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Running head: SKIN TO SKIN CONTACT DURING CESAREAN SECTIONS 1

Education on the Use of Skin to Skin Contact During Cesarean Sections

Katelyn Swanger

The Pennsylvania State University Harrisburg Campus

SKIN TO SKIN CONTACT DURING CESAREAN SECTIONS 2

Abstract

A review of literature was conducted to address the PICO question: in maternal-newborn dyads,

is immediate skin to skin contact post cesarean section as effective as usual care in promoting

infant stability, breastfeeding and maternal satisfaction. Significant findings of this review of

literature include newborn temperature regulation, decreased newborn stress, more effective

breastfeeding and positive maternal opinions with the experience. Nursing staff at the Holy Spirit

Birthplace were surveyed and educated utilizing the findings of the literature review. Analysis of

data obtained from pre and post education surveys indicates improved knowledge of the use of

skin to skin contact intra-operatively. Data on perceived barriers and necessary changes for

implementation of this practice were also collected. The implications of these finding are that

further education needs to be conducted to all members of the surgical team and continued

development of protocols is necessary.

Keywords: Skin to skin contact, cesarean, newborn, benefits, breastfeeding, education


Education on the Use of Skin to Skin Contact During Cesarean Sections

Problem Statement

A clinical problem that has been identified among labor and delivery units and

specifically at the Holy Spirit Hospital Birthplace, is the lack, or infrequent use of skin to skin

contact immediately after a caesarean section delivery. Skin to skin contact is the practice of

placing a naked or diapered newborn on the bare chest of either their mother or father while

covering them with warm blankets (Lowdermilk, Perry, Cashion & Alden, 2012). This practice

is significant because research has shown that there are many benefits associated with its use

both in the post-delivery setting and throughout infant development. Some of these benefits

include thermoregulation, increased infant stability, increased infant-mother bonding, and

improved breastfeeding (Moore, Anderson, Bergman, & Dowswell, 2012). The World Health

Organization (WHO) has two recommendations pertaining to this type of practice (World Health

Organization, 2012). The first recommendation is that all healthy newborns should spend the

first hour of their lives in skin to skin contact with their mothers due to temperature regulation

and breastfeeding benefits (World Health Organization, 2012). The second recommendation is

that once the mother and newborn are stable, breastfeeding should be initiated as early as

possible for all able newborns (World Health Organization, 2012). With these recommendations

the practice of skin to skin contact has become common after vaginal deliveries; however,

“usual” or common practice after cesarean section involves separating the mother and newborn

until both patients are transported into the PACU or later (Gouchon et al., 2012; Zwedberg,

Blomquist, & Sigerstad, 2015). Similar post-operative care was also observed at the Holy Spirit

Birthplace as well.


According to the CDC, for the last several years (2010-2013) around 32.7-32.8% of all

births are performed via cesarean Section (Martin, Hamilton, Osterman, Curtin, & Mathews,

2015). Studies have also shown that newborns delivered via cesarean section have lower

breastfeeding rates and increased risk of developing negative outcomes, like hypothermia, than

infants delivered vaginally (Zwedberg et al., 2015; Gouchon et al., 2012). Due to the benefits

associated with the use of skin to skin contact and the recommendations of the World Health

Organization, researchers believe that implementing skin to skin contact immediately or shortly

after cesarean delivery may be beneficial to newborns. After some informal discussions with the

nursing staff, education director, manager and lactation specialist on the Holy Spirit Birthplace, it

is understood that this floor is looking into developing protocols and procedures that are aimed at

incorporating this technique into common practice. However, through research it was identified

that there are several barriers to the implementation of this practice. Zwedberg et al. (2015)

identified that one of the largest barriers to implementation of skin to skin contact after cesarean

section included a general lack of knowledge of both medical staff and patients about its use.

