#74 Skin-to-Skin in the OR: Our Take to Promote Science

Sarah Lavonne: Hi, I’m Sarah Lavonne, and I’m so glad you’re here. Here at Bundle Birth, we believe that your life has the potential to make a deep, meaningful impact on the world around you. You as a nurse have the ability to add value to every person and patient you touch. We want to inspire you with the resources, education, and stories to support you to live your absolute best life, both in and outside of work. Don’t expect perfection over here. We’re just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together. By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.

I need you to stick around for this episode, because I think at face value, you’re like, “Oh my God, skin to skin, what can we talk about skin to skin?” We are here to tell some stories. We’re here to make it real fun and exciting and interesting along the way, because skin to skin in general, whether that be for a vaginal birth or in a cesarean, is such an important experience for our clients. Yes, I’m calling them clients at times, because there is that whole movement of not calling them patients because they’re not sick, and if they’re going skin to skin, that means that the patient is stable and the baby is stable.
Skin to skin is one of those things that has evolved over the last years, I’ll say in my career. I know it has in Heidi’s career as well, so we’ll talk about that. It is one of those things that I think is really underrated and has such incredible physiologic benefit that we sort of just brush off to the side, and I’m still hearing at births that like, “Do you want me to just take the baby to the warmer quick and get you a weight or give the eyes and thighs?” I’m like, “No, we don’t.”
First of all, that was their preference. Second of all, we are the protectors of that space. If the baby and patient, meaning client, are stable, then they really should be receiving skin to skin as much as possible in the first hour, hours, days of life. We’re going to talk all about skin to skin in this episode and where it came from and what the benefits are, and also about implementing change. I’d love for us to talk about particularly the skin to skin in the OR thing, because that is the more recent practice change. I know back in the day when I first started, it was not standard to do skin to skin, even in a vaginal birth.

Heidi: Yes, totally wasn’t. When we decided that we were going to talk about this, I was like, oh, good. I love an excuse to like go down a rabbit hole on anything. Little fact, I actually wrote my senior nursing research paper on kangaroo care.

Sarah: Cutie.

Heidi: I had to write it for whatever class you were in at the time. It had to be based around that. I was in critical care and I was like, oh, I know I’m never going to do ICU. I’m like, okay, at least I still get to like dabble in that.

Sarah: Cute.

Heidi: Yes. I did it. I did it on kangaroo care. I should see if I still have that paper somewhere.
Sarah: I know I wouldn’t have any of those. I did mine on birth control. It was boring.
Heidi: Skin to skin. It was first developed in the 1970s by Dr. Edgar Rey Sanabria in Columbia.
Sarah: Developed? We were doing skin to skin for all of time. You mean like in a hospital setting?
Heidi: In a hospital setting.
Sarah: Okay.
Heidi: Really seen as beneficial. Particularly, it was called like kangaroo care because this doctor worked in a NICU. They were noticing, wow, our little babies are having such better outcomes and able to be discharged sooner with doing kangaroo care. That was the first movement within the hospital because obviously we’ve been holding our babies forever.
Sarah: Can you define kangaroo care for those that are wondering?
Heidi: Yes. Kangaroo care–
Sarah: Our resident expert kangaroo care genius.
Heidi: That’s where you are skin to skin with the baby, where the baby is on your chest, their skin is touching your skin and then they’re covered over by blankets. Like how an actual kangaroo have their babies in the pouch. This is our makeshift pouch on the outside.
Sarah: I think it’s interesting that this came from Colombia because, and you mean Colombia, South America?
Heidi: Yes. Not like–
Sarah: Missouri, right?
Heidi: No.
Sarah: Colombia, because if you didn’t know this already, I did grow up in South America in Ecuador. We were neighbors to Columbia. In general, Ecuador, meaning South America doesn’t have the greatest C-section rates and they’re pretty medicalized to date. I think that’s a fun fact. Shout out to South America for helping out.
Heidi: I know. It’s cool. Anyway, that was the first thing that was like, yes. Why do we want to do this? It’s supposed to improve thermal regulation within the baby, which if we understand what happens, with the baby, they aren’t able to regulate their temperature like we are. They rely off of that brown fat metabolism to generate heat. If they don’t have a lot of that, then they’re looking at other sources to maintain their heat, like by burning off their glucose levels and their sugar drops. When their sugar drops, then they’re going to get cold and it starts this whole cascade of events. They found, oh, having them skin to skin where they have that conduction going. It’s conduction, right? Going on where–
Sarah: Conduction, convection, radiation. It’s conduction. Yes.
Heidi: Okay. I was right. You looked at me for a second, but I think you were just looking at me.
