Abstract

Purpose: Experts recommend immediate skin-to-skin (SSC) contact for all alert and stable mothers and newborns
after birth. Clinicians are working to incorporate immediate (intraoperative) SSC during cesarean birth. The purpose of
this systematic review is to describe the state of the science of intraoperative SSC for mother and baby and increase
clinician’s awareness of its potential benefits and risks.
Study Design and Methods: A systematic approach was followed throughout the review process. CINAHL, PubMed,
and Embase databases were searched using strategies constructed by an academic health sciences librarian. Articles
included in the review focused on SSC initiated during cesarean birth.
Results: Thirteen studies were selected for the mixed-method systematic review. Six prospective studies, four retro-
spective chart reviews, and three qualitative studies met the inclusion criteria. Maternal stress levels were reduced,
whereas comfort, oxytocin, and antioxidant levels increased with intraoperative SSC. Physiologic measures of successful
newborn transition showed little difference between newborns held in intraoperative SSC and those who were not. Syn-
thesis of qualitative experiences revealed mothers’ intense desire to hold and know their baby immediately after birth.
Clinical Implications: Intraoperative SSC is a safe, beneficial, and highly desirable practice for mothers and
newborns experiencing cesarean birth. Although barriers exist to its implementation, nurses can facilitate and support
Downloaded from http://journals.lww.com/mcnjournal by BhDMf5ePHKbH4TTImqenVNPUfnk57qBdmrXCMt4rfimHovB1Ay6dHZVjL7zNmvLa on 10/04/2020

this practice. Evidence-based, family-centered intraoperative SSC should be offered to all stable mothers and babies
according to recommendations and in a manner that promotes safe outcomes, including following current nurse staff-
ing guidelines.
Key words (MeSH headings form): Baby; Cesarean section; Kangaroo mother care; Mother; Skin-to-skin contact;
Systematic review.

INTRAOPERATIVE MOTHER AND

BABY SKIN-TO-SKIN CONTACT
DURING CESAREAN BIRTH:
SYSTEMATIC REVIEW
Anitra Frederick, PhD, RN, CNE, Tena Fry, DNP, WHNP-BC, IBCLC, CNE, and Licia Clowtis, PhD, RN

kin-to-skin contact (SSC) is placement of the bare (or wearing a diaper and hat only)

S newborn, directly skin-to-skin on the chest of the mother after birth. Benefits of SSC are
well documented (Johnston et al., 2017; Moore et al., 2016) and SSC is the gold standard
for perinatal and postpartum care. Current recommendations for alert and stable mothers
and babies suggest immediate SSC (within minutes of birth) that continues for at least 1 hour or
until the first feeding is completed (American Academy of Pediatrics [AAP], 2012; World Health
Organization, 2018). Recommendations do not differ by mode of birth; however, incorporating
SSC immediately after cesarean birth may be challenging in the context of issues such as nurse
staffing, operating room culture, and concern for physiologic instability of mother or newborn
post birth (Balatero et al., 2019; Boyd, 2017).
More than 1.2 million women in the United States (31.9%) gave birth via cesarean in 2018
(Martin et al., 2019). To provide evidence-based clinical care for all mothers and babies, nurses,
midwives, and physicians are working to implement intraoperative SSC (Boyd, 2017; Hung &
Berg, 2011), defined as immediate SSC in the operating room during completion of the cesarean
surgery. Previous literature reviews have examined use of early SSC following cesarean birth,
but few studies of intraoperative SSC have been included. A Cochrane review of early SSC for
mothers and newborns includes studies of cesarean SSC; however, most of these studies ini-

296 volume 45 | number 5 September/October 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

