Kangaroo Care after Cesarean

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From “The Mindful Cesarean”: “Jill Bergman on How to do Kangaroo Mother Care Following a Cesarean”

By Mary Esther Malloy


“When a baby must be born by cesarean, what can families do to optimize healthy birth hormones to best ensure that mothers and babies thrive?”

This question inspired my new project, “The Mindful Cesarean.”

A key feature of “The Mindful Cesarean” is a cesarean birth visualization in which I suggest birth hormone-enhancing practices for each stage of a cesarean. My goal is to help families who birth by cesarean to what nature intends: mothers and babies who are healthy, happy, well-adjusted, breastfeeding, and bonded, even with the challenges of a surgery.

Because skin to skin contact between mother and baby is one of nature’s heavy lifters when it comes to launching a happily bonded and breastfeeding mother and baby, I reached out to Nils and Jill Bergman, international promoters of Kangaroo Mother Care (KMC).

With an abundance of research demonstrating improved outcomes following Kangaroo Mother Care (on-going skin to skin contact between a mother and her baby),[i] KMC has recently been accorded its rightful place as an important element of care for vulnerable newborns. In November, 2016, six major international health associations endorsed the universal use of KMC for preterm and low birthweight infants.[ii]

While this endorsement is fantastic news, KMC benefits all babies (and their parents!) and deserves to be a central part of care for every mother and baby. When a baby is born by cesarean, Dr. Nils Bergman considers KMC essential.

Unfortunately, KMC is not yet a standard of care post-cesarean. Families may have to ask nurses and doctors to do things differently to assist with on-going skin to skin contact.  Extra help may be needed from family, friends, a doula or KangaroulaSM  to make this happen in the sensitive hours, days and weeks following a cesarean.

“A KangaroulaSM ?” you ask. “What’s that?”

As Nils and Jill Bergman explain, “Kangaroo Mother Care plus doula equals kangaroula!”

The work of the Bergman’s foundation, Neuroscience for Improved Neonatal Outcomes (ninobirth.org), conducts research into and advocates for conditions that support optimal brain development for babies at birth.  Jill Bergman now also trains birth attendants to offer what she and Nils Bergman call KangaroulaSM care. Doulas trained in this approach understand the importance of skin to skin, breastfeeding and a low-stress birth environment for the health of mother and baby, and do their best to help families get off to a strong start, no matter the circumstances of the birth.

To gather practical tips on offering families Kangaroo Mother Care in the days and weeks after a cesarean, especially if extra medical attention is needed, I got in touch with Jill Bergman at her home in Cape Town, South Africa.


Skin to Skin with a Cesarean: Interview with Author and Doula Jill Bergman

Mary Esther: First of all, I would like to thank you and your husband, Dr. Nils Bergman, for the work you’ve done to promote skin to skin contact between mother and baby as a new—but of course very old—norm. When it comes to cesarean, you and Dr. Bergman are integrating what is biologically ancient—skin to skin—with our technologically new surgical births.  I’d love to talk about how you support families to maximize Kangaroo Mother Care during and following a cesarean. To start, how would you describe the particular benefits of skin to skin contact during a cesarean?

Jill: Sure. In a vaginal birth, a baby comes from a warm, dark peaceful place with mum’s familiar voice, heartbeat and smell, into a normally brightly lit room with nurses and doctors and noise. This takes a lot of adjustment for the baby.

In a cesarean, the adjustments are even greater for a baby. The operating lights are acutely bright. The room smells of antiseptic and is colder than a regular delivery room.  The baby may have had no preparation from contractions to prepare him for the birth, so the sudden transitions are even more scary for him. He is held by doctors with strange smelling plastic gloves, examined on a resuscitation table with extremely bright lights and then often routinely placed into a warm incubator and wheeled away to the nursery for “observation.” This is separation from everything that is familiar to the baby. This causes instability in the newborn.

However, if the baby is placed on mother’s chest while the mother is being sewn closed, mother’s familiar voice, heartbeat and smell will calm him. Her chest will warm him and he will stabilize physically much faster. The smell of colostrum will draw him to move towards the nipple and he will self-attach and start to breastfeed. In the strange operating environment, he has the “buffering protection of adult support.”  The contact also helps the mother to bond with her baby. It helps her to be less anxious about the operation as she focuses on her baby on her chest. She can skip the worry of seeing her baby being wheeled away.

Mary Esther: Do you have any tips for how partners can help mothers hold their babies skin to skin in the operating room, even as the surgery is still underway?