Sarah: No, I was.
Heidi: Where they’re touching something, they’re going to match whatever temperature that is. The same thought is if they’re being touched by something that’s really cold, they’re going to be cold. We’re regulated at around 98.6, give or take. The baby’s going to stay that too. Then they’re not going to have to tap into other resources. Also helps with their oxygen levels and their cardiovascular stability as they’re adapting to extra uterine life.
Also helps the pregnant person with their hormonal responses and starting that cascade of oxytocin and it really promotes bonding. It’s just going to bleed into all these other areas that we work so hard to promote. If they’re wanting to do breastfeeding, it really improves breastfeeding rates and milk production. It just makes a world of difference.
Sarah: It is to me one of the most, and this is something just to note in OB that I think is an interesting component to our specialty, is there are so many things that we can do that are “natural”, where it goes back to physiologic birth, right? That when we don’t over-intervene, that we can actually support the body to do what it knows how to do by actually working less and trusting the body and recognizing and understanding the physiology helps us clinically support what’s best for the patient, for the baby, and then ultimately for their transition postpartum or intra-extra uterine life.
It’s so simple. When I talk to families about it, I’m it helps to regulate your baby’s temperature. It helps with their stress response. They know your heart. They know your heartbeat. They know your voice. They’re warm. They can eat if they want. Your areola smell amniotic fluid. When they’re ready to like, “Familiar.” Then they can feed themselves. It helps with all of their reflex stimulation, which they have to go through a whole 12 steps before they’re ready to feed. Everything you just said, it’s all of that. We know this is not just a theory of maybe it’s good for them. It is the best thing for them if they’re not needing resuscitation.
For us in our nursing care, we have to protect that space. I know that might be more of an inconvenience to our jobs. I get it. You have a job to do, but also we didn’t start out doing skin to skin in all cases. Then I remember when that was starting to be implemented, I was actually a part of that because I did my whole breastfeeding certification stuff in the process and they were becoming baby friendly. It was a whole movement. I remember even just doing meds or doing vitals on the patient was like a, “What? How would I do that? How would I perform an assessment?”
“Well, a stethoscope.” It’s awkward to make any change. Really, that is the best thing for both patients that you have in front of you. The other thing I just want to point out, again, if you’ve been a part of this universe and this movement of nursing through the Bundle Birth community, one of our missions is, and what keeps me going, and I say this in Physiologic Birth and I’ve said this in various other podcast episodes, but we genuinely believe that the care that we give at birth impacts the future of our world.
I say that and it’s like, okay, drama, but I think skin to skin is one of those links in terms of changing the future because what we know outside of obstetrical research is that the number one indicator for, what I’m calling “life success”, that means you are not a criminal. That means that you can carry a job, that you have a brain and a smart one that is educated and grows and gets a job and makes your own family someday and contributes back to society. The number one indicator of life success is establishing secure attachment with a caregiver.
We know that begins in pregnancy, but that the opportunity or what we will call here bonding happens the biggest, the highest level of oxytocin they will ever experience in their life happens right after birth and oxytocin is one of our bonding hormones. They are primed for bonding, they’re primed for bonding through the labor, they’re primed for bonding right after birth, which is a hormonal adaptation to survive the species, to keep our species going so that they can feel bonded. If we are interrupting that skin to skin and that bonding time, we are potentially, and I know this is a little bit of a stretch, but it’s not, that we are potentially impacting the future of our world.
This is where, I’m definitely a soapbox that we can talk about, but you think about our NICU parents where they miss that bonding, they miss that skin to skin time, it is the thing that they talk about forever. Every birth debrief I’ve done, every family I’ve talked to, my baby went to the NICU, the hardest part was bonding, I had a hard time with this, it led to X, Y, Z, there is a separation and that’s probably why a Colombia doctor, was seeing that the kangaroo care was helping because as mammals, we are primed for that connection, it’s what we’re created for and when we have it, that’s where all of our physiology aligns.
Even into some of the fascia research, if you’ve taken Physiologic Coping, if you haven’t, it is online, you can take it for a little bit longer, but our fascia reorganizes, which is our communication network between all of our organ systems. It reorganizes with connection. This is scientific, this is a big deal and again, it’s the Michelle O’Dent quote that I quote in Physiologic Birth, we are interrupting, shoot, I’m going to mess it up, it’s we are interrupting the normal physiology without knowing what we’re doing and it was much more articulate than that, but the idea is that we don’t realize how much we’re getting in the way of these processes that are meant to work and that have lifelong impact.
