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Home About Evidence Giving Birth Based on Best Evidence Can Hospitals Keep Moms and Babies Together after a Cesarean? © by Rebecca Dekker, PhD, RN, APRN of www.evidencebasedbirth.com In my previous article on skin-to-skin care after a C-section, I wrote that skin-to-skin care after a C-section has many benefits for moms and babies. However, I have come to realize that women cannot do early skin-to-skin if they are routinely separated from their babies after a C-section. In order to do early skin-to-skin, women and newborns must stay together—a process known as “couplet care.” However, the vast majority of women are separated from their babies after a C-section. Why don’t more women and babies receive couplet care? Is it possible for hospitals to make the switch from routine separation to routine couplet care after a Cesarean? Keep reading to find out. What is the history of mother-infant separation after birth? Separation of human mothers and newborns is unique to the 20-21st centuries and has been a complete break from natural human history. In the past, infant survival depended upon close and virtually continuous mother-newborn contact. The practice of routinely separating mothers and newborns started around 1900. At the time, most women received general anesthesia that made them and their babies incapable of interaction after birth. Because mothers couldn’t care for their babies, hospitals created central nurseries to care for newborns, and infants were typically separated from their mothers for 24-48 hours. Separation from parents was also meant to ”protect” infants from maternal illnesses (Anderson, Radjenovic et al. 2004). In her book Hypnobirthing, Marie Mongan described her experience of being separated from her infant in the 1950′s… My head was held as the ether cone was forced onto my face. That was the last I remembered. I awakened sometime later, violently ill from the ether, and was informed that I had “delivered” a beautiful baby boy, whom I would be able to see in the morning…. My husband saw our son only through the window of the nursery for the next five days, as no one was allowed to visit when “the babies are on the floor.” Our family bonding was nonexistent. When did things begin to change? In 1961, Dr. Brazelton published a classic study showing that general anesthesia was harmful to newborns (Brazelton 1961). As a result of his research, more people began to move away from using general anesthesia during birth, which resulted in mothers and infants being more alert—and capable of interaction—immediately after birth (Anderson, Radjenovic et al. 2004). In addition, most mothers who give birth by Cesarean receive regional anesthesia instead of general anesthesia, so these mothers, too, are usually alert after giving birth. Furthermore, in the past 30 years, an abundance of research evidence has shown that when mothers and babies are kept close and skin-to-skin after birth, outcomes improve (Moore, Anderson et al. 2012). It is very important for you to understand that when researchers study human mother-newborn contact, keeping mothers and babies together is always considered the “experimental” intervention. In contrast, when researchers study other non-human mammals, keeping mothers and babies together is the control condition, while separating newborns from their mothers is “experimental” (Moore, Anderson et al. 2012). What is routine practice today? Although most mothers now are capable of taking care of their babies after birth, and despite the fact that research overwhelmingly supports couplet care—hospital practices have been very slow to change. Routine separation of moms and babies during the recovery period still happens at 37% of vaginal births in the U.S., with rates ranging widely from state to state. In Alaska, only 5% of babies are separated from their mothers after a vaginal birth, while in Mississippi, 81% of infants are separated from their mothers after a vaginal birth. (Centers for Disease Control, 2010) After most C-sections, babies are sent to the nursery for routine care Credit: brettneilson How often are women separated from their infants after a C-section? Separation of mothers and infants is very common after a surgical birth or C-section. In the U.S., 86% of women who give birth by C-section are separated from their babies for at least the first hour (Declercq, Sakala et al. 2007). With more than one-third of U.S. women now giving birth by Cesarean, this means that a substantial proportion of mothers and babies experience a critical delay in bonding, skin-to-skin contact, and breastfeeding. Research shows that most of the time when babies are separated from their mothers after a C-section it is so that the hospital can provide routine mother/baby care in separate rooms—not because the babies need any kind of special care (Declercq, Sakala et al. 2007). When infants are brought to the nursery while their mothers recover separately, it is common for a nurse to give a first feeding of formula (Elliott-Carter and Harper 2012). What are the benefits to keeping moms and babies together? To read the benefits of keeping moms and babies together, please refer to my article on skin to skin care after a Cesarean. To summarize, babies who receive couplet care—in other words, who stay with their mothers and receive early skin-to-skin care—are 2 times more likely to be exclusively breastfeeding at 3-6 months, compared to babies who receive routine hospital care. You can read about the many other benefits of early skin-to-skin care—and the potential harms of separating mothers and babies— here. Submitted by an anonymous reader. Dads can do skin-to-skin care, too. Everyone can stay together. Are there any potential harms to keeping moms and babies together after a C-section? It is important to know that some mothers may not capable of independently caring for their infants immediately or for several hours after a C-section. For example, if mothers received strong sedatives, are nauseous, or were sleep-deprived for many hours before the Cesarean, then they may need supervision or assistance in caring for their newborns. The mother’s level of awareness and her ability to remain awake when caring for and feeding infants must be assessed and closely monitored by nursing staff, especially when a Cesarean follows a prolonged labor or when sedative drugs have been given (Mahlmeister 2005). In this case, then the father or partner can do skin-to-skin with the infant. Is it possible for hospitals to keep moms and babies together after a Cesarean? Yes, it is possible for hospitals to keep moms and babies together after a Cesarean. Two different hospitals have published quality improvement reports describing how they switched from routine separation to routine couplet care after C-sections (Spradlin 2009; Elliott-Carter and Harper 2012). As both reports were very similar, I will focus on the most recent article by Elliott-Carter (you can read the article for free in its entirety here). Why did this hospital decide to make the change? In 2011, nurses at Woman’s Hospital in Baton Rouge, Louisiana, led a switch from routine separation