Therefore, the purpose of this capstone quality improvement project is to answer the following

PICO question, in maternal-newborn dyads, is immediate skin to skin contact post cesarean

section as effective as usual care in promoting infant stability, breastfeeding and maternal

satisfaction, and to educate the nursing staff at the Holy Spirit Birthplace about the findings.

Literature Review

The evidence utilized in this study was obtained from the Pennsylvania State University

library’s collection of databases. The PubMed, CINAHL and Cochrane databases were searched

for peer reviewed, English speaking, journal articles from the last ten years, 2005-2015.

Keywords like “skin to skin contact,” “newborn,” “cesarean,” “hypothermia,” and


“breastfeeding” were utilized to obtain articles during this search. The articles were then

reviewed and those chosen focused on skin to skin use with cesarean sections and the newborn

outcomes, breastfeeding outcomes and maternal satisfaction associated with its use.

Skin to Skin Contact with Cesarean Sections and Newborn Outcomes

The literature indicates that a common misconception around skin to skin contact after a

cesarean delivery is that it increases the newborn’s risk of developing hypothermia due to the

operating room environment (Gouchon et al., 2012). This is a concerning assumption because if

an infant is hypothermic they have the potential of developing cold stress, which can lead to

increased oxygen demand and can result in negative cardiovascular and neurological effects

(Lowdermilk, Perry, Cashion & Alden, 2012). Several studies were obtained that addressed this

concern. The literature indicates that the use of skin to skin contact after cesarean section does

not increase the risk of newborns developing hypothermia anymore than the usual care that is

currently being performed (Gouchon et al., 2012; Beiranvand, Valizadeh, Hosseinabadi, &

Pournia, 2014; Stevens, Schmied, Burns, & Dahlen, 2014; Moore, Anderson, Bergman, &

Dowswell, 2012). Both Gouchon et al. (2012) and Beiranvand et al. (2014) randomly assigned

their clients to either an intervention group that used skin to skin contact or a control group that

received usual care post-operatively to find that there was no significant difference between the

temperatures of the two groups. Another study of 50 mother-infant pairs conducted by Nolan and

Lawrence (2009) specifically looked at the effectiveness of utilizing the NIMs protocol, which

focuses on decreasing the amount of separation time between the mother and the newborn by

utilizing techniques like skin to skin contact. This study found that the infants that received

implementation of this protocol had higher average temperatures than those that received the

care that is customarily performed (Nolan & Lawrence, 2009). Other studies conducted literature


reviews and meta-analyses in order to obtain their data (Steven et al., 2014; Moore et al., 2012).

Overall, the misconceptions of health care employees involved with cesarean sections around the

risk of hypothermia should be corrected and educated about so that it is no longer considered a

barrier to implementing the practice. However, since the studies previously reviewed

implemented skin to skin contact early after cesarean section, more research needs to be

conducted in this area to see if the risk of hypothermia is still insignificant when skin to skin

contact is implemented intra-operatively.

After reviewing the literature, several other measures were identified pertaining to

newborn outcomes. The study conducted by Nolan and Lawrence (2009) discussed above also

looked at several other infant outcome measures. It was determined that the infants not only had

higher temperatures but they also had lower respiratory rates and higher salivary cortisol levels.

These findings indicate that the infants, that were placed skin to skin and had less time away

from their mothers, were under less stress than those that received usual care (Nolan &

Lawrence, 2009). A qualitative study conducted by Frederick, Busen, Engebretson, Hurst, and

Schneider (2014) also observed that the use of skin to skin contact had a calming effect for both

the mother and the infant. When skin to skin contact was conducted with the partner or father

figure of the newborn it was found that there is less newborn crying (Erlandsson, Dsilna,

Fagerberg, & Christenson, 2007). This practice is ideal for situations where the mother is not

able to perform skin to skin (Erlandsson, Dsilna, Fagerberg, & Christenson, 2007). Overall, the

literature indicates that infants placed in immediate and early skin to skin contact exhibit

behaviors that are indicative of being under less stress which, could indicate that they are having

an easier transition to life outside of the womb.