Heidi: Yes, and really the best outcomes happen when we don’t intervene in normal and being able to hold and connect with your baby is normal. For those of you number nerds out there, like me, I know that there are some out there, we’re going to put some numbers behind it. In babies that underwent skin to skin, 80% of infants that were skin to skin were able to keep stable temperatures during skin to skin. That’s such a high percentage.
Breastfeeding success, there was a study found that 90% of infants who had immediate skin to skin were able to establish breastfeeding in the first hour compared to 30% who [crosstalk]. Who either did not have skin to skin or it was started a lot later. Also NICU admissions, they were able to be discharged 5 to 10 days sooner in preterm infants.
Sarah: Whoa, do you know how much cost savings that would have. If you’re an administrator, this should be a policy for sure, for that alone. I saw a TikTok of somebody that was talking about their NICU bill and it was $375,000.
Heidi: That’s insane. How does anybody pay for that?
Sarah: Also for crying, babies who were skin to skin found in this particular study cried 43% less. That’s wild. While they’re skin to skin or skin to skin in the first hour?
Heidi: While they’re skin to skin. They’re calm, they feel comfortable. They like boundaries because they’ve been inside a uterus and then all of a sudden, they’re out in this world with no boundaries. That’s why they do so well with swaddling too.
Sarah: I tell that to my families when they’re saying– In fact, literally this last birth I was at, they just text me the day after and he’s like, “Somewhere in there got it in my head that we should leave her in the bassinet but she’s crying so much.” I’m like, “What? No. Just put her skin to skin. Let her be skin to skin forever. All the time.” Then he texts me the next day. He’s like, “When you gave me that tip.” I’m like, “It’s not really a tip, but I’ll take it. Credit. “All of a sudden the whole world changed for us,” and they’ve had no issues. Imagine because they were just ripped from their safety and now you put them back where they’re safe, they need anything that mimics the womb.
Heidi: Then this little statistic here is particularly for low birth weight infants, it decreased their mortality rates by 50% if they were able to implement kangaroo care into their treatment. That’s wild. That’s so big. That’s a flip of a coin.
Sarah: Metaphorically, you talk about how we need each other. We are not meant to be separate and alone.
Heidi: No. Then on the side of the pregnant person, it’s found to reduce postpartum depression by 40%. That’s so significant and it also increases their confidence. They’re three and a half times more likely to be exclusively breastfeeding after three months. Just plays into that bonding piece and building on that connection. We can link the studies that these are from if people want to read them, but I just think that’s just so interesting and powerful. We talked a little bit about how we’ve noticed it change in our practice. When you started nursing, at what point did you start noticing a change in doing skin to skin?
Sarah: Very early.
Heidi: [crosstalk] Pretty normalized.
Sarah: Yes, very early. Probably only been a nurse for six months and then that all was going on. It came with the same six is the new four movement. Were you around for that too? We wore buttons, huge buttons that said six is the new four, but it was a part of a practice change that now six is the new four, meaning six centimeters is active labor, not early labor anymore. I remember, I came from a much more medicalized hospital with residents and it was a teaching hospital. There was all the opportunity for learning was the goal. I remember it being a fight with the pediatric team, a fight with the NICU team.
Luckily, we had leadership support in that. It was a thing that we were doing together. Honestly, I will say, it probably took less time of a change than some of the other practice changes that I’ve been a part of in my career because once you realize that, one, you can assess the baby on the skin and two, it’s better for them, they’re less fussy and you just go on with your life. I think it makes your job easier than having to manage a baby in a warmer and then they want it and the parents are asking about, it’s just let them be.
Heidi: Yes, totally. I clearly remember, it was probably about the same amount of time into my career, maybe six months or so. Within that first year, we started adding this piece of paper because we were very much selling the paper at that time to their admission folder that was this gold sheet. It was called the Golden Hour. It clearly explained why they should be skin to skin for the first hour and really talked about if people are coming to visit you, no one should be holding the baby except for you during that first hour or your partner, if you are unable to or whatever.
I remember that being a huge shift and people being like, “I told my mom, she can’t come until the two-hour mark because we don’t want to interrupt that golden hour.” That’s a vivid memory, which it seemed like such a big deal and thing that we were implementing at that time. Then now it’s just something that we do and you don’t think of, but now it’s more weird. If they’re not skin to skin, especially my facility, we’re very pro into that, even in the operating room.
Sarah: I remember when it was a note on a birth preference, that came in our birth plan. People would be like, I really want the golden hour. They’re feeling they need to advocate for the golden hour or skin to skin. Whereas now, again, I think, and we see that on a birth plan and you’re like, okay, cool. We know, that’s normal. You don’t need to tell us, we’ll do that.
