“stuck on you” skin to skin as a standard of care for ......“stuck on you” skin to skin as a...
TRANSCRIPT
“Stuck on You” Skin to Skin as a Standard of Care for Newborns in the OR/PACU
Introduction
References
Implementation
Conclusion
Acknowledgements
Methods & Materials
Model of Care Committee Sub-Group OR/PACU
Dr John Wimmer, Neonatology
Dana Bryant,RN, MBA, Director OR/PACU
Cleo Montpellier, RN, BSN,MHA,CPAN, Assistant Director PACU
Amy Skrinjar, MSN, Director Birthing Suites
Myra Kelly,CRNA, Director of Anesthesia
Helen Sneed RN,MSN Maternity Admissions,
Camilla Wood RN, BSN PACU Assistant Director
Wynn Fussell, CRNA,MSN, ANP
Nancy Kazmar, RN PACU
Miranda Hill, RN Mother-Baby
Beth Olson RN, OR
Beverly Daly, RN,BSN, IBCLC
Donna Wear, RNC,BSN ,Mother-Baby Unit
Christie Wicker RNC ,Birthing Suites
Laura Stines, RN, MSN Infection Prevention
Kathleen Kohut, RN MSN Infection Prevention
After a successful pilot of 310 vaginal deliveries in January of 2012 resulted in a
change to skin to skin (S2S) care for all our vaginally delivered babies and we had a 100% success
rate in maintaining optimal axillary temperatures even after being bathed in the mother’s room, we
wanted to venture into the same practice following cesarean sections.
Parents with planned and unplanned cesarean deliveries heard about what was going on with
the S2S care after vaginal deliveries so they began to expect S2S care for their cesarean birth
experience. They communicated this request often through “birth plans” presented to staff upon
arrival.
Our goals at Women’s Hospital were:
S2S contact as a transitional method for all stable newborns following a cesarean section
Axillary temperatures and vital signs to remain stable through the transitional period
Increase our breastfeeding rate
Parent participants in the pilot were interviewed the day after the birth of their baby. They were
asked about their experience of S2S contact immediately after birth. We asked them to
rate their experience on a Likert scale of one to five: “1” being that they “did not like it” and “5”
that they “loved it”. Results: 100% participants rated their experience as a “5”. Three parents
rated it as a “10”!
Data collected for the PDSA was shared with the OR/PACU Sub Committee. There were no
negative outcomes for the 10 couples participating in the pilot. Lengthy and detailed discussions
were held about how this could be accomplished as the standard of care for all newborns at Cone
Health Women’s Hospital.
The OR/PACU subcommittee of the Model of Care committee, consisted of staff from Birthing
Suites, Postpartum, Nursery, OR, PACU, Infection Prevention and NICU and included RN’s,
CRNA’s, and physicians. September of 2012 this committee began the work to Plan, Do, Study,
Act (PDSA). Every question and reason to not change was addressed and answered from fears
of contaminating the OR to having enough room for the extra nurse at the “table-side” in the OR.
A PDSA-based pilot was planned for providing S2S in the OR and PACU for 10 scheduled
cesareans over 2 weeks. Guidelines were written and communicated extensively. Participants
were randomly selected from the OR schedule and asked if they would like to participate. Every
mother/support person asked was very willing to participate in S2S contact and have a nursery
nurse stay with them.
S2S contact was initiated in the OR after the 5 minute Apgar score. Baby remained S2S
during the entire surgery. Baby was removed from the mother only for the brief transport of the
mother to the PACU bed. Then the baby was returned to the mother’s chest in the PACU bed
and transported to the PACU. Families were allowed to see the new baby on the mother’s chest
briefly outside the PACU. The goal was for the baby to remain S2S for at least one hour and until
the first feeding was accomplished. All routine care of the newborn was performed at the bedside
and continuing S2S if able. One nurse was chosen by a senior leader to provide care for all 10
deliveries.
Staff resistance to change was addressed. Staff was educated about the process through
multiple meetings. They were encouraged to express concerns at unit meetings about the
change in our model of care. As more staff witnessed the benefits for families and newborns,
resistance was resolved.
This project represents innovation:
First hospital in North Carolina (and one of very few hospitals in the nation) that is a high-
volume referral center that practicing S2S after both vaginal and cesarean deliveries as a
standard of care for all patients
Maintain S2S contact through the first feeding and transfer of the mother/baby to the
postpartum room.
Our bottom line became: “What is best for the patient?”. Many more practice changes have
taken place since the skin to skin set the ground work and changed our culture of care.
We were able to achieve this goal without additional staff. It was just a matter of moving
current staff and equipment to the bedside and being willing to not only think but practice
“outside the box”.
Concerns about implementation of this model of care included staffing. The nursery nurse stayed
with each couple for an average of 3 hours and 20 minutes. Because we firmly felt this was
evidenced based best practice, we decided to implement this in phases, “baby steps in the OR”.
In Phase One, we would commit to providing S2S for all stable infants born by cesarean in the
OR for 30 minutes. The baby and support person would then go to the nursery and resume routine
care. The baby did return to the mother in the PACU for feeding and bonding.
In Phase Two the baby remained S2S in the OR during the entire procedure and remained with
the mother in the PACU until the first feeding was accomplished and then the baby would be
transferred to the nursery until the mother was brought to her postpartum room.
In Phase Three the baby stayed with the mother during the entire OR, PACU and transfer to the
postpartum room. This phase 3 was accomplished by having supervision help with the recovering
couplet by involving PACU RN’s and Lactation assistance in the PACU. The support person is
encouraged to remain with the mother and baby to help with the transition to the postpartum room.
Phase three began March 4,2013.
Smith, Pat Bohling, MS,RNC, Moore, Karen, MSN, RNC, IBCLC, Peters, Liz, BSN, RNC, CLC (July/August
2012) Implementing Baby –Friendly Practices: Strategies for Success, Maternal Child Nursing, Vol 37,No 4,
pp228-233.
Berg, Ocean, MSN, RN, CNS, Hung, MS, RN, CNS (September/October 2011) Early Skin to Skin After
Cesarean to Improve Breastfeeding, Maternal Child Nursing ,Vol 36,No 5, pp 318-324.
Spradlin, Ludmila R. RN,BSN,MS,CNOR (March,2009)Implementation of a Couplet Care Program for
Families After a Cesarean Birth, AORN Journal, Vol 89,No3,pp 553-562.
After analyzing the data, it became clear that there was an immediate overall
improvement of infant health. Admissions to NICU for hypoglycemia and infant
readmissions for hyperbilirubinemia dropped to half the numbers seen under the
old model of care.
Pilot Results Long Term Outcomes
One year after the process change 10 couples were randomly chosen and interviewed once again
about the process of S2S in the OR and keeping the baby with the mother during the entire
recovery time. The same question was asked about their experience of S2S contact immediately
after birth. We asked them to rate their experience on the same Likert scale that was used during
the pilot. Again,100% of the participants gave us a ”5”. Parent comments included the baby being
calmer and the parents feeling less anxious. Frequently in both the pilot and now a year later,
parents who had a previous delivery that did not include S2S speak openly about how meaningful
the experience was for them and how they wish they had the opportunity with their previous
birth(s). Lactation consultants and parents note improvements in breastfeeding outcomes
regarding ease of the first latch-on and the frequency and length of breastfeeding while in the
hospital. No adverse outcomes of S2S in the OR/ PACU have been demonstrated.
Newborns now stay with their parents in the OR and in the PACU. All routine care takes place at
the bedside. Babies are allowed to be transported to the PACU on their mother’s chest and briefly
greet the visitors before entering the PACU. This process change is a huge satisfier for patients
and families. In the old model the mother was not able to participate in the family ‘s first view of the
new baby.
An unexpected result has been PACU staff has commented that mothers complain of
pain and itching less frequently when the baby remains S2S.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2012 2013 2014
Breastfeedinginitiation
ExclusiveBreastfeeding