Skin to Skin Contact with Cesarean Sections and Breastfeeding


Due to benefits associated with breastfeeding for both mothers and newborns, hospital

labor and delivery units often have goals around the use and exclusivity of breastfeeding for its

clients. The WHO, Healthy People 2020 and The Joint Commission have recommendations and

measures associated with breastfeeding practice as well (The Joint Commission, 2015; U.S.

Department of Health and Human Services, 2014; World Health Organization, 2012). Therefore,

hospitals are continually looking for ways to increase their breastfeeding rates. The literature

indicates that the use of skin to skin contact with cesarean section patients may help to improve

breastfeeding. A common measure studied among the reviewed research articles was the

initiation of infant pro-feeding behaviors like rooting and sucking. A qualitative study performed

by Frederick et al. (2014) studied skin to skin contact being performed with 11 mother-newborn

pairs intra-operatively. During the experiment the researchers observed infant pro-feeding

behaviors; however, there were no documented incidences of the newborns latching onto the

mother’s breast in the operating room (Frederick et al., 2014). Another study, that randomly

assigned 96 mother-newborn pairs to either receive skin to skin contact or usual care

postoperatively, observed infants receiving skin to skin contact to be significantly more ready to

breastfeed than those receiving usual care (Beiranvand et al., 2014). Interestingly though, when

Erlandsson, et al. (2009) randomly assigned 29 infants to receive either skin to skin contact with

a paternal substitute or the usual post-operative care, they observed there to be less pro-feeding

behaviors among the skin to skin contact infants. The researchers attributed this to a higher levels

of infant comfort because they also found there to be less infant crying (Erlandsson, 2009).

Other common measures found during this literature review included effectiveness of

breastfeeding and formula supplementation. Hung and Berg (2011) utilized a LATCH score,

which is a breastfeeding measuring tool that allows medical professionals to measure the


effectiveness of breastfeeding by monitoring for an effective Latch, listening for an Audible

swallowing, observing the Type of nipple, measuring maternal Comfort and inspecting the infant

Hold (Hung & Berg, 2011). After 9 months of implementation, the researchers found that when

skin to skin contact was implemented early with cesarean sections there was on average higher

LATCH scores (Hung & Berg, 2011). Hung and Berg (2011) also found there to be decreased

formula supplementation during hospitalization. Stevens et al. (2014) performed a review of

literature that also looked at formula supplementation among infants that received skin to skin

contact immediately or early after cesarean section. This research found the use of skin to skin

after cesarean sections to lead to a 41% decrease in formula supplementation. They also found

that the newborns latched on to the mother’s nipples approximately 21 minutes earlier than those

that received usual care (Stevens et al., 2014).

The last common measure among the researchers studied in this literature review was

exclusivity of breastfeeding. A randomized control trial performed by Gouchon et al. (2012)

reported that though there was not a significant difference between groups, a greater amount of

infants receiving skin to skin contact after a cesarean section were breastfeed more exclusively at

discharge and at 3 months of age than those receiving usual care away from their mothers. Other

researchers including Steven et al. (2014) found there to be no statistically significant difference

in the exclusivity of breastfeeding among the newborns receiving skin to skin contact and those

receiving the customary care. Overall, there appears to be mixed findings related to exclusivity

of breastfeeding; however, there was not a significant amount of data pertaining to this topic and

more research should be conducted to determine how immediate and early skin to skin contact

post cesarean section effects breastfeeding exclusivity.

Skin to Skin Contact with Cesarean Sections and Maternal Satisfaction


Another measure commonly found among the literature being reviewed pertained to

maternal perceptions of the use of skin to skin contact with cesarean sections both intra and post-

operatively. Studies that initiated the skin to skin contact intra-operatively including Frederick et

al. (2014) and Sundin and Mazac (2015) utilized qualitative methods in order obtain their data.