Heidi: I know. I was looking up, I was like, okay, who coined the term golden hour? Where did that really come from? I asked ChatGPT because I’m always like they can all find this stuff, but they said they couldn’t find, that there’s no specific person that it’s coined to, but it’s heavily linked to World Health Organization and Academy of Pediatrics, American Academy of Pediatrics.
Sarah: Interesting.
Heidi: They started recommending that be a normal part of practice in the ’80s and ’90s.
Sarah: Stop.
Heidi: Yes. I double fact-checked it. It’s crazy how, if you think about that, so that’s 35, 45 years ago, whatever, how long that really took for things being like, this is what you should be doing to when it’s actually implemented into practice. It made me think, man, what are some things out in research now that are like, you should do this and we’re not doing it yet. It’s just like, there’s always growth happening within the field. I just find that so fascinating.
Sarah: I think anything physiologic birth that, when we started the physiologic birth class, close knee pushing was like, what? It was this outrageous thing or pushing in any other position or anything from the physiologic birth classes is what’s in my head. That’s what I want to see the practice change, and mind you, it’s not a change because we’ve been working at this for all of time physiologic birth has existed and the concepts behind how the body works, but us really coming back to a place where we’re thinking through the lens of physiologic birth, that’s one of my dreams.
Heidi: Yes, where that’s just a standard, where that can be something on someone’s birth plan that we’re like, we already do that.
Sarah: Right. Of course, we’re going to turn you, or of course, I’m going to assess your fascia, or of course I’m going to consider the various things that could be interrupted. I was at this recent birth I was also at, the nurses all knew who I was and it was a thing, which worked out for the patient’s sake because they were like, “Here, do whatever you want. Show us what you’re doing. Tell me why you’re doing it.” This baby was perfectly positioned, perfectly. I was like, “Oh, we’ll turn her. I am so confident that the position is exactly where we need it to be. There’s other things going on. This patient is the first C-section I’ve had this year.”
We did all the things and she needed a C-section. I think it was partially a power thing, but also, I think it was an actual CPD, which is one of the indications for a C-section that we’re not going to be able to adjust the fact that the pelvis doesn’t fit the baby. The baby was engaged correctly. There was no asynclytism. The position was perfect, but they kept being like, “Well, what can we do to turn the baby?” I’m like, “I’m not trying to turn the baby. I’m trying to help some of the other reasons why the baby is not coming down.” Stuff like that, that I’m like, us thinking through that lens. For us to all be on the same page about it, it’d be so nice.
Heidi: Yes.
Sarah: Skin to skin, though, in the OR would be another one. I will say that I have definitely seen more. At my hospital, I was a part of the committee that was the first people to enforce a policy around it and a process and get everyone involved and roll it out as a thing. Prior to that, they had said that we could, in our nursing practice, as long as we could stay with the baby, we could try it, but it was up to our nursing judgment. What we would normally tell the patient was, if a nurse is available to be exclusively dedicated to skin to skin in the OR, then we can do it.
Otherwise, if staffing doesn’t allow, we can’t do it. Let me remind you, that’s something, but I was the one that was like, “Let’s try it. I don’t know, it’s weird. I’m uncomfortable.” Then there was the other concern of cold baby because the OR is colder than our labor rooms historically and has to be. We did a whole project around bringing skin to skin to the OR and found that the number one indicator of cold baby was if mom was cold. If the patient’s cold, the baby will be cold, which imagine that’s how the thermoregulation works.
Heidi: Induction.
Sarah: Yes. We put in all of these different efforts like the heating blanket, not like a K-pad, but we got this special OR.
Heidi: Kind of like the bear hugger type thing?
Sarah: They do a bear hugger too, but it goes under. It’s a blanket that’s almost a warm blanket under the patient. It might be a K-pad, it might be water. I don’t know. It’s this very thin, warm thing so that they’re being warmed from the bottom and then warm blankets and then bear hugger. Bear hugger usually would come off for skin to skin because it’s so cumbersome. Then they would take a maternal temperature as well as a, who’s taking a temp in the OR? maybe they have the sticker on their head, but otherwise, they take a maternal temperature and a baby temperature. Once we did that and we made sure and we went above and beyond to make sure that the mom was warm, we never had cold babies.
Heidi: Yes, that’s so awesome. I don’t know that we have a policy like that at our place, but it’s just like we definitely push for it. I will talk to the patient before about what that will look like. I also like to give them the disclaimer too, because sometimes they don’t feel good in the OR and they do want to hold their baby but when you’re puking or you feel dizzy or horrible, you don’t want to, but then you feel so much guilt saying that you don’t want to hold your baby.
