Implementing the practice of early skin-to-skin contact among infants ≥34 weeks gestation born by caesarean section: A quality improvement study

Abstract

Background

Separating mothers and newborns after caesarean delivery prevents early skin-to-skin contact (SSC), despite WHO recommendations to initiate SSC immediately at birth. Early SSC promotes breastfeeding success, enhances thermoregulation, reduces maternal postpartum complications, and fosters bonding. In our hospital, SSC was not practiced after caesarean deliveries, prompting this quality improvement (QI) initiative.

Methods

Conducted in the operating theatre of a tertiary care hospital over 4 months (January–April 2024), with a 3-month sustenance phase. Inborn infants ≥34 weeks gestation and ≥1.8 kg delivered via caesarean section, with good tone and breathing at birth, were eligible. Sequential Plan-Do-Study-Act (PDSA) cycles were implemented to introduce SSC within 5 minutes of birth, aiming for ≥90% compliance. Interventions included staff training, SSC protocol development, operating room reorganization, and maternal support during recovery.

Results

SSC compliance increased from 0% at baseline to 100% by cycle 4. Breastfeeding initiation improved from 48% to 95%, and exclusive breastfeeding at discharge increased from 77% to 97%. Deferred weighing and vitamin K administration rates increased from 10% to 100%.

Conclusion

Through systematic interventions, we achieved and sustained 100% SSC compliance for caesarean births. This study demonstrates that with a structured, multidisciplinary approach, SSC can be successfully integrated into caesarean delivery routines, potentially enhancing maternal-infant bonding and early breastfeeding initiation.

Keywords

caesarean section newborn care PDSA cycles quality improvement skin-to-skin contact (SSC)

Introduction

Separating mothers and newborns post-caesarean often prevents immediate Skin-to-skin contact (SSC), despite WHO’s recommendation to begin SSC at birth for all deliveries, including caesareans, and continue for at least 1 hour to promote early breastfeeding.¹ SSC improves newborn outcomes, reducing morbidity when initiated early.² It also enhances breastfeeding rates in caesarean-born infants, matching those of vaginal births.³

Skin-to-skin contact is linked to successful first lactation, longer breastfeeding duration up to 4 months, and a higher chance of exclusive breastfeeding for 6 months.^4,5 Exclusive breastfeeding significantly reduces the risk of morbidity and mortality in the first 6 months of life, including neonatal mortality.^6–8 Additionally, SSC improves thermoregulation, and reduces weight loss at discharge.^9,10 For mothers, SSC enhances birth experience, induces uterine contractions, reduces postpartum haemorrhage risk, shortens placenta expulsion time, lowers postpartum depression incidence, and strengthens maternal-infant bonding.¹¹ Evidence suggests that while one-third of newborns do not initiate breastfeeding within the first hour, most do by 90 minutes, making prolonged SSC until a full breastfeed (at least 90 minutes) a more effective clinical indicator.³ Additionally, many preterm infants are born by caesarean section, making SSC even more crucial for this vulnerable group. Studies show that even infants born <34 weeks gestation can achieve high exclusive breastfeeding rates with SSC.¹²

In India, no national data on SSC is available. Reports suggest that only 15% of vaginally delivered babies receive early SSC.¹³ SSC is not routinely practiced during caesarean deliveries in most hospitals, despite the rising rate of caesarean sections. At our institution, 80–90% of stable infants born via vaginal delivery receive SSC, but this is not the case for caesarean deliveries. To address this, we launched a quality initiative to increase SSC rates at birth for infants delivered by caesarean section.

Methods

The study was conducted at IPGMER & SSKM Hospital, Kolkata, a tertiary care teaching hospital with 83 maternity beds and a 100-bed NICU (30-bed Level 4, 70-bed Level 2 Special Care Nursery). The hospital serves a low- to middle-income population across West Bengal, one of India’s largest eastern states. The unit cares for both inborn and outborn infants, handling referrals for various neonatal conditions. In 2024, the hospital recorded 6796 live births, with 2993 inborn and 770 outborn admissions to the neonatology department. The unit handles 550–800 deliveries per month, 70% of which are caesarean sections. The study was conducted in the operating theatre from January to April 2024, followed by a sustenance phase from May to July 2024.