tiate SSC in the recovery period rather than in the op-
erating room (Moore et al., 2016). Similarly, a review
conducted by Stevens et al. (2014) includes studies of re-
covery room initiated SSC as well as studies incorporat-
ing paternal SSC data in findings. Although these reviews
draw important conclusions and offer valuable insights
for practice, the literature specific to intraoperative SSC
has grown rapidly since their publications. The purpose
of this systematic review is to describe the state of the
science of intraoperative SSC for mother and baby and
increase clinician awareness of its potential benefits and
risks.
Methods
A systematic review including quantitative and qualita-
tive evidence was conducted using a segregated design
approach (Sandelowski et al., 2006) to synthesize the
science on intraoperative SSC. The Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines were followed for systematic search
and reporting methodology (Moher et al., 2009). An
academic health sciences center librarian was consulted
to construct database searches for CINAHL, PubMed,
and Embase. Keywords for the search included skin-to-
skin, kangaroo, cesarean, and intraoperative. The initial
search was conducted in May 2019 with further search
for any new articles conducted in March 2020. Luding-
ton’s Kangaroo Care Bibliography (United States Insti-
tute for Kangaroo Care, 2018) and references from stud-
September/October 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ies meeting the inclusion criteria were hand-searched for
additional articles.
Articles included in this review were quantitative or
qualitative research studies focused on intraoperative
SSC’s effect on the mother or baby. Intraoperative SSC
was defined as placing the bare baby or baby wearing
a diaper and hat only, directly on the bare chest of the
mother within minutes of birth during surgical cesarean
closure. Excluded were articles in which SSC was initi-
ated in the recovery room or where the baby was not
placed on the chest of the mother. Studies with a focus on
the father, parents, nurses, staff, or on a hospital program
including the use of intraoperative SSC, but not as a main
focus of the study, were excluded. Articles not available
in English were also excluded.
Following database searches and removal of dupli-
cates, 276 articles remained. The flow diagram in Fig-
ure 1 outlines the screening process and article selection.
Following the screening process, and the reading of 36
full-text articles, 13 articles remained meeting review
criteria. Data were extracted from reports and orga-
Intraoperative skin-to-skin contact
may increase oxytocin and stimulate
maternal antioxidant production after
cesarean birth.
Credit / Photo Credit
Shutterstock
MCN 297
nized using excel spreadsheets. Individual articles were tributed to the iterative process of drawing conclusions
examined for their use of intraoperative SSC, outcomes from the data.
of interest, and conclusions drawn by investigators. Like
methodologies and outcomes of interest were grouped Results
for comparison and contrast of findings. Ten quantitative and three qualitative research articles
were included in the review. Each article was examined for
Two authors appraised included articles using the
study design, aims, initiation, and duration of intraopera-
Critical Appraisal Skills Programme (2014) tools as
tive SSC, outcomes of interest for mother and baby, report-
a guide to evaluate methodological quality and risk of
ed themes in qualitative works, and conclusions drawn
bias within each study. The Critical Appraisal Skills Pro-
from the findings. Table 1 provides a summary of the in-
gramme offers specific tools according to study design.
cluded quantitative studies. Five studies used a prospective
No study was removed as a result of the appraisal; how-
design with randomization into study groups (Bancalari
ever, rigor and bias were considered throughout the it-
et al., 2016; Crenshaw et al., 2019; Gregson et al., 2016;
erative process of data analysis and synthesis of review
Kollmann et al., 2017; Yuksel et al., 2016), one used pro-
results. First and second authors met regularly to discuss
spective observational approach (Vamour et al., 2019) and
the articles and how each additional article informed the
four used retrospective chart review (Billner-Garcia et al.,
growing knowledge base of the review. The third author
2018; Narayen et al., 2018; Posthuma et al., 2017; Wag-
reviewed the articles, added content expertise, and con-
ner et al., 2018) to address the identi-
FIGURE 1. FLOW DIAGRAM OF SCREENING AND ARTICLE fied research aims. Table 2 summarizes
the qualitative articles included in the
SELECTION PROCESS review. Qualitative designs included
phenomenology (Bertrand & Adams,
Records identified through 2020) and ethnography (Frederick et
Identification

database searching
al., 2016; Stevens et al., 2019).
(n = 429) and other
sources (n = 2)
Initiation and Duration of Intraop-
erative SSC
A clear description of the total contact
time of SSC is necessary in an attempt
Records excluded to differentiate between the effects of
(n = 240) SSC and other postbirth care proce-
Records after duplicates
removed (n = 276) Reasons: dures (Moore et al., 2016). All stud-
* Not specific to mother ies included initiation of SSC during
Screening

or newborn (n = 18) completion of the cesarean surgery

* Not specific to SSC
during cesarean (n = 137)
* Abstract only or confer-
Records screened
ence report (n = 24)
* Not a research study
(n = 276)
(n = 44)
* Not in English (n = 17)
Eligibility
but varied on how soon after birth,
and for how long, the mother and
baby remained in SSC. Initiation and
duration of SSC as reported in each
article is included in Tables 1 and 2.
Maternal Outcomes
Pain, anxiety, and comfort. Maternal
pain and anxiety were measured by