We talked through that and I’m like, “If you’re not feeling well and you don’t want to, at that point, just tell me. It doesn’t make you a bad parent or anything. We’ll focus on getting you feeling better. Then we’ll put the baby right there with you. Then the baby can be with your partner.” We work pretty closely with anesthesia to have a little space where we can be. We make sure their gown is unbuttoned and then shove all these big warm blankets around them and then button up their gown and then another blanket over. Then I really heavily involve the partner and help them support and hold onto the baby because their arms are outstretched and they can’t really–
Sarah: It’s awkward. It’s very awkward. Then they’re looking down in the head’s like here and they’re like, “I can’t really see their face,” but they’re there. I think I always love to remind them too that one minute matters. I also remind nurses that as well, that one minute really matters to these families. This last case, we went to the OR, she did skin to skin in the OR. At one point she was like, “Ooh, I don’t feel good.”
We were like, “No problem, we’ll take the baby.” She still talks about the skin to skin being so important. She didn’t have it forever. It doesn’t have to be an hour uninterrupted, but it’s something. That it’s the effort to soothe that counts. We talk about that in our trauma classes that the key to preventing trauma is the effort to soothe that counts, even in hard scenarios.
Heidi: Yes, I think that that’s so important. I remember a few years ago, I had this one patient that had this, she came in, had this very traumatic thing happen where we pretty much had to just rush her immediately back to the OR. She ended up being under general for the C-section. The kiddo came out and the kiddo was totally fine, but she was still completely asleep. I remember, I was like, “We’re putting the kiddo skin to skin.” I asked her partner for her phone and recorded all of these videos skin to skin. Then ask anesthesia.
I’m like, “Can we just leave her in here a few minutes longer before we roll her over to PACU.” My coworker was with me and we’re like, she’s still not really aware or awake yet, but we’re like, “You’re hugging your baby right now even though you don’t know it.” We took all these pictures, all these videos and stuff so that she would have that moment, even if she may not really remember it because I just think that’s that’s so important.
That’s the one thing that when you’re pregnant that you look forward to those first few moments with your baby and when things go different and you don’t have that. Obviously, it wasn’t the ideal situation, but we still tried to do that for her. Anyways, she goes to PACU to be recovered and everything. Then five months later, she shows up to our unit and me and the same coworker are working that day. She asks to see us. She’s like, “You guys were the nurses when I had my baby. I don’t know if you remember me, but I was looking through my phone and I hadn’t seen these photos and videos because I was feeling so upset that it had been quite a while before I really got to be awake and hold my baby.
I had all these videos that you guys took of me and my baby and holding my baby, even though I didn’t know.” It was just like, that’s why we do what we do. It was annoying that we were slowing things down. That’s where you got to take it back to, who is this for? It’s not for us. It’s for them that are going to be these memories that they’re going to have forever, whether they’re good or bad. Just taking control of the things that we can have control over.
Sarah: 100%. It reminds me, oh, it reminds me so much. Yesterday at a team, we have this thing called Focus Forward. Basically, it’s a component of a team meeting that we could never get to. We made it its own session of basically professional development, brainstorming, working, dreaming, whatever, where it’s space for our team to come together and discuss certain things. What we’ve been discussing is what does it mean to bundle birth our customer? Really one of my dreams, and one of the things we teach is this idea of you guys seeing them, helping them feel safe and soothing their nervous system.
Then what came out of Cancun the first time around was we want them to feel seen, safe, soothed, and spoiled. That has become a company value. In the efforts of defining what it means to bundle birth our customer, we know that to bundle birth a patient has become a verb. That feels so exciting to me and so hopeful for our profession. We talked about what are the characteristics of a bundle birth nurse? I’m going to read you some of them because Heidi, I feel what you did in that example is so everything that I dream for the future of the world and this community, what a example of a bundle birth nurse.
We said going above and beyond being a lifelong learner, someone who doesn’t take the norm for granted and basically says it’s like this now, but it doesn’t have to be this way. They advocate, they’re engaged, they’re informed, they assume the best in people, they take ownership of their role, they’re culture’s changing pioneers. They see individuals or people not just as scenarios or cases. They understand the person and their experience and stories that informs their experience and their care. They listen really well. They’re willing to make time and take time.
There’s above average communication coupled with emotional intelligence and intuition. They honor this huge moment and respect this huge moment in the family’s lives. They’re hopeful that things can get better. They’re always getting better in their practice in life. They’re hungry and curious to be the best. They’re critical thinkers. They work probably the hardest because they hold themselves to this standard of excellence, not in a braggy way, but it’s just what they do because they choose to do the right thing.