Eligible participants were inborn infants ≥34 weeks gestation, ≥1.8 kg, with good tone and breathing at birth. Mothers had to be alert or recover post-anaesthesia. Exclusions included infants with congenital malformations, those needing ventilation, and maternal complications during or post-surgery (Figure 1).

Figure 1.

Algorithm for implementing skin-to-skin contact during caesarean section.

Baseline data were collected December 15–31, 2023, showing a 0-minute SSC baseline. The intervention aimed to initiate SSC within 5 minutes of birth for at least 1 hour, with a target of increasing SSC rates from 0% to 90% in 3 months using Plan-Do-Study-Act (PDSA) cycles (Video).

A QI team was formed, led by the neonatology consultant, including OT nursing in-charge, nursing staff, paediatric and obstetric trainees, and the head of the obstetrics department. The team was briefed on the evidence supporting early SSC and its absence in our unit. Regular meetings addressed concerns and identified obstacles, documented using fishbone analysis (Figure 2). Frontline OT nursing staff, led by the motivated sister-in-charge, played a key role in driving the initiative.

Figure 2.

Fish bone analysis.

Initial analysis identified: (1) No standard hospital policy, (2) lack of awareness, (3) inadequate support for post-caesarean SSC in recovery, and (4) routine mother-infant separation, prioritizing weight and vitamin K administration. Multiple PDSA cycles were used to test and refine the interventions (Table 1). The team met at the end of each cycle to review data and discuss the next steps.

Table 1.

PDSA cycles.

PDSA cycle	Plan	Do	Study	Act
Cycle 1: Raising awareness and training on SSC post-caesarean	Identify barriers like lack of awareness, resistance among staff, concerns about aseptic technique, and infant temperature stability. Educate staff, address concerns, and train on SSC benefits. Provide education to mothers and families to create individualized care plans	Conducted training sessions, workshops, and hands-on demonstrations. Organized special sessions for postgraduate trainees through emails, flyers, and workshops to ensure widespread awareness	Feedback revealed improved understanding of SSC benefits but lingering concerns about safety and workflow impact	Adjusted training materials to address safety protocols and clarify team roles. Scheduled follow-up sessions, reducing resistance and improving understanding
Cycle 2: Developing and implementing an SSC protocol for caesarean deliveries	Create a Standard Operating Procedure (SOP) for SSC initiation within 5 minutes of birth. Delay non-urgent tasks like weighing and vitamin K administration until after SSC. Emphasize infant monitoring during SSC	Implemented SOP, distributed to staff with a checklist. Emphasized immediate SSC, delayed cord clamping, and deferred non-urgent tasks	Initial increase in SSC rates observed. Some trainees prioritized weighing and vitamin K due to habits. Lack of infant monitoring caused some cases of positive pressure ventilation and NICU admission	Revised SOP to emphasize delaying non-urgent tasks and prioritizing infant monitoring. Reinforced staff training to improve compliance with the SOP
Cycle 3: Modifying OT and recovery room setup for SSC	Rearrange OT and recovery room setups to facilitate SSC. Create a conducive environment with adequate space for SSC and introduce special OT gowns to support safe infant placement	Reorganized the OT and recovery room. Designated an SSC zone with clear markings. Introduced special OT gowns to simplify infant placement	Observations showed improved SSC initiation rates. Minor issues with equipment placement near the SSC area were noted, requiring adjustments	Refined the OT layout and SSC zone markings. Ordered additional gowns to ensure availability. Workflow and comfort during SSC initiation improved
Cycle 4: Enhancing post-caesarean Support for mothers in recovery area	Assign staff to assist mothers in recovery with SSC due to limited mobility and pain. Ensure SSC continuation for at least 1 hour by providing dedicated support	Assigned dedicated team members (nurses or postgraduate trainees or female attendant) to support mothers in SSC positioning and monitoring during recovery. Provided staff training to handle minor adjustments without interrupting SSC	SSC duration improved significantly. Mothers reported positive experiences, but some staff felt overburdened with the added responsibilities	Adjusted staffing schedules to balance workloads. Additional training improved recovery area staff competence. SSC compliance improved, and mothers expressed high satisfaction with the support provided

SSC: skin-to-skin contact, PDSA: Plan-Do-Study-Act, NICU: Neonatal Intensive Care Unit, EBF: exclusive breastfeeding, OT: operating theatre, SOP: Standard Operating Procedure, WHO: World Health Organization, BF: breastfeeding.

