logistically easier to accomplish SSC with the support
person if he or she has only the scrub top on without
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additional layers underneath. Alternatively, a buttoned
paper-scrub top has been designed and implemented at
Nottingham University Hospitals in the United Kingdom
to facilitate SSC in the OR with the patient’s support
person.10 Anesthesia staff can aid in the success of SSC
by placing the peripheral intravenous catheter in the
nondominant arm in a site other than the antecubital
region, the electrocardiogram leads as lateral as pos-
sible, and the oxygen saturation on the nondominant
hand or an alternative site such as the earlobe.
Intraoperatively
When the entire team is convened in the OR, the
plans are incorporated for SSC as part of the “time-out”
procedure to ensure a shared mental model on care
for the infant and the mother immediately after birth.
Once the infant is born and handed off to the pediatric
or nursing staff, the initial newborn evaluation takes
place. Individual hospital teams are encouraged to
consider the advantages and disadvantages of the
infant placed immediately in SSC and evaluation of
infant there versus a brief evaluation at the warmer
prior to initiation of SSC. Data suggest that immediate
SSC decreases maternal oxidative stress, but adequate
drying of the infant and the initial evaluation may be
hindered by immediate SSC.11 If the decision is made
to first evaluate the infant at the warmer, care must be
taken to make this separation from the mother as brief
as possible. It is feasible to meet a goal of measuring
the 5-minute Apgar score during SSC. At the time of
delivery, the anesthesia staff is evaluating the mother
for suitability for SSC as well, which may be hindered
by pain, nausea, or the patient’s uneasiness.
Figure 1. Protocol for SSC in the OR after cesarean
birth. SSC indicates skin-to-skin care; OR, operating room.
Reprinted with permission from Sundin et al.8
April/June 2018
 EXPERT OPINION E PERINATAL

Composing a script and developing team simulations
to run through communication and workflow logistics
with the OR staff enhance collaboration.5 Just as with
SSC at the time of vaginal delivery, infant efforts to latch
are encouraged and supported in the OR. There are
several different positions identified that may assist in
achieving comfortable SSC for the mother. One example
is depicted in Figure 1.
Successful mother-infant SSC is dependent upon the
medical status of each member of the dyad following
delivery and continuously evaluated as it is subject to
change.12 In the event that the infant is a candidate for
SSC but the mother is not, an alternative option exists to
offer SSC with the father of the baby or other support
person joining the mother in the OR. In some cases,
such as general anesthesia of the mother, the infant

Figure 2. Protocol for SSC in the OR after cesarean birth. SSC indicates skin-to-skin
care; OR, operating room; ICS, infant care specialist; CNRA, certified registered nurse
anesthesia; OB MD, obstetric medical doctor. Reprinted with permission from Sundin
et al.8

The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 99

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 EXPERT OPINION E PERINATAL
could initiate SSC outside the OR with another adult.
Data support decreased infant crying, drowsy state, and
increased rooting, suckling, and wakefulness in infants
experiencing SSC with the father compared with those
receiving conventional care.13
Postoperatively
A goal of SSC is initiation within 2 to 5 minutes from
birth and continuation of SSC for as long as possible in
the OR. One option to consider is cessation of SSC at the
completion of the surgery, when drapes are removed
and the dressing applied to the cesarean incision. By
moving the infant to the warmer at this point, an op-
portunity exists to complete any infant evaluations by
the nursing staff before moving to the recovery area.
Skin-to-skin contact resumes prior to the family leaving
the OR. Others advocate that SSC not be interrupted
at the completion of the surgery but rather the mother
is encouraged to maintain SSC and hold her infant as
she is moved from the operating table to a stretcher for
transport.2–5 For all eligible dyads, SSC may continue
in the recovery period. A recommended workflow is
depicted in Figure 2.
Coupled with the responsibility to enact system
changes that establish a strong foundation for mother-
infant dyads at the time of birth, this is an era of con-
tinuous quality improvement. Indeed, both the Joint
Commission Perinatal Care Core Measure set and the
Association of Women’s Health, Obstetric and Neona-
tal Nurses (AWHONN) proposed nurse-sensitive quality
measures include breastfeeding exclusivity. AWHONN
further details initiation and duration of SSC.5 Con-
sumers evaluate publicly available data as they make
decisions about where to seek obstetric care. Further-
more, the financial incentives for institutions to meet
quality metrics are substantial.5 Achieving improved
metrics across the board may be accomplished by in-
corporating SSC as part of larger system change of
family-centered cesarean birth, as outlined thoroughly
by Schorn et al.5
CONCLUSION
Emily Dickinson’s words echo in the setting of a
cesarean birth. Cesarean births are riddled with difficul-
ties in breastfeeding and shorter breastfeeding duration
compared with vaginal deliveries.2 Multidisciplinary
attention to the details and nuances of OR culture to
develop safe patient-centered workflow influence the
experience of both the mother and the infant. It is es-
sential to ensure that the lives that begin in the OR are
provided the same opportunities to survive and thrive
in the minutes, hours, days, and months to come, just
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as their counterparts who enter the world via vaginal
birth. Perinatal nurses play a pivotal role in quality and
value transformation.4 Their diverse knowledge of both
the labor and OR birth environments positions them
as key leaders in advocating for and ensuring best
practices for the mother-infant dyad. The challenges
presented by an OR setting must be addressed and
tackled rather than cited as reasons to exclude this
population from participation in and benefits of SSC.
—Erin Cleary, MD
Obstetrician-Gynecologist
Assistant Professor of Obstetrics and Gynecology (Clinical)
Alpert Medical School
Brown University
Providence, Rhode Island
—Michael Cohen, MD
PG-Y3
Obstetrics and Gynecology Residency
Brown University
Providence, Rhode Island
—Elisabeth D. Howard, PhD, CNM, FACNM
Director
Midwifery Women and Infants Hospital
Associate Professor
Obstetrics and Gynecology (Clinical)
Alpert Medical School of Brown University
Providence, Rhode Island
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