There’s a whole other list that I’m not going to keep reading, but I think about what, imagine our current state of our profession and then think of those nurses that embody some of those characteristics. I know for me, I want to be that nurse that whether I get the accolades or not, and luckily you did, that actually sees the human being in front of them and knows that this is one of the biggest moments of their life. One of the ways that we can rob them of that experience is by doing eyes and thighs in the warmer versus on skin to skin. It’s so simple.
There’s so many of these little baby interventions. In fact, that’s part of the conversation that came up talking about what are those little baby things that we think don’t matter that matter so much. The one you’ve heard me say in physiologic birth is latch the damn door when you leave, I’m sorry. This last birth, my patient was talking about it. They’re like, “Why does she keep leaving the door open?” Here I am. I said something to her like, “Could you please close the door all the way?” Sure, she did. Then she kept leaving it unlatched.
I know that it’s not intentional, but we can hear people laughing. It’s interrupting her psyche. It makes you feel who’s listening to our conversation. It doesn’t feel you’re seen, safe or soothed. So often we think about, and I think about this episode going in or I’m like, “Don’t leave.” Because skin to skin is like, yes. Skin to skin is good for the baby and good for the mom but these are these seemingly small but hugely impacting things that we can be doing.
If you’re doing it, feel encouraged that you’re doing the right thing. Often I ask myself that question and hold myself to that standard of, well, what is the right thing? What if we just did the right thing? often, we’re thinking about the right thing for us rather than the right thing for the patient. With skin to skin, whether it be in the OR or in a vaginal birth, so long as there’s no complications, so long as they’re stable and for the most part they are, it is the right thing.
Heidi: It totally is. Yes, it may generate a little bit more work that you’re having to watch them closely, but it’s not about us. It’s about them. Even with kiddos that maybe have to be on a pull socks and stuff, it’s like, yes, you could have them on the pull socks in the warmer or you could have the pull socks on them and have them skin to skin. It’s just those little things that create big change that you don’t realize how much it’s impacting people, whether you get recognition for it or not.
It’s not about the recognition. I think at the end of the day, it’s your shift’s done and you’re going home being like, did I do all that I could have done for my patient? Did I do the right thing? Was I presented with these obstacles? Did I choose something based off of what was going to be easiest for me or what was going to be best for the patient? Sometimes those two things aren’t the same. Sometimes the hardest thing and the right thing are the same thing. We got to look at why we’re doing what we’re doing.
Sarah: For those of you that don’t do skin-to-skin in the OR, let’s just talk through your process. I think we might have different processes. It’ll be interesting to compare, but first and foremost, we want to check our policy. We don’t want to be doing anything against our policies and procedures. We want to follow the policy. If you don’t have a policy for skin-to-skin in the OR, what a beautiful leading change project because it probably just hasn’t come up yet. You need one, would be the goal.
What you might find is that you may actually have a policy that everyone’s saying, well, we can’t because it’s against policy. Then you look it up and you’re like, “Oh wait, hold on, we’re good here.” Know what your policy says and keep in mind that the patient preference also matters and safety also matters. We’re keeping that in the back of our mind without making excuses for I don’t feel safe. If you don’t feel safe, then find someone on your unit that can help you feel safer in helping with skin to skin in the OR. What’s your process, Heidi, when you do skin skin in the OR?
Heidi: Obviously, it’s first going to be dependent on are both the patients stable? Okay, we’re able to answer yes to both of those things. At my facility, we have a specific baby nurse or what we call the R nurse or resuscitation nurse that attends every delivery and we stay there the whole time during the OR. When the baby comes out, we are handed the baby. Then I always check with them because it’s not as easy to dry and stimulate them on the patient.
I’ll usually grab them, dry them off really good, grab a couple of blankets, dry them off, and then bring them right over and put them skin to skin. They’re still skin to skin within less than 30 seconds of being born, but just making sure that they’re getting dried off really well because they are more at risk for becoming cold in the OR. Then I’ll unbutton the gown, tuck the baby in there, put a big grown-up warm blanket over them, button up the gown, and then another blanket over.
I’ll try and make sure I turn the head so that the patient can see it, see the baby and the partner. I’ll turn the head specifically to one side and then I’ll guide the partner in how to hold on to the baby because the patient can’t really do that and it’s awkward. Then I’m just standing right there making sure that everyone’s positioned okay and comfortable and also checking in with the patient, making sure that they’re feeling okay because at times, they may start feeling a little bit panicked and they don’t feel they have control and they’ll be like, “Okay, I’m done right now.”
Just having someone there that they know so that it goes into one of those S’s of them feeling safe and secure. That’s how we do it. Then we generally will just leave them skin to skin the whole time until they’re closing up the last layer and we’re bringing the bed in. Then I’ll talk to them like, “Do you want us to quickly do meds right now as they’re moving you over onto your bed or do you want us to wait until we’re back in the room and the baby’s on you?”