Results

Baseline data from December 2023 showed no early SSC among 112 eligible newborns. A total of 1085 eligible mother-newborn dyads participated in the study, with 289, 267, 278, and 251 newborns in PDSA cycles 1–4, respectively. SSC compliance progressively improved, with 87 (30.1%), 151 (56.6%), 200 (71.9%), and 251 (100%) newborns receiving SSC in cycles 1–4, respectively (Table 2, Figure 3). Breastfeeding initiation increased from 48% to 95%, and EBF at discharge increased from 77% to 97% by cycle 4, demonstrating the sustained impact of SSC integration on early feeding practices. Deferred weighing and vitamin K compliance improved from 10% to 100%, ensuring SSC was prioritized without delaying essential newborn care. Sequential PDSA cycles led to significant improvements in SSC compliance. After a 1-month gap, a 3-month sustenance phase maintained 100% SSC compliance, confirming the successful integration of SSC into routine post-caesarean care. Unfortunately, among preterm infants, four required discontinuation of SSC within the first 10 minutes due to apnoea and desaturation, necessitating transfer to the resuscitation table and positive pressure ventilation.

Table 2.

PDSA cycles with compliance rates.

PDSA cycle	Number of eligible newborns	Newborns receiving early SSC	Compliance rate (%)	Breastfeeding initiation (%)	Exclusive breastfeeding at discharge (%)
Cycle 1	289	87	30.1	48	77
Cycle 2	267	151	56.6	65	81
Cycle 3	278	200	71.9	80	88
Cycle 4	251	251	100	95	97

Figure 3.

Line diagram for SSC compliance rate.

Discussion

This study shows that implementing early SSC for caesarean-born infants in a tertiary care hospital is achievable with systematic interventions and teamwork. Baseline data revealed no early SSC, highlighting a gap from WHO recommendations. Through PDSA cycles, compliance reached 100% by the fourth cycle and was sustained for 3 months, demonstrating the potential of a well-executed quality improvement initiative to make enduring changes in clinical practice. Additionally, breastfeeding initiation rates improved from 48% in cycle 1 to 95% in cycle 4, while exclusive breastfeeding at discharge increased from 77% to 97%, reinforcing the impact of SSC on early feeding practices.

The challenges addressed in each PDSA cycle highlight the complexity of changing practices in high-stakes settings like operating theatres. Barriers such as lack of awareness, absence of protocols, and logistical issues were systematically targeted in each cycle.

The first PDSA cycle focused on raising awareness and training healthcare providers, resulting in a modest increase in SSC compliance. However, anaesthetists, surgeons, and OT nurses initially resisted due to concerns about safety, sterility, and workflow disruption. Targeted training, strengthened safety protocols, and interdisciplinary discussions effectively addressed these concerns, securing their support for SSC implementation. The second cycle introduced a structured protocol, clarifying roles and prioritizing SSC over routine tasks like weighing and vitamin K administration, with added emphasis on infant monitoring. Aligning with AAP NRP guidelines, ongoing assessment of newborn breathing, tone, activity, colour, and temperature was emphasized.¹⁴ Compliance improved significantly, demonstrating the critical role of standardized protocols in addressing barriers and changing practice patterns effectively.

The third PDSA cycle tackled logistical barriers by reorganizing the OT and recovery room and introducing specialized gowns, facilitating SSC implementation and boosting compliance. The fourth cycle improved maternal support in recovery by assigning designated nursing staff. In some cases, a female attendant was allowed to assist the mother, ensuring comfort and sustaining SSC for at least 1 hour post-operatively. This intervention extended SSC duration and enhanced maternal satisfaction and bonding, as reflected in positive feedback from mothers. A mother shared her experience, saying: “The doctors placed my baby on my chest immediately—I never expected it! It felt so good, like I could protect and hold my baby close.”

The 3-month sustenance phase showed 100% SSC compliance post-intervention, supported by continuous monitoring and staff reinforcement. Empowering OT and recovery nurses with ownership of the SSC protocol ensured success. This project offers a replicable framework for improving SSC rates in resource-limited, high-demand settings.