self-report or administration of anal-

Full-text articles assessed
for eligibility (n = 36)
Studies included in
Included
Full-text articles excluded
(n = 23)
Reasons:
* Case studies, QI, or EBP:
(n = 7)
* Examined fathers,
parents, staff, or doulas:
(n = 9)
* SSC initiated in recovery:
gesics and anxiolytics during and af-
ter the surgical procedure (Crenshaw
et al., 2019; Kollmann et al., 2017;
Vamour et al., 2019; Wagner et al.,
2018; Yuksel et al., 2016). No signifi-
cant differences were found at the p <
0.05 level for maternal pain or anxiety
with intraoperative SSC. Vamour et
al. (2019) used a heart rate variability

systematic review (n = 13) (n = 3) index, evaluating parasympathetic ac-

Qualitative: 3 * Intraoperative SSC not tivity associated with pain and stress,
Quantitative: 10 focus of study: (n = 4) as a means to measure maternal com-
fort. Mothers were more comfortable
following intraoperative SSC than
before its initiation (p = 0.034).

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

TABLE 1. DESCRIPTION OF QUANTITATIVE STUDIES (N = 10)
First Author Design and Sample ISSC Initiation Outcome Results
and Setting and Duration

Bancalari • Observational (N = 216) Initiation: Within 2 Newborn: SpO2 Significantly higher SpO2 in
(2016) • 3 groups: min of cord clamping. and HR at newborns born vaginally
Duration: At least 1–10, 15, 30, than those in the ISSC group
n = 136 post vaginal SSC
10 min. and 60 min. in first 10 min (p < 0.01).
Chile n = 24 standard CB,
HR lower in standard CB
n = 56 ISSC
group than vaginal or ISSC
• Healthy newborns, 37–41 group at 6–8 min (p < 0.05).
weeks GA

Billner-Garcia • Retrospective chart Initiation: After 5-min Newborn: 56% of newborns with ≥
(2018) review (N = 91) Apgar. Axillary axillary temperature at T2.
• Mother–newborn Duration: SSC concluded temperature 44% of newborns with lower
couplets with beginning of before ISSC (T1) axillary temperature at T2.
California,
surgical skin closure. and immediately n = 4 newborns with
United States • Maternal age:
Range: 3–25 min, after (T2) temperature <36 °C at T2.
23–49 years, 38–41.5
weeks GA Mean: 13.6 min. No associated morbidities,
NICU admits, or adverse
events reported.

Crenshaw • Pilot quasi-experimental Initiation: Couplet: Overall ISSC mothers’

(2019) time-interrupted (N = 40) Immediately after Stress (sC) HR higher (p = 0.007)
• 2 groups: umbilical cord cut. Exclusive SpO2 lower (p = 0.034)
Southwest, n = 20 ISSC Duration: Continued breastfeeding at but within normal range;
United States uninterrupted for discharge sC lower (p = 0.030).
n = 20 SSC started in
at least 2 hr—goal Newborn: Stability No significant differences
OR after mother moved
of 5 hr. (HR, RR, tempera- for N/V/pain.
to recovery bed.
Range: 272–341 ture, SpO2) More satisfied with care
• Maternal ages: 24–45
min, Mean: 301 min. Maternal: Stabil- (p = 0.015).
years, 39.0–40.1 weeks
GA; elective CB. ity (HR, RR, BP, ISSC newborns had
temperature, SpO2); lower temperature in OR
comfort (N/V/pain); (p = 0.029), but all within
satisfaction normal range; HR higher
at 2 hr after admission
(p = 0.044).
No significant difference in
exclusive breastfeeding.

Gregson • RCT (N = 366) Initiation: At birth. Couplet: No differences found

(2016) • 2 groups: Duration: Continued Primary: between groups. Authors
for as long as pos- breastfeeding reported potential
n = 182 ISSC
sible. rate at 48 hr “contamination” of
England n = 187 SSC started at control group due to
completion of operation Note: Use of a Secondary:
great durations of SSC
garment to facilitate Feeding method
• Maternal mean age and holding after surgical
holding in OR. at 10 days, 6
GA: 34 years & 39.3 closure.
weeks
weeks (ISSC), 33.2 *Unexpected respiratory
years & 39.2 weeks Newborn:
collapse noted in two
(SSC); elective CB NICU admit
newborns.