after Cesareans to couplet care—keeping moms and babies together. The hospital was motivated to change for several reasons, including a desire to stay competitive with other hospitals and repeated requests from patients to not be separated from their babies. Perhaps most compelling, the staff felt it was simply “not fair” that moms who gave birth vaginally were allowed to stay with their babies, while moms who had C-sections were automatically separated from their babies. The C-section rate at Woman’s hospital was 40%, and they have more than 8,000 births per year. So making this change affected 3,200 families per year. How did the hospital change to couplet care? Amy and her baby Kareanna stayed together after a Cesarean– which allowed them to do very early skin-to-skin care. One of the first things the hospital did was put together a leadership team to plan for the change. This team included nurse managers from labor and delivery, postpartum, and newborn care, as well as pharmacists and materials management. The team communicated the plan to other groups (such as medicine). One of the team’s challenges was finding a large enough space where moms and babies could recover together after a C-section. They ended up choosing overflow labor and delivery suites that were big enough to accommodate the couplet. They also modified the existing recovery room (PACU) so that it could be used in case the overflow rooms were full. They moved curtains to make each patient’s space big enough for both mothers and infants to recover together, and they put a radiant warmer for the infant in each recovery space. The team had to make several other small changes. They had to train the recovery (PACU) nurses in neonatal resuscitation. They made sure baby blankets were placed in the heated blanket warmer, and that appropriate medications for both moms and babies were stocked in each room. Perhaps most importantly, staff made a commitment to provide care where the mothers and babies were, instead of always taking the baby away to the nursery. Although taking the baby to the nursery was easier and more convenient for the staff, they realized that keeping the couplet together was best for moms and babies. It took about 6 weeks from the beginning of this process until couplet care was fully implemented. How did it go for this hospital in Louisiana? In the first year after starting couplet care, the percentage of infants who were separated from their mothers dropped from 42% to 4%. Nurses stated that everyone was extremely satisfied with the change—including staff, physicians, and mothers. Nurses report that mothers are able to have skin-to-skin contact earlier, and that the first breastfeeding session goes smoother. Inspired by the bonding they witnessed between moms and babies, nurses decided to delay administration of erythromycin ointment and the vitamin K shot until after the initial breastfeeding. As nurses from the Woman’s Hospital said, “If a hospital that delivers 8,000 infants annually can find a way to decrease the separation of mothers and newborns, concerned nurses everywhere should be able to implement this type of care.” In the ideal situation, mom does skin-to-skin in the operating room. The family is never separated during recovery. So what is the bottom line? Evidence has shown that it is possible—and best practice—for moms and babies to stay together after a Cesarean. If a hospital staff member tells a mother that it is “impossible” for her to stay with her baby after a C-section, that statement is false. Making the switch from routine separation to couplet care can be done—some hospitals have already done so. Although couplet care may be more inconvenient for staff in the beginning, in the end, keeping mothers and babies together after a Cesarean is what is best. Mothers who want to do very early skin-to-skin care and interact with their babies after a C-section should talk with their providers about this mother-friendly and baby-friendly practice. Moms should also talk with their anesthesiologists to make sure that they do not receive sedative drugs unless medically necessary, as these drugs may make some women incapable of early interaction with their newborns. If you want to read more medical research: These researchers describe how critically ill babies had a higher mortality rate when they were separated from their mothers after birth. These researchers found higher cortisol (stress) levels in infants who were not held by their mothers after birth. In this small randomized, controlled study, researchers experimented with keeping moms and babies together after a C-section. Not surprisingly, the intervention group had earlier first mother-baby contact, earlier first feedings, and more stable infant body temperatures. In this landmark study, researchers randomly assigned mother-baby pairs to several different groups, and one of the groups was assigned to mother-baby separation for 2 hours after birth. Mothers and babies who were separated for 2 hours had a higher risk of poor maternal/infant bonding outcomes one year later. This risk was not alleviated by “rooming in” for the rest of the hospital stay. In this animal study, baby horses were separated from their mothers for one hour after birth (intervention group) or left undisturbed with their moms (control group). The separation increased the risk for poor bonding and other adverse social outcomes. If you Google “hospital”, “couplet care” and “cesarean” you will find a large number of hospitals that already offer this mother-friendly and baby-friendly practice. If you liked this article, you may be interested in: The evidence for skin-to-skin care after a C-section An interview with a mother who received skin-to-skin care in the operating room An interview with a mother who asked to stay with her baby after a Cesarean An interview with a doula who helps facilitate skin-to-skin care in the operating room Our Facebook album with amazing photos of skin-to-skin care in the operating room References: 1.Anderson, G. C., D. Radjenovic, et al. (2004). “Development of an observational instrument to measure mother-infant separation post birth.” J Nurs Meas 12(3): 215-234. 2.Brazelton, T. B. (1961). “Effects of maternal medication on the neonate and his behavior ” Journal of Pediatrics 58: 513-518. 3.Centers for Disease Control (2010). Maternity Care Practices Survey. Accessed online January 5, 2013. 4.Declercq, E. R., C. Sakala, et al. (2007). “Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International.” J Perinat Educ 16(4): 9-14. 5.Elliott-Carter, N. and J. Harper (2012). “Keeping mothers and newborns together after cesarean: how one hospital made the change.” Nursing for Women’s Health 16(4): 290-295. 6.Mahlmeister, L. R. (2005). “Couplet care after cesarean delivery: creating a safe environment for mother and baby.” J Perinat Neonatal Nurs 19(3): 212-214. 7.Moore, E. R., G. C. Anderson, et al. (2012). “Early skin-to-skin contact for mothers and their healthy newborn infants.” Cochrane Database Syst Rev 5: CD003519. 8.Spradlin, L. R. (2009). “Implementation of a couplet care program for families after a cesarean birth.” AORN J 89(3): 553-555, 558-562.