Jill: Partners are very important. Partners can support by holding the baby on mum’s chest. Remember, mum’s one arm has a drip and the other has a blood pressure cuff. Partners can also check baby’s breathing and color and make sure he is covered by a blanket.

Mary Esther: Dr. Bergman discusses the importance of enhancing oxytocin for mother and baby for the first 1000 minutes after birth.  Following a cesarean, a mother is in the first stages of recovering from surgery and simultaneously figuring out breastfeeding and how to parent her baby. What helps families keep babies skin to skin during this sometimes challenging time?

Jill: A mother recovering from a cesarean knows she has to look after her baby and this helps the recovery.  All of her maternal instincts will be focused on her child.  But she needs help. If she has just had a cesarean, she won’t be able to pick up her tiny newborn, so there needs to be someone to assist her, possibly her partner, another family member, or a doula we call a “kangaroula.”  If both parents are allowed to stay in the unit for the first days, it is hugely helpful for the mother’s recovery as they share the load and work out together how to care for their baby. It makes father much more part of the family and care. Fathers have a special role to play as the baby can sleep on him without the stimulation of the smell of breastmilk. The baby is born, but in this way, the family is born too!

Mary Esther: You mentioned support by a doula known as a “kangaroula.” What is kangaroula care?  How does a doula trained in this approach help make the time after the birth as oxytocin-rich as possible for mother and baby?

Jill: Doulas care for and support a mother in labor and focus on her needs.  A kangaroula does this as well but is also a voice for the baby’s needs. For example, she might help a mother delay or avoid an epidural to minimize the transfer of drugs to the baby; she might help a woman avoid an unnecessary, planned cesarean since this is unexpected and stressful for the baby.

After the baby is born, a doula trained to offer kangaroula support will be thinking about the baby’s experience as well as the mother’s and do what she can to limit stress on the baby. She will dim the lights or cover the baby’s eyes, ask for quieter voices and set up a gentle environment for the baby and mother.  Most of all, a kangaroula will advocate for the baby not to be separated from mother unnecessarily and will support undisturbed time for the first two golden hours to bond and start breastfeeding. A kangaroula will also help new parents transition to parenthood by helping parents understand ways to protect togetherness and minimize interferences in the days to come.

Mary Esther: There are many reasons why a baby born by cesarean might be taken to the NICU, some for observation and others for needed medical care. In most U.S. hospitals this means we now have a baby and mother who are separated, sometimes for days, with scheduled visits, every two to four hours, although sometimes more frequently. Usually skin to skin and breastfeeding are permitted and often encouraged during these visits, but the baby remains in the nursery while the mother stays in her recovery room or at home. Dr. Bergman speaks to this point directly, saying the incubator “is the wrong place for the baby. Incubators destabilize. We bring needed medical care to mother and baby whenever possible.”

Jill: Yes. Absolutely. The design of the NICU as a separate space from the maternity ward needs to be challenged as it makes the start of breastfeeding nearly impossible and negatively impacts early bonding.  We need the baby on the mother’s chest nuzzling at the breast, stimulating breast milk production and the hormones that we know promote healthy bonding.

Mary Esther: Do you have any tips for parents who feel strongly about maximizing skin to skin contact if their baby is in a NICU in a typical U.S. hospital where separation is the norm and contact is scheduled, especially if medical attention is needed for the newborn?

Jill: Of course some babies need medical care. The answer is to bring the medical support to the right place: the mother’s chest. There is always room for a chair next to an incubator, even a fold-up deck chair so the mother can lean back and rest. We have to ask doctors to adapt their practices so that care is available to the baby on its mother’s chest.

Mary Esther: Change can come slowly to hospitals. What have you seen on this front in South Africa?

Jill: I’ve seen parents and doulas change hospital practices by asking questions and being assertive. I’m thinking of a father who politely refused to leave the recovery ward because his wife needed help with breastfeeding. Eventually they allowed him to stay and now they have put up more curtains between beds and fathers are permitted to stay. When I first asked OBGYN for permission to attend cesareans at one of our local hospitals five years ago as a doula, it was unheard of.  Now partner and doula are allowed in routinely. But some hospitals are unbending. In those cases, it makes sense to switch hospitals if possible. I recently had a mum needing a third caesarean who phoned me at 40 weeks because she would not be allowed to hold her baby in the operating room, and her baby would be taken to NICU. We found another doctor and another hospital where she could breastfeed her baby in the operating room and remain together. She was very pleased with the change.