Kollmann • Pilot RCT (N = 35)
(2017) • 2 groups:
n = 17 ISSC
Austria
n = 18 postoperative SSC
• Maternal mean age: 34
years (ISSC), 32.1 years
(SSC); inclusion criteria:
≥37 weeks GA, singleton,
elective CB
Initiation: Within Newborn: Apgar Mothers had greater sAA
5 min, following score at 1/5/10 levels prior to initiating ISSC
initial exam. min; SpO2 & HR (p < 0.004) than control.
Duration: every 1 s for 25 No other significant
min; temperature
Continuously differences found between
until return to at 1 min and 25 min. groups for any outcome.
birth room. Maternal: Pain *No report on newborn
(self-report); N/V; stress levels (sC, sAA) due
analgesia request to large amount of “missing
Both: Stress data” (p. 10).
(sC and sAA)

(Continues)

September/October 2020 MCN 299

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TABLE 1. DESCRIPTION OF QUANTITATIVE STUDIES (N = 10) (CONTINUED)
First Author Design and Sample
and Setting
Narayen • Retrospective chart
(2018) review (N = 163)
• 2 groups:
Netherlands n = 71 standard CB
(1/2013–1/2014)
n = 92 family-centered
ISSC (7/2014–11/2015)
• 38.6–39.3 weeks GA,
low-risk; elective CB
Posthuma • Retrospective chart re-
(2017) view (N = 650)
• 2 groups:
Netherlands n = 365 standard CB
(8/2011–8/2012)
n = 285 ISSC (1/2013–
12/2013)
• Maternal mean age
and GA: 32 years &
39.3 weeks (ISSC),
32.2 years & 39.3 weeks
(standard CB), gen-
eral anesthesia and fetal
distress excluded.
Vamour (2019) • Pilot prospective,
observational (N = 53)
• Mother–newborn
France
couplets
• Maternal age: 20–42
years, 37.1–41.3 weeks
GA; elective CB
Wagner (2018) • Retrospective chart
review (N = 199)
• 2 groups:
Florida,
United States n = 99 no ISSC (before
2014)
n = 100 ISSC (2014–2015)
• Maternal mean age: 27.42
years (no ISSC), 29.7 years
(ISSC); inclusion
criteria 37–42 weeks
GA, medically stable
Yuksel (2016) • Randomized prospective
case-control (N = 90)
• 2 groups:
Turkey
n = 45 ISSC and breast-
feeding in the OR
n = 45 breastfeeding offered
1 hr after CB complete
• Maternal mean age:
27.3–28.4 years; preterm
excluded, elective CB
Note. ANI: Analgesia Nociception Index (measure of heart rate variability); BP: blood pressure; CB: cesarean birth; GA: gestational age;
HR: heart rate; ISSC: intraoperative skin-to-skin contact; N/V: nausea/vomiting; NICU: Neonatal Intensive Care Unit; OSI: oxidative stress
index; RCT: randomized controlled trial; sAA: salivary alpha-amylase; sC: salivary cortisol; SpO2: oxygen saturation; SSC: skin-to-skin
contact; TAS: total antioxidant status; TOS: total oxidant status.
300 volume 45 | number 5
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSC Initiation Outcome Results
and Duration
Initiation: After Newborn: Apgar Unplanned admissions
cord clamping score at 1 and 5 increased (p < 0.03) in
and placement min; temperature ISSC newborns. Authors
of SpO2 sensor. at 10 min and ar- attribute this to continuous
Duration: rival to unit; SpO2 SpO2 monitoring in ISSC,
Not specified. at 10 min of life; not done in standard CB,
respiratory pathol- which led to intervention.
Note: Forced-air
warming system ogy (tachypnea or No difference in respiratory
retractions); NICU pathology or temperature
used during ISSC.
admit. between groups.
Initiation: Newborn Newborn: Maternal length of stay
handed over lowered Apgar score; arte- longer in standard CB group
surgical drape and rial pH; infection (p < 0.001). Suspected
placed on mother’s and admission. neonatal infection higher
chest after birth. Maternal: in standard CB group
Duration: As long as (p < 0.002). Admit to
Primary: site
possible throughout neonatal ward higher in
infection (≤6 weeks
the procedure. standard CB (p = 0.000).
postpartum)
Secondary: fever,
sepsis, antibiotic
treatment, blood
loss, death.
Initiation: Immediately Maternal: Comfort Median ANI was significantly
after birth (Range: (ANI index) and higher, reflecting maternal
2–14 min, Mean: 4min) pain (self-report), comfort, at end of ISSC than
Duration: Until the recorded before before (p = 0.034).
end of the surgery ISSC and at end of No difference reported in
(Range: 4–40 min, SSC holding. maternal pain measured
Mean: 21 min) before and after ISSC.
Initiation: Immediately • Maternal: Administration of analgesic
after cord cut. • Primary: Analge- and anxiolytic medication
Duration: Continued sic or anxiolytic not significant at the
through recovery, if given in the OR, p < 0.05 level.
possible. recovery, and Women were more
postpartum. likely to breastfeed initially
• Secondary: (p = 0.0001) and exclusively
at discharge (p = 0.0001)
Breastfeeding
after ISSC.
initiation and
exclusivity at
discharge.
Initiation: Immediately Maternal: Pain Time to first opioid adminis-
after birth. (total tramadol tration not significant.
Duration: Maintained used after CB & Oxytocin levels significantly
for at least 10 min. self-report at 48 hr higher in ISSC and breast-
after CB); oxida- feeding group (p = 0.003).
tive stress (serum Higher postoperative
draw before spinal oxytocin correlated with
and 15 min after lower TOS (r = -0.986, p <
closure). 0.001), lower OSI (r = -0.970,
p < 0.001), and higher
TAS (r = 0.899, p < 0.001).
September/October 2020
 Maternal stress and oxytocin. Crenshaw et al. (2019),
Kollmann et al. (2017), and Yuksel et al. (2016) exam-
ined physiologic aspects of maternal stress associated