One of the common themes developed from maternal responses during these qualitative studies

included that the implementation of skin to skin contact worked as a distraction from the

operating room environment (Frederick et al., 2014; Sundin & Mazac, 2015). Other disclosures

included reported calming effects of the intervention, greater feelings of satisfaction among the

mothers, and stating that they were able to bond with their newborn (Frederick et al., 2014;

Sundin & Mazac, 2015). Gouchon et al. (2012), who randomly assigned mothers to either

receive skin to skin contact or usual care post cesarean section, surveyed their clients about the

experience and found that most of the mothers who received skin to skin contact reported high

levels of satisfaction and feelings of improved infant bonding (Gouchon et al., 2012). Maternal

pain levels were also studied and qualitatively mothers reported decreased levels of pain;

however Stevens et al. (2014) and Nolan and Lawrence (2009) found there to be no statistical

significance in the pain scores of the mothers who used skin to skin contact when compared to

the mothers who used usual care (Sundin & Mazac, 2015).

Techniques for Implementation

Smith, Plaat and Fisk (2008), described different techniques used in order to implement

skin to skin contact in the operating room. They recommend starting by educating the women

and partner on how skin to skin will be implemented and the benefits of its use (Smith et al.,

2008). Then, while preparing for surgery, it is suggested that equipment, including telemetry

stickers, pulse ox meters, and IV catheters be placed away from the women’s chest and dominant


hand in order to keep the area open for the newborn (Smith et al., 2008). During delivery these

practitioners focus on making the experience as natural as possible, so while the baby is birthed,

they lower the sterile drape to allow for the mother to observe the delivery (Smith et al., 2008).

After delivery, if both patients are able, the operating room team works together to initiate

immediate skin to skin contact (Smith et al., 2008). This includes the anesthesiologist clearing

the mother’s chest and the sterile baby-nurse placing the newborn skin to skin with the mother

(Smith et al., 2008). These researchers also recommended utilizing bubble wrap and placing it

over top of the blanketed newborn in order to help maintain temperatures (Smith et al., 2008).

The baby-nurse then remains at the head of the bed with the newborn and performs usual initial

post-delivery care (Smith et al., 2008). During transfer to PACU, newborn weight and

measurements can be assessed and then skin to skin contact can be reestablished in the PACU

(Smith et al., 2008).

In conclusion, the literature shows that when skin to skin contact is initiated either

immediately or early after Cesarean section delivery it can have significant positive outcome for

newborns, breastfeeding and maternal satisfaction. Temperature and respiratory regulation,

decreased stress, less crying, increased pro-feeding behaviors, decreased formula

supplementation, earlier breastfeeding, and improved bonding are just some of the benefits

identified. These findings indicate that clinically, if the intervention of skin to skin contact after

cesarean section would be implemented more exclusively, hospitals may see improvements in

breastfeeding rates, patient satisfaction and newborn outcomes which, follows the

recommendations of the WHO and the Joint Commission (World Health Organization, 2012;

The Joint Commission, 2015). Although a lot of positive results are found more research still

needs to be conducted specifically looking at implementation of skin to skin contact in the intra-


operative area in order to improve the reliability, validity and generalizability of the research.

Overall, however, it can be concluded that this practice is beneficial for mother-newborn dyads

and clinically education should be implemented to both medical staff and patients in order to

increase the use of this practice.

Action Plan

Methods

Starting in September 2015, this researcher began communicating with individuals at the

Holy Spirit Birthplace in order to identify a clinical problem on the floor. When this researcher

observed skin to skin contact being conducted in the operating room and the negative responses

from several members of the interdisciplinary team more investigating was conducted. Through

several discussions with different members of the Holy Spirit Birthplace team including the

nurse manager, nurse educator, lactation specialists and nursing staff, it was determined that the

Birthplace was in the process of conducting research on this topic in the hopes of eventually

developing protocols pertaining to the use of skin to skin contact in the operating room. After

conducting research and finding that one of the largest barriers to implementation of this practice

was lack of education among hospital staff and patients this researcher set a goal to educate the

nursing staff at the Holy Spirit Birthplace on the use of skin to skin contact in the operating room

and gather data from the nurses about past experiences with the practice and what they perceive

to be the barriers to its implementation (Zwedberg et al., 2015).