Mary Esther: Because women are usually on pain medication that can affect their mental clarity and alertness, hospital personnel are often concerned about women sleeping with their newborns on their chests in the days following a cesarean. They insist the mother place the swaddled infant in a nearby bassinet for sleep. Given what we are learning about how stressful this separation can be for a newborn how do you think about this issue?

Jill: Let’s keep in mind that the baby needs the smell of mother to sleep-cycle properly. The baby does need to be carefully observed and mum and baby should not be left alone. The baby can be tied on safely to the mother’s chest with the airway open. We have developed what we call a Kangacarrier for this purpose.  This is what we do even for preterm babies. It makes a tremendous difference.

Mary Esther: When the family gets back home, what tips would you offer to support on-going skin to skin contact?

Jill: Get a carrier that is non-stretchy and carry your baby when you are home. Mothers can undress the baby and place her in skin to skin contact on her chest. Fathers can wear the baby too. Get lots of help so you can focus on the baby!

Mary Esther: I’d also like to ask you about small, frequent feeds. Dr. Bergman describes one- hour sleep cycles syncing up with one-hour feed cycles as what nature intended.  We often think in terms of feeding a newborn every two to three hours and many NICUs invite moms to nurse every four hours.

Jill: Babies inside the mother are swallowing amniotic fluid every 40 to 60 minutes.  After birth, the sleep cycle is about 60 minutes. When the baby is born, keep to this one-hour cycle. The size of a newborn’s stomach is only five ml which is about one teaspoon. But the baby needs this small amount every hour or so. This is very natural if you keep your baby close to you with lots of skin to skin contact. With frequent feeds that follow the sleep cycle, the baby will learn food security as she sleeps and wakes and nuzzles on the breast and feeds and falls back asleep.

Mary Esther: If a separation does happen, do you have any tips for reconnecting and recovering from the separation?

Jill: Yes. If a separation has happened, the question we can ask is “how quickly can we get mum and baby together again?” As soon as that happens, undress the baby and mother’s chest and let them lie together for hours, giving the baby a chance to go through the wriggling and nuzzling towards the breast. Let the baby latch supported, but undisturbed, for as long as it takes for both of them to calm and settle and be together, even for days. This is healing for both of them!

Mary Esther: Thank you so much, Jill.

 

Read Part I: The Mindful Cesarean


Mary Esther Malloy holds a MA in anthropology. She is a doula, Bradley educator, and mother of three children who writes frequently about birth. Please visit themindfulcesarean.com for her newest project: “The Mindful Cesarean”!  You will find additional articles and recordings by Mary Esther at mindfulbirthny.com. If you are interested in the neuroscience of skin to skin and breastfeeding, she invites you to visit her blog thebirthpause.com where you will find her popular post “Kangaroology: The First 1000 Minutes” about Dr. Nils Bergman’s 2016 talk at NYU.  Mary Esther is proud to announce that she recently certified with Jill Bergman to offer KangaroulaSM Care. She can be reached at info@mindfulbirthny.com


Jill Bergman has been involved with Dr. Nils Bergman in supporting and promoting Kangaroo Mother Care for 25 years. As a teacher and counselor she wants all parents to be given the neuroscience of caring for their newborn babies in normal non-medical English. She has written and produced four DVDs on KMC and written a book called “Hold Your Premie,” a practical workbook on skin-to-skin contact for parents of premature babies. Jill is a qualified DOULA, and her knowledge of developmental care, and the neuroscience on KANGARoo Mother Care, makes her a unique advocate for the baby at birth, a KANGAROULA! She can be reached at jill@ninobirth.org


Dr. Nils Bergman calls himself a public health physician and currently promotes and researches skin-to-skin contact on a full-time basis. He is an honorary research associate and honorary senior lecturer at the University of Cape Town, South Africa. Dr. Bergman was born in Sweden and raised in Zimbabwe, where he also later worked as a mission doctor.  He received his medical degree at the University of Cape Town and later a Masters in Public Health at the University of the Western Cape. His last posting was senior superintendent of Mowbray Maternity Hospital in Cape Town, overseeing 18,000 births per year. He enjoys sharing the wildlife of Africa with his wife, Jill, and their three children. Nils can be reached at nils@kangaroomothercare.com 

 


[i]ICEA Position Paper, “Skin to skin contact,” (n.d.). Retrieved at

http://icea.org/sites/default/files/Skin%20to%20Skin%20Contact%20PP-FINAL.pdf, June 2014.

See also http://skintoskincontact.com/research.aspx#2

[ii] http://www.healthynewbornnetwork.org/resource/kmcjointstatement).