with cesarean birth. Crenshaw et al. found lower levels
of maternal salivary cortisol (sC) overall (p = 0.003), in
the OR (p = 0.021), and 2 hours later (p = 0.017) for
mothers who held their newborns in intraoperative SSC.
Kollmann et al. (2017) compared sC and salivary
alpha-amylase (sAA) levels in mothers receiving early
intraoperative SSC with those receiving late SSC after
cesarean closure. They reported no significant difference
in maternal levels of sC between groups. A significant
increase in sAA was found in mothers prior to initiating
intraoperative SSC when compared with those who did
not initiate SSC intraoperatively (p < 0.004). Although
this finding indicates an increase in mothers’ stress, it is
unclear if this is a positive or negative stress, thus larger
scale studies are needed.
Yuksel et al. (2016) examined the impact of intraop-
erative SSC and breastfeeding on levels of maternal serum
oxytocin. Postoperative levels of oxytocin in maternal se-
rum were higher in mothers who received intraoperative
SSC compared with mothers offered breastfeeding 1 hour
after cesarean birth (p = 0.003). They also reported a neg-
ative correlation among SSC and maternal measures of
oxidative stress. Specifically, higher levels of postoperative
oxytocin were highly correlated with lower postoperative
total oxidant status (TOS) levels (r = -0.986, p < 0.001),
lower oxidative stress index (OSI; r = -0.970, p < 0.001),
and higher total antioxidant status (TAS; r = 0.899, p <
0.001) in mothers who received intraoperative SSC com-
pared with mothers who waited 1 hour after birth to initi-
ate breastfeeding. These data suggest intraoperative SSC
and breastfeeding increase oxytocin and may stimulate
TABLE 2. DESCRIPTION OF QUALITATIVE STUDIES (N = 3)
First Author Design and Sample
and Setting
Bertrand (2020) • Phenomenological (N = 13)
• Interview via Facebook chat at average
Alabama, United of 21.3 months after birth
States • Mothers self-identified into study
• Maternal mean age 31.6 years, 64.3%
unscheduled CB, 38.5% scheduled CB
Frederick (2016) • Medical ethnography (N = 11)
• Observation and interview in hospital
Texas, United • Purposive sampling
States • Maternal age 23–38 years, 39–42
weeks GA; elective CB
Stevens (2019) • Ethnography, data from larger study (N = 21) Initiation and Duration:
• Interview at 6 weeks postpartum
Australia • A portion of mothers experienced ISSC
• Maternal age: 18–40 years, planned CB
Note. CB: cesarean birth; GA: gestational age; ISSC: intraoperative skin-to-skin contact.
September/October 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
maternal antioxidant production after cesarean. Yuksel et
al. reported intraoperative SSC paired with breastfeeding
and the effects of each were not differentiated.
Surgical outcomes. Site infection, blood loss, total
surgical time, and admission of more than 4 days were
examined by Posthuma et al. (2017). They reported no
significant differences between the two groups examined
retrospectively for site infection, total surgical time, or
maternal blood loss. Duration of hospital stay was sig-
nificantly greater in mothers who did not hold their baby
in intraoperative SSC (p < 0.001). No further explana-
tion was offered for this finding.
Neonatal Outcomes
Temperature. Kollmann et al. (2017), Narayen et al.
(2018), and Posthuma et al. (2017) found no significant
differences in neonatal temperature between those held
in intraoperative SSC and those who were not. Crenshaw
et al. (2019) reported lower temperatures in newborns
being held in intraoperative SSC in the OR (p = 0.029),
but noted all temperature readings remained within an
acceptable range. Billner-Garcia et al. (2018) found more
newborns were warmer (56%) following intraoperative
SSC than cooler (44%).
Apgar scores. Apgar scores at 1 minute and 5 minutes
were similar across groups (Crenshaw et al., 2019; Greg-
son et al., 2016; Kollmann et al., 2017; Posthuma et al.,
2017). Narayen et al. (2018) found lower Apgar scores
in newborns not held in intraoperative SSC (p = 0.02),
but noted this finding was not of clinical concern due to a
few low scoring outliers requiring respiratory assistance
within this group.
Oxygen saturation and heart rate. Four studies con-
sistently measured oxygen saturation of the baby (Ban-
ISSC Initiation Findings
and Duration
Initiation and Duration: Themes: Concerns
Not specified. and Expectations:
I just want to hold my baby;
Experience: It made me okay
with cesarean birth, My baby
felt safe, calm, and at home.
Initiation: Themes: Mutual Caregiv-
After 5 min Apgar score ing, Father’s Influence, and
Duration: Continued Cesarean Environment
until mother or
neonate desired ces-
sation. Range: 12–62
min, Mean: 33 min.
Themes: I want our baby,
Not specified for this Disconnected when separated
data set. from baby, Want to explore
my naked baby, I want my
partner involved, It felt right
MCN 301
 Previous reviews have examined use of early skin-to-skin
contact between mother and baby after cesarean birth, but
have not highlighted the impact of intraoperative cesarean
Shutterstock
skin-to-skin contact.
calari et al., 2016; Crenshaw et al., 2019; Kollmann et
al., 2017; Narayen et al., 2018), three of which exam-
ined heart rate over time (Bancalari et al.; Crenshaw et
al.; Kollmann et al.). Crenshaw et al. (2019) reported
no significant differences for heart rate or oxygen satu-