In order to educate the nursing staff, an education board was developed that highlights

information summarized in the literature review above. The major topics highlighted on the

education board included definitions and facts, benefits of using skin to skin contact, barriers to

implementation and techniques for implementation. Prior to the staff reviewing the education


board, a pre-survey was taken in order to obtain demographic data and measure their knowledge,

perceptions, opinions and past experience with skin to skin contact. After the staff members

completed the survey they were instructed to review the education board and complete the post-

survey that further measured their knowledge and opinions of the practice. Both surveys utilized

Likert scoring and open ended questions in order to measure the staffs’ knowledge and opinions

related to the topic. Samples of the pre and post surveys can be found in appendixes A and B.

After data collection was completed, the research was analyzed. Averages of Likert responses

were calculated and pre and post surveys were compared to determine if the education was

effective in improving the nursing staffs’ knowledge. The open ended questions were then

reviewed and themes were developed among the given answers.

In order to encourage participation in this education, Bernie Anderson the lactation

specialist sent an email to the nursing staff at the Holy Spirit Birthplace. Also, individual

promotion of education was performed in change of shift huddle by this researcher and the

student nurse preceptor Nicole Kertes. Education and surveys were available for completion

from October 28th thru November 14th 2015.

Results

After two and a half weeks of implementation, data was collected from a total of 15 Holy

Spirit Birthplace staff members. Demographic data was collected on the participants. The lowest

level of education of the participant was a BSN with the majority having OB certifications. There

were also several other participants with different certification like lactation consultants and

master level degrees. The participants ranged between 4 to 44 years of nursing experience and

between 2.5 to 36 years of labor and delivery experience. The surveys indicate that the majority

of nurses utilize skin to skin contact immediately after vaginal deliveries for 75-100% of their


patients. However, they also identified that they only implement skin to skin with about 50-75%

of their patients in the PACU and only 7 out of the 15 participants had actually participated in the

implementation of skin to skin contact in the operating room. Furthermore, according to the

participants, women undergoing cesarean section are educated on the benefits of skin to skin

contact significantly less than women undergoing vaginal delivery.

While taking the pre-survey, participants were asked to identify which members of the

surgical team they have noticed resistance from and what they feel are barriers to implementation

of skin to skin contact in the operating room. After analyzing the results, it was identified that the

anesthesiology team is significantly more resistant to implementing this practice than nursing,

surgery and pediatrics which all averaged about the same resistance levels. Also the most

common response when asked about barriers to implementation was changing the opinions and

beliefs of the anesthesiology team. Other common barriers to implementation that were

identified included a general lack of knowledge, surgical and patient monitoring equipment

getting in the way and lack of communication among the entire surgical team.

To test the participants’ knowledge of skin to skin contact in the operating room

questions about its benefits, breastfeeding, patient satisfaction, risk and hypothermia were asked.

Both Likert scoring and open ended questions were utilized to measure the participants’

knowledge about the use of skin to skin contact in the operating room. The Likert scorings were

used in order to determine the level of knowledge prior to and after education. After analyzing

the results, it was found that the participants’ knowledge increased after reviewing the

educational board. All participants were also able to correctly answer open-ended knowledge

based questions.