Our QI project aligns with the study by Maria et al. at Dr. RML Hospital, New Delhi, which demonstrated an increase in early SSC rates from 0% to 80% within 8 weeks for caesarean deliveries.¹⁵ Maria et al. achieved 100% SSC compliance through staff sensitization, formal policies, and procedural adjustments. While their initiative also targeted early breastfeeding, our focus was on sustaining SSC, with plans to track breastfeeding rates in future cycles.

Several similar studies from developed countries have been conducted on this topic, often in similar settings, with comparable interventions and varying durations.^3,12,16–19 Li et al. found that in a study across 150 hospitals, SSC lasting less than 30 minutes had no significant impact on exclusive breastfeeding at discharge compared to no SSC, while SSC lasting 60–90 minutes resulted in the highest EBF rates at discharge. This aligns with our findings, where sustained SSC contributed to improved breastfeeding initiation and EBF rates.³ Similarly, Hoang et al. demonstrated that early essential newborn care, including SSC, significantly improved neonatal outcomes, reducing morbidity and increasing breastfeeding success.² These findings highlight the importance of not just initiating SSC but ensuring an adequate duration of at least 60–90 minutes for optimal breastfeeding outcomes. Thompson and Maeder’s (2021) initiative at a U.S. Midwest tertiary hospital demonstrated a significant increase in SSC after caesarean sections, rising from 30.4% to 61.3% for SSC lasting at least 15 minutes within the first hour after birth. This was achieved through nurse education, the incorporation of SSC into the interdisciplinary time-out (TTO) protocol, and the implementation of a new SSC guideline.¹⁶ Brady k. et al. emphasizes the importance of interprofessional collaboration in implementing skin-to-skin contact during caesarean deliveries.¹⁷ Key factors for success included data analysis and educational support among disciplines, reinforcing the need for teamwork in promoting SSC practices effectively in the operating room setting.

Few studies have examined the benefits of extending early SSC beyond the standard 60 minutes, with positive findings.^3,12,20,21 Extended SSC (60–90 minutes) is associated with higher exclusive breastfeeding rates at discharge and improved neonatal morbidity outcomes.^3,12 Additionally, research indicates that while the global indicator defines breastfeeding initiation within 60 minutes, the median time for natural initiation is 55 minutes, with over a third of newborns initiating after 60 minutes. Based on this, extending SSC to at least 90 minutes may further optimize breastfeeding outcomes. We maintained SSC for up to 60 minutes. Sustaining quality improvement initiatives is challenging due to staff workload, distractions, and the difficulty of keeping motivation high over time.

Another important aspect is that 70% of deliveries in our unit are by caesarean section (CS). As a tertiary care teaching hospital and statewide referral centre, we handle high-risk pregnancies, leading to a higher CS rate. However, we recognize this issue and are actively working to reduce unnecessary CS deliveries.

Limitations

The study focused on SSC compliance without evaluating outcomes such as temperature stability, maternal bonding, or mental health. Maternal pain perception and comfort during SSC were also not assessed, which could impact feasibility and satisfaction. Staff awareness of being monitored may have temporarily increased compliance, potentially differing under routine conditions. Additionally, the study was conducted in a single tertiary care hospital, limiting generalizability. As a pre-post intervention study, it is susceptible to temporal changes that could have influenced outcomes. However, no major changes in hospital policies or staffing occurred during the study period that would have significantly impacted SSC practices. Potential measurement challenges include observation bias, interrater variability, and day-night staffing differences, which may have influenced SSC compliance rates. Future studies should incorporate blinded assessments and standardized training to minimize these biases.

Conclusion

Early SSC for infants born via caesarean is feasible and sustainable in a tertiary hospital setting. Using a structured QI approach, we overcame logistical and cultural barriers, achieving 100% compliance. Multidisciplinary teamwork, standardized protocols, and ongoing monitoring were key to success. Future studies should assess SSC’s long-term effects on breastfeeding and bonding and explore its implementation in other settings.