ration overall between groups. Other researchers noted
finding expected physiologic rise in heart rate and oxy-
gen saturation over the first 10 minutes of life for all
newborns, but no significant differences were reported
between groups.
Bancalari et al. (2016) included a group of newborns
born vaginally. They reported oxygen saturation signifi-
cantly higher over the first 10 minutes of life in newborns
born vaginally compared with those born by cesarean or
held in intraoperative SSC (p < 0.01). When comparing
only babies born by cesarean, no significant differences
were found between those held in intraoperative SSC and
those who were not.
Safety. Gregson et al. (2016) described two occurrences
of unexpected respiratory collapse in newborns experienc-
ing intraoperative SSC. In these cases, a wrap garment was
used to assist SSC, each baby required respiratory support,
and both made full recoveries. One of the two newborns
was diagnosed with an underlying disease process.
Admission to Neonatal Intensive Care Unit. Study
findings were mixed on admission to the neonatal in-
tensive care unit (NICU). Posthuma et al. (2017) found
newborns who did not experience intraoperative SSC
were more likely to be admitted to the NICU than those
who did (p = 0.000). Newborns held intraoperatively
SSC newborns less likely to have “suspected infection”
(p. 160) defined as treatment with antibiotics regardless
of culture results (p < 0.002). In contrast, Narayen et al.
(2018) reported increased NICU admissions of newborns
in the intraoperative SSC group (p = 0.03). They note
intraoperative SSC newborns were monitored for oxygen
saturation more frequently than the control group and
believed this led to increased provider intervention. No
associated respiratory morbidity or hypothermia was re-
ported in the intraoperative SSC group (Narayen et al.,
2018). Gregson et al. (2016) found no significant differ-
ences in NICU admissions between groups.
Breastfeeding Outcomes
Three studies examined effects of intraoperative SSC on
breastfeeding (Crenshaw et al., 2019; Gregson et al.,
302 volume 45 | number 5
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
2016; Wagner et al., 2018). Wagner et al. (2018) reported
women who experienced intraoperative SSC were more
likely to initiate breastfeeding (p = 0.0001) and continue
exclusively breastfeeding their baby at discharge (p =
0.0001). Neither Crenshaw et al. (2019) nor Gregson et
al. (2016) found significant differences in breastfeeding
rates between groups at any time-point. Crenshaw et al.
attributed this finding to the similar breastfeeding teach-
ing and encouragement received by both groups during
the hospital stay. Gregson et al. noted a potential “con-
tamination” (p. 22) of the control group, resulting from
lengthy periods of SSC from recovery and beyond.
Qualitative Experiences
Qualitative work of Bertrand and Adams (2020), Fred-
erick et al. (2016), and Stevens et al. (2019) sheds light
on the maternal experience of intraoperative SSC and
mothers’ desire for it to be offered as standard practice
after birth. Themes and quotes from the articles highlight
mothers’ feeling that holding in intraoperative SSC is
natural and fulfils an intense longing to “know” and ex-
plore their newborns right away. Mothers felt the intra-
operative SSC intervention “made them okay” (Bertrand
& Adams, 2020, p. 55) with the cesarean mode of birth
by offering them a more natural experience and sense
of control (Bertrand & Adams; Frederick et al., 2016).
Mothers believed that the intraoperative SSC holding ses-
sion benefitted breastfeeding initiation (Frederick et al.;
Stevens et al., 2019) and deepened the bond shared with
their baby (Bertrand & Adams; Frederick et al.; Stevens
et al., 2019).
Importance of a support person’s presence during the
cesarean birth was commonly reported. Mothers wanted
to have their partners witness and be actively involved
in the intraoperative SSC. Although mothers’ focus re-
mained primarily on their newborns, they commented
on their partner’s presence during intraoperative SSC as
playing a profound role in establishment of a new famil-
ial bond (Frederick et al., 2016; Stevens et al., 2019).
Discussion
This systematic review captures the current state of the
science on intraoperative SSC for mother and baby.
Results indicate intraoperative SSC is a safe, benefi-
cial, and highly desirable intervention for mothers and
newborns experiencing cesarean birth. Separation of
September/October 2020
the mother and baby immediately after cesarean birth
has been implicated as a significant source of stress
(Buckley, 2015). Intraoperative SSC has the potential to
ameliorate this stress. This review included three stud-
ies in which researchers measured stress biomarkers
in maternal and neonatal serum and saliva. Research-
ers reported increased regulation of physiologic stress
response systems as evidenced by decreased levels of
biomarkers associated with physiologic stress response
(OSI, sC, TOS) and increased neuroendocrine products
associated with stress buffering (TAS). Exposure to high
levels of physiologic stress can impact hypothalamic-
pituitary-adrenal axis regulation that may impact risk
for maternal mood disturbances and newborn develop-
mental pathways resulting in lasting changes associated
with increased risk for disease later in life (Duthie &