Lastly, after educating the participants, they were asked to identify what they felt were

some of the major things that needed to change in order for skin to skin contact to be regularly

implemented in the Holy Spirit Birthplace operating room. After analyzing the data several

common themes were identified. The most common opinion of the participants was that

everyone including patients and all members of the surgical team needed to be educated on the

importance and benefits of the practice. They also identified that all members of the surgical

team needed to be on the same page and it was frequently suggested that the best way to achieve

this was to create and implement a policy that outlines the protocols. Other ideas that the nurses

identified included possibly having an extra nurse in the operating room so that one nurse is able

to stay at the head of the mother’s bed with the newborn. They also suggested rearranging some

of the equipment in the operating room in order to create more space at the head of mother’s bed.

Lastly, some of the nurses were still concerned with the temperature in the operating room

leading to hypothermia and suggested increasing the room temperature slightly.

After collecting and analyzing the data, the results were brought to and shared with the

nurse manager at the Holy Spirit Birthplace. During this conversation the improvement in

knowledge was discussed, as well as the common themes that were identified during data

analysis. Lastly, the nurse manager was made aware of the changes and barriers that the

participants in this study identified so that they can be used during the next stages of the protocol

development and implementation process. The next step, for the Holy Spirit Birthplace, is to

develop a protocol while collaborating with the entire surgical team in order to insure that all

members of the team agree on the changes. Once the protocol is developed and accepted, they

plan to continue to educate both patients and staff about the use of skin to skin contact in the

operating room so that this practice will eventually be regularly implemented. Once this practice


is regularly implemented the Birthplace can then assess to see what positive effects it has on

quality measures like newborn outcomes, breastfeeding and maternal satisfaction.

Summation

Evaluation of Implementation

To summarize the implementation of this project, a literature review was conducted to

gain knowledge on the implementation of skin to skin contact in the operating room. Using this

research, an education board was then developed and used to improve the knowledge of the Holy

Spirit Birthplace staff. A pre and post survey that utilized Likert scoring and open ended

questions was used to measure the knowledge, perceptions, opinions and past experience of the

nursing staff with skin to skin contact. After analysis of the data it was found that the education

board was effective at improving the participant’s knowledge. Common themes were also

identified including that the anesthesiology team appears to be the most resistant to the changes

being made. Also, protocols need to be developed and all members of the surgical team need to

be educated and up to date on these them.

Barriers to Implementation

Overall, the results indicate that the implementation of education was successful in

improving the knowledge of the Holy Spirit Birthplace nursing staff; however, several barriers

were identified during the implementation of this project. To start, due to time constraints several

modifications had to be made to the implementation process. For instance, it would have been

more ideal and the data would have been more accurate if the pre-survey would have been given

separately from the education and post-survey; however, due to lack of time for implementation

the researcher had to administer the pre and post surveys at the same time and ask the

participants to review the education board after completing the pre-survey. Also, if there had


been more time for implementation, it would have been better if all members of the surgical

team, including anesthesiology, surgery and pediatrics, participated in the education and

measurements so that a larger number of team members could be educated and more opinions on

barriers and implementation could be identified. Another barrier to implementing this education

was staff non-compliance. Even after sending an email to all staff members and individually

promoting participation in the education only 15 staff members participated. With more time for

implementation, there could have been a greater number of participants in the study which could

have helped increase the reliability and validity of the results. The last barrier being identified

was that even though current research was presented, this researcher still sensed resistance from

the nursing staff with believing and accepting some of the new knowledge presented, which

could have negatively impacted the results of the study.

Conclusion

To conclusion, the use of skin to skin contact has been found to have many positive

benefits for newborn outcomes, breastfeeding and maternal satisfaction. With these benefits

hospital labor and delivery floors would ideally have improvements in the quality measures

identified by the Joint Commission. Therefore, to increase the knowledge of the Holy Spirit

Birthplace nursing staff, education was conducted and knowledge and opinions were measured

both before and after implementation. It was found that the education improved the knowledge

of the participants. It was also found that the anesthesiology team is the most resistant to change

and that protocols and continued education needs to occur in order to get to a point where skin to

skin contact is regularly implemented in the operating room. There were several barriers

identified during implementation that could have affected the results of the study including

limited time and number of participants. However, overall knowledge levels appeared to increase


and valuable data was collected and presented to the Birthplace management that could be useful

in the future as they continue to develop protocols and encourage implementation of skin to skin

contact in the operating room.