I feel most of the time our patients are like, “Just do it really quickly in the warmer and then wrap them up,” because I feel a lot of people don’t to see that at first. They’re like, “I don’t want to see my baby be poked.” Then the disruption is very minimal. Then we’re wrapping them back up as they’re in their bed and then give them their baby back.
Sarah: Yes. I think the only thing I would add, because my process is very similar, I think is noting that because of the C-section, you’re not going full frog with the skin to skin. The skin to skin’s more horizontal across their chest. That was one of the things. When I was a part of the rollout for change on our unit, we did what’s called a Test of Change. We talk about it in our leading change class, but basically we did a cohort or own little mini study and tried to address all of the objections that our pediatric and NICU teams were having to us doing skin to skin in the OR, particularly tracking vital signs and patient, we would interview the patients whole thing anyway, regardless.
I was pulled from the floor to go to all of the cases in the operating room and assist to help teach the nurses about the system of the new practice change because also we have our routines, and you get in that OR and it’s like, it’s so normal and you don’t even hardly think about it. Whereas now you’re like, wait, when do I this and that? I was there helping them. One of the biggest things was the awkwardness of skin to skin when you’re in the OR of it being across the chest, almost above the boobs or across the boobs.
One of the things I would find was that there were layers between the skin and the patient that the gown got caught underneath, or they brought the baby over in the swaddle, the baby blankets, and they’d sort of unwrap and then tuck, but there’d still be something in between. To be clear, the best thermoregulation that happens, so long as maternal temperature is normal, is when you have the most surface area touching baby and parent. That was where I’d come and I would find and pull out the blanket from underneath and tuck a leg, and again, it might be awkward.
I usually would try to warn them that like, “You might not be able to see their face fully. You’ll see them in recovery, but they’re there and you can feel them. You can give them kisses. You can smell their yummy heads or whatever, and be nice and close,” but really paying attention to the surface area of skin actually touching the baby. We also would do a full set of vital signs.
I’d load up my pockets with the thermometer and with my stethoscope on, and I might even have my meds drawn, not drawn, depending on vitamin K, we’d have an ampule or it would come in the pre-loaded syringe and the erythromycin, throw them in my pocket and then do them actually skin to skin in the OR. I agree, some people, it was also just a lot, depending on how fast your providers go, there’s a lot going on and you’re like, “Oh shoot, I’m behind. I’ll do it in recovery.”
Heidi: Ours are pretty fast in how OR is set up. We definitely do vital signs like skin to skin. Sometimes I have done meds skin to skin in the OR, but it is awkward because you’re weaseling between the FAD and the IV pull. Yes, it’s a little bit of a thing. I’ve found more patients don’t want that when they’re in the OR, because it feels they’re like–
Sarah: There’s a lot going on.
Heidi: [crosstalk] the baby and then there’s these needles everywhere, but still just giving them that extra skin to skin makes such a difference.
Sarah: I would always be ready. I agree. The partner can help. We had a policy that you have to be observing the baby and be able to, if it starts to fall, catch the baby so it doesn’t actually fall. I remember too, remember meaning, I’m still aware of this, that being able to quickly, if the patient’s like, “I don’t feel good. I’m going to throw up,” or they’re hypotensive, that you can quickly reach in, grab the baby and bring the baby to the warmer. It’s sort of just being on guard, like having your gloves on. I will say, we did have really short cases and then we’d also have really long cases.
There were over 150 doctors at this hospital that had privileges. You just never knew. If you’re in there for an hour, at some point I’m like, “Let me get my meds done.” It feels a little less rush, but again, you’re using your judgment call for that because if it’s in and out, that’s not the priority, they will be okay. Do it later. Then, also, I think the other little thing is just paying attention to any leftover fluids. We also would dry off the baby first and give a good rub down, good, nice cry, good little look-see-loo. One of the conflicts that we had was whether or not to do a set of vital signs and get the five minute Apgar at the warmer.
That we had to fight tooth and nail for us to go with that quick, not even the one minute, within 30 seconds. If your baby needs resuscitation, you’re watching it and you’re like, “Okay, this is looking good.” Maybe they perk up and then you don’t put them skin to skin in that first minute. If they are crying and screaming and mostly pink already and great talk, we don’t need to wait the full minute. We fought for that one. Then also it was like, we will get a temperature, we will take the vital signs on the skin. It did require that planning ahead to get them there as quick as possible.