Reynolds, 2013). Our findings indicate intraoperative
SSC immediately after birth may protect mother and
baby from neuroendocrine responses associated with
the stress of cesarean.
Researchers have called for more study on the impact
of SSC on maternal cesarean pain (Stevens et al., 2014).
An explanation for the potential of SSC to reduce pain
is the mother’s longing to hold and know her baby cou-
pled with higher levels of oxytocin during intraopera-
tive SSC. Emerging research finds oxytocin may modu-
late pain in animal models (Li et al., 2020), but the role
of oxytocin in reducing pain associated with cesarean
birth is unclear. Five studies within this review investi-
gated intraoperative SSC and maternal pain and anxiety
resulting in no significant differences reported at the p <
0.05 level. This lack of significant findings may be due
to underpowered samples of pilot studies (Crenshaw et
al., 2019; Kollmann et al., 2017; Vamour et al., 2019)
or due to the regional anesthesia received during cesar-
ean birth. Further research, in larger prospective con-
trolled trials, is needed to identify the potential use of
SSC as an intervention to decrease perinatal and post-
partum pain.
The newborn transition period is a time of rapid adap-
tation to extrauterine life. Skin-to-skin contact is known
to offer stability to the baby during the immediate period
following birth (Crenshaw, 2014; Moore et al., 2016).
Use of intraoperative SSC did not hinder newborns’
physiologic adaptation when measured by temperature,
Apgar score, oxygen saturation, and heart rate. Few dif-
ferences were reported between newborns who received
intraoperative SSC and those who did not.
Studies in this review repeatedly reported use of SSC
during cesarean closure to be a safe and feasible inter-
vention. It is important to note, however, Gregson et al.
(2016) included two cases of unexpected respiratory col-
lapse in neonatal participants, both of whom recovered
fully. Previous reports of unexpected respiratory collapse
in newborns held in SSC can be found in the literature
(Andres et al., 2011; Colson, 2014; Fleming, 2012) and
bring to light concerns about safe implementation of in-
traoperative SSC. Cesarean birth does not allow the baby
the same stressors as vaginal birth and, when coupled
September/October 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
with placing the baby in the prone position after cesarean
birth and the lack of space on the mother’s chest during
the surgical procedure (Colson; Ma et al., 2015), there is
potential for respiratory morbidity in the baby. Appro-
priate nurse staffing and active monitoring of mother and
baby during intraoperative SSC are imperative for safe
care. Current staffing guidelines recommend one nurse
in continuous bedside attendance for each patient (AAP
& American College of Obstetricians and Gynecologists
[ACOG], 2017; Association of perOperative Registered
Nurses [AORN], 2019; Association of Women’s Health,
Obstetric and Neonatal Nurses [AWHONN], 2010;
Feldman-Winter et al., 2016). This level of nurse staff-
ing should continue during the 2-hour immediately post-
partum recovery period (AAP & ACOG; AWHONN;
Feldman-Winter et al.).
Intraoperative SSC holding is empowering for the
mother, supports maternal role attainment, enhances
breastfeeding, and provides a sense of control over the ce-
sarean birth experience. Mothers felt strongly about their
desire to share intraoperative SSC with their newborns
and their voices should not be ignored. This sentiment
is echoed in intraoperative SSC quality improvement
reports capturing mothers’ quotes on the irreplaceable,
first moments shared with their newborns and increased
satisfaction scores (Moran-Peters et al., 2014; Sundin &
Mazac, 2015). Skin-to-skin contact during cesarean birth
is becoming increasingly known in the public through so-
cial media and the sharing of stories. Mothers want to
experience intraoperative SSC with their newborns and
are willing to find a different hospital and provider for
the opportunity to do so (Bertrand & Adams, 2020).
Limitations and Future Research
A limitation of this review is the small number of arti-
cles included and the wide range of outcomes of interest.
Therefore, some findings are based on reports of one or
two articles. Several researchers used a retrospective de-
sign that incorporates limitations associated with tempo-
ral ambiguity. Prospective studies were limited by small
samples, loss of data, and contamination of the control
group. Future research on the effects of intraoperative
SSC on maternal surgical outcomes, such as blood loss,
would benefit our understanding of how intraoperative
SSC affects the mother during, and after, the surgical ce-
sarean procedure.
Clinical Implications
All stable mothers and newborns should be offered the
opportunity to practice SSC immediately after birth.
This irreplaceable moment has long not been available
for mothers having cesarean birth. Nurses, midwives,
physicians, and those in clinical leadership roles have the
power to support and implement this beneficial practice
for their patients.
Barriers to intraoperative SSC include inadequate
nurse staffing, overcoming current operating room cul-
ture, and procedural uncertainties (Balatero et al., 2019).
Nurses are encouraged to use implementation reports
MCN 303