References

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skin contact on temperature and breastfeeding successfulness in full-term newborns after

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doi:10.1155/2014/846486

Erlandsson, K., Dsilna, A., Fagerberg, I., & Christenson, K. (2007). Skin-to-skin care with the

father after cesarean birth and its effect on newborn crying and prefeeding behavior.

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78-84. doi:10.1097/NNR.0b013e3181d1a8bc

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data for 2013. National Vital Statistics Reports, 64(1).

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mothers and their healthy newborn infants (review). Cochrane Database of Systematic

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Appendix A: Pre-Survey

1. Education level (Ex: BSN; include any certifications):

2. Number of years of nursing experience:

3. Number of years experience at the Holy Spirit Birthplace:

4. Number of years total labor and delivery experience

5. What percentage of your patients utilized skin to skin contact IMMEDIATELY after vaginal deliveries?

a. less than 25%b. 25%-50%c. 50%-75%d. 75%-100%

6. Have you participated in c-section that utilized skin to skin in the OR?a. yesb. no

7. What percentage of your patients utilized skin to skin contact IMMEDIATELY (intra-operatively) after c-sections?

a. less than 25%b. 25%-50%c. 50%-75%d. 75%-100%

8. What percentage of your patients utilize skin to skin contact in the PACU after c-sectiona. less than 25%b. 25%-50%c. 50%-75%d. 75%-100%

9. How frequently do you educate your patients on skin to skin contact?1 2 3 4 5

Never Rarely Sometimes Most of the time Always

10. How frequently do you educate your cesarean section patients on skin to skin contact prior to surgery?

1 2 3 4 5Never Rarely Sometimes Most of the time Always

11. Skin to skin contact is beneficial for newborns.1 2 3 4 5



12. Skin to skin contact negatively affects breastfeeding. 1 2 3 4 5


13. Skin to skin contact improves patient satisfaction.1 2 3 4 5


14. Skin to skin contact in the operating room creates a high risk environment for newborns.1 2 3 4 5


15. Skin to skin contact will result in infant hypothermia in the operating room.1 2 3 4 5


16. I am resistant to implementing skin to skin contact in the operating room.1 2 3 4 5


17. I have witnessed resistance from nursing staff when implementing skin to skin contact in the operating room.


18. I have witnessed resistance from anesthesiology staff when implementing skin to skin contact in the operating room.


19. I have witnessed resistance from surgical team when implementing skin to skin contact in the operating room.


20. I have witnessed resistance from pediatrics when implementing skin to skin contact in the operating room.


21. What are some of the barriers to implementation of skin to skin contact in the operating room:

22. In your opinion what needs to be done for skin to skin contact to be regularly implemented in the operating room


Appendix B: Post survey

1. Skin to skin contact is beneficial for newborns.1 2 3 4 5


2. Skin to skin contact negatively affects breastfeeding. 1 2 3 4 5


3. Skin to skin contact improves patient satisfaction.1 2 3 4 5


4. Skin to skin contact in the operating room creates a high risk environment for newborns.1 2 3 4 5


5. Skin to skin contact will result in infant hypothermia in the operating room.1 2 3 4 5


6. I am resistant to implementing skin to skin contact in the operating room.1 2 3 4 5


7. List at least 3 benefits of the use of skin to skin contact.

8. Name at least 1 barrier to implementing skin to skin contact in the operating room.

9. Name at least 2 ways implementing skin to skin contact in the operating room will change your practice.

10. How can you, as a nurse, promote the implementation of skin to skin contact in the operating room?

11. In your opinion what changes need to be made in the Holy Spirit operating room in order to regularly implement skin to skin contact intra-operatively (list at least 2 things)?

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