I will say from the patient perspective, what I hear all the time is, “It felt like an hour before I saw my baby and everyone else saw my baby before I did, and I carried and made this thing.” That’s really hard. Keeping that in mind of, at this last one, she didn’t require resuscitation, but she had a whole lot of secretions, a whole lot. They did do some suctioning before they brought her over. She’s real gurgly. Regardless, I sent the dad over and I sat with her and was like, “She has such dark hair. Oh my goodness, her little cute toes, she’s scrunching up her toes,” all the little things that like, who cares?
For them, they’re laying there staring at this bright light on their open abdomen and everybody else is now attending to the baby, include them in the process. Then I quickly ran over and took a picture and brought it back and was like, “Look how perfect she is.” She’s bawling and, “Oh my gosh, thank you.” It helped with that delay because it was probably three minutes before the baby came. It wasn’t that immediate. Her husband was over there with the baby at first. They just feel so left out. That’s where as much as we can, again, remember that there’s a human being in front of us, include them in the process, talk them through.
If there’s resuscitation needed, this goes for skin to skin or not, “They’re working on the baby, they’re in such good hands.” Notice there’s no cry, what do you say? I normally would just say, “They’re trying to figure out what’s going on.” I can’t also diagnose and I can’t really give an update. I’m like, “Your baby’s in such incredible hands, I’m right here with you, take some deep breaths, we’ll get an update soon,” but not forgetting the patient along the way, whether they go skin to skin right away or not. I agree that also setting those expectations of what it will be and if they ever opt out, great, no problem, we’ll do it again right away, as soon as possible.
Heidi: Yes, I think that’s so helpful to have a good policy like that in place where it’s just like, yes, there’s a way to do it. We’ve figured out what is the best safe way to do this. Really, if we even think back to what A1 staffing guidelines are, is before the baby can really be included in that couplet care, the mom has to be deemed stable. If they’re opened up on the OR table, they’re not considered stable at that point.
The nurse that’s responsible for the baby, you need to be watching the baby and being right there. Also them being skin to skin is not your ticket out to step away and do whatever you want.
Sarah: Do they ever go skin to skin with the partner in the OR?
Heidi: I don’t feel that happens as much. I feel it’s normally they’re skin to skin with the mom. Again, all of our providers are pretty fast.
Sarah: By the time you get them all set up, they’re like, “We’re wrapping up.” Yes. I know that’s definitely not common. We used to try and do that too. That was a part of our rollout that I think is real extra, so flexible.
Heidi: I think that would affect some of the the AOR and OR stuff that you have to follow because then they’d have to unzip their bunny suits.
Sarah: Yes, you prep them ahead of time. It would be mostly for our scheduled cases.
Heidi: Yes.
Sarah: I love talking to nurses from all over the place and getting to see nurses in practice. This also happens in mentorship calls too because we’ll start talking about this stuff and it’s just so fascinating to learn what other places do and what’s been normalized, what’s not normalized. I’m sure there’s lots of you listening that are like, “Wait a second, they do what? Wait a second. I’ve never done skin to skin in the OR. That’s actually happening?” Yes, it is. It is actually pretty normal, many places. For those of you that are thinking it’s not the norm, no, it’s not.
This is where I love. I love being a part of this community because it also helps us all get on the same page and be one community. We are one community, all trying to just have better outcomes and do the right thing and help our families have a better birth experience and walk away emotionally intact as well as physically intact. I know that all of you listening are here because you want that experience for them. Also side note, we want that experience for us. It feels better when we know that we’ve gone above and beyond and we’ve really impacted someone’s birth experience which is one of those markers on their timeline for the rest of their life.
If you want more from us, I really would suggest our mentorship program. If you are new to practice, new nurse, that’s going to be probably the program that I would guide you towards, especially in relation to all of these conversations but also if you’re experienced and you’re just needing a little bit of an uplift, is that a word? A little spunk in your step related to your job or you’re feeling really burnt out and just needing a fresh take, needing some new inspo, needing that community of other like-minded nurses to go on a journey with you.
That’s where our 12-month mentorship comes in. If you haven’t taken physiologic birth, that’s the foundation of your practice. You really need to be taking a physiologic birth class as a foundation but also there’s lots of free resources out there. Thank you for listening. We’re always here for you and we’ll drop our contact info in the show notes below so you can be in contact and we hope to see you in a future episode and in a future class sometime soon.
Heidi: Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you liked what you heard, it helps both of us if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head on over to bundlebirthnurses.com or follow us on Instagram.
Sarah: Now, it’s your turn to go and help your babies be skin to skin. Do something new, pay attention to your practice related to skin to skin and be that advocate for that experience for the families that we care for. We’ll see you next time.