CLINICAL IMPLICATIONS
• All alert and stable mothers and newborns should be
offered intraoperative SSC during cesarean birth.
• Intraoperative SSC provides mothers and babies
known physiologic benefits of SSC and supports
mothers’ desires to hold and know their newborns
immediately after birth.
• Nurses should maintain vigilance in monitoring the
baby throughout the intraoperative SSC session, and
into the postpartum period, to support healthy transi-
tion to extrauterine life.
• Nurse leaders should make sure their units are
supported in following nurse staffing guidelines that
recommend one nurse in continuous bedside atten-
dance for each patient throughout the cesarean and
during the 2-hour immediate postpartum recovery
period (AAP & ACOG, 2017; AORN, 2019; AWHONN,
2010; Feldman-Winter et al., 2016).
• Resources, such as previously published implementa-
tion projects, can be helpful in planning for a practice
change to incorporate intraoperative SSC. Educational
seminars and interprofessional work-groups may
serve as additional facilitators to change.
containing procedural flow recommendations (Hung &
Berg, 2011) and nursing standards of practice (Boyd,
2017) for intraoperative SSC. Other facilitators to prac-
tice change include educational seminars and forming in-
terprofessional work-groups to discuss institutional bar-
riers and formulate implementation plans. The goal is to
offer safe, evidence-based, family-centered intraoperative
SSC for all stable mothers and newborns.
Acknowledgment
Licia Clowtis’ work reported in this publication was sup-
ported by the National Institute for Nursing Research,
NIH T32 NR015433. The content is solely the respon-
sibility of the authors and does not necessarily represent
the official views of the National Institutes of Health.
First and second authors have none to declare. ✜
Dr. Anitra Frederick is a Clinical Assistant Professor, The
University of Texas Health Science Center (UTHealth),
Houston, TX. Dr. Frederick can be reached via email at
anitra.frederick@uth.tmc.edu
Dr. Tena Fry is APRN for Women’s and Newborn Ser-
vices, The Children’s Hospital of Oklahoma City, OK.
Dr. Licia Clowtis is Postdoctoral Fellow, Case Western
Reserve University, Francis Bolton College of Nursing,
Cleveland, OH.
The authors declare no conflicts of interest.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/NMC.0000000000000646
304 volume 45 | number 5
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
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