Supplemental Material

Footnotes

ORCID iDs

Md Habibullah Sk

Saugata Chaudhuri

Bijan Saha

Authors’ contributions

Dr. Md Habibullah Sk – Conceptualized and designed the study, led the implementation of the PDSA cycles, analyzed data, and drafted the manuscript. Dr. Sougata Chowdhury – Contributed to the study design, facilitated training sessions, supported protocol development, and reviewed the manuscript for intellectual content. Dr. Bijan Saha – Led the implementation of the PDSA cycles, assisted in data collection, contributed to protocol adjustments in the operating theatre, and participated in manuscript revisions.

Ethical consideration

Each author approved the final version of the manuscript and agreed to be accountable for all aspects of the work.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

References

Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised baby-friendly hospital initiative: 2018 implementation guidance: frequently asked questions. Available: https://www.who.int/publications-detailredirect/9789240001459 (Accessed 24th September 2024).

Tran

Murray

JCS

Sobel

, et al. Early essential newborn care is associated with improved newborn outcomes following caesarean section births in a tertiary hospital in Da Nang, Vietnam: a pre/post-intervention study. BMJ Open Qual 2021; 10(3): e001089.

Mannava

Murray

JCS

, et al. Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational -study. BMJ Glob Health 2020; 5(8): e002581.

Mikiel-Kostyra

Mazur

Bołtruszko

. Effect of early skin-to- skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatr 2002; 91: 1301–1306.

Thukral

Sankar

Agarwal

, et al. Early skin-to-skin contact and breast-feeding behavior in term neonates: a randomized controlled trial. Neonatology 2012; 102(2): 114–119. DOI: 10.1159/000337839.

Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Lancet 2000; 355(9202): 451–455.

Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials. Lancet Global Health 2016; 4(4): e266–e275.

Sankar

Sinha

Chowdhury

, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta‐analysis. Acta Paediatr 2015; 104(S467): 3–13.

Moran

Thomson

Moran

, et al. The content, experiences and outcomes of interventions designed to increase early skin-to-skin contact in high-income settings: a mixed-methods systematic review. Acta Paediatr 2023; 112(2): 200–221.

10.

Srivastava

Gupta

Bhatnagar

, et al. Effect of very early skin to skin contact on success at breastfeeding and preventing early hypothermia in neonates. Indian J Publ Health 2014; 58(1): 22–26.

11.

Moore

Bergman

Anderson

, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2016; 11(11): CD003519.

12.

Tran

Luu

, et al. Factors associated with high exclusive breastfeeding rates among preterm infants under 34 weeks of gestation in Da Nang, Vietnam: a retrospective cohort study. J Glob Health 2023; 13: 04121.

13.

Sinha

Pujara

Patel

, et al. Improving early initiation of skin-to-skin contact among newborns delivered vaginally at a tertiary care hospital: a quality improvement study. Journal of Neonatology 2024; 38(2): 167–173.

14.

Weiner

Zaichkin

(eds). Textbook of Neonatal Resuscitation. 8th ed. American Academy of Pediatrics.

15.

Maria

Shukla

Wadhwa

, et al. Achieving early mother-baby skin-to-skin contact in caesarean section: a quality improvement initiative. Indian Pediatr 2018; 55(9): 765–767.

16.

Thompson

Maeder

. Initiative to increase skin-to-skin contact in the operating room after Cesarean. J Obstet Gynecol Neonatal Nurs 2021; 50(2): 193–204.

17.

Brady

Bulpitt

Chiarelli

. An interprofessional quality improvement project to implement maternal/infant skin-to-skin contact during cesarean delivery. J Obstet Gynecol Neonatal Nurs 2014; 43(4): 488–496.

18.

Bingham

Boisvert

Webb

, et al. Feasibility of AWHONN's immediate and continuous skin-to-skin nursing care quality measures. J Obstet Gynecol Neonatal Nurs 2019; 48(5): 516–525.

19.

Holmes

McLeod

Bunik

. ABM clinical protocol #5: peripartum breastfeeding management for the healthy mother and infant at term, revision 2013. Breastfeed Med 2013; 8: 469–473.

20.

Marín Gabriel

Llana Martín

López Escobar

, et al. Randomized controlled trial of early skin-to-skin contact: effects on the mother and the newborn. Acta Paediatr 2010; 99(11): 1630–1634.

21.

Robiquet

Zamiara

Rakza

, et al. Observation of skin-to-skin contact and analysis of factors linked to failure to breastfeed within 2 hours after birth. Breastfeed Med 2016; 11: 126–132.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB