Carol L'Esperance asks for input on how one implements S2S in large
maternity units.  As far as I can see, the size of the unit is not the
issue, but rather availability of space and staff.  Carol, you don't say
anything about the logistics of your unit.  Do mothers give birth in the
same room where they labor?  When are babies normally weighed and measured
after birth, and where does this take place?   It may be that modifications
are in order for how your space is used.

A unit with upwards of five thousand births per annum would need more than a
dozen birthing rooms if every mother is to be able to spend the first couple
of hours in undisturbed skin contact with her baby.  This assumes that the
babies are born in the room where mother labors, and that they remain in
that room for a normal recovery and observation period after third stage.
Of course if the CS rate is very high, a lot of mothers would be in
postoperative recovery, but I will only address this for vaginal births.

If the mother is whisked to a special room for the actual expulsion of the
baby and placenta and then taken somewhere else, either back to her labor
room or a postpartum room, then it's this *somewhere else* that needs to be
available for those first couple of hours when mother and baby are skin to
skin.  Everything that needs to be done right after birth can be done with
baby on mother's body, including moving the two of them to the room where
they can spend that first skin to skin time.  There is no innate need to
take a baby away from the mother to examine it, remove secretions from nose
and throat or even to do gastric suction, or to take blood glucose
measurements or give Vitamin K or eye prophylaxis or hepatitis B vaccine, if
those should happen to be part of routine care in the immediate post partum
period where you are.  If the policy on recording weights and lengths is
absolutely inflexible with regard to timing, then I would try to do it as
soon as possible, like within seconds of dividing the cord, rather than
waiting until baby has started to settle on mother's body and is preparing
to set about finding the nipple.  No research to back this up, just a gut
feeling that it is easier for baby to adjust once, rather than to start
adjusting and then get interrupted, only to have to start all over again.  

What you will discover is that there are fewer abnormal findings on all the
parameters normally observed postpartum, in both mothers and babies, when
they are cared for in close contact with each other, and it is less
stressful than what you are used to because the babies are calm within
moments.  The simple absence of newborns screaming makes a huge difference.
Babies come to breast sooner and with less assistance.  All this makes
charting that much easier.

A couple of years ago there was a post explaining how babies and mothers
were observed immediately after birth at one hospital in the US.  I printed
that post out at the time and read it aloud at work to the complete
disbelief of everyone who heard about it, because routine care involved
twice as many staff and MUCH more space than what we have available.  There
was a nurse for the baby and a nurse for the mother, in designated, separate
rooms, where we make do with one midwife for both of them in the labor,
birth and recovery room, unless there are complications necessitating moving
either mother or baby to special care.  If mother needs manual removal of
the placenta, a normal healthy baby will be deposited unceremoniously in her
partner's arms while she goes to the operating room.  We don't check vital
signs of mother or baby repeatedly unless there is some sign that there is a
problem.  (I probably shouldn't reveal this, but we don't even count a
healthy baby's heart rate for the Apgar score, we don't have pediatric
stethoscopes in the birthing rooms at all!)  

I'm convinced that in hospitals with limited space, skin to skin is even
more of a timesaver than it is in those with plenty of staff and room.  You
can't give safe care without enough staff, whether you are doing skin to
skin or not, and I bet you will discover that staff are freed up to use
their time doing more meaningful care if mothers and babies are kept where
they belong, namely, together.  

You are welcome to get in touch if you want to organize a study tour of some
of our maternity units :-)  I am serious.

Rachel Myr
Kristiansand, Norway
Where skin to skin for the first couple of hours is in fact the standard
procedure in every unit in the country, including those few with over 5000
births per annum

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