In the Literature: San Francisco General Hospital implements skin-to-skin care in the operating room for mothers and infants after cesarean surgery

This project was selected from among many reported in the peer reviewed literature. For a list of more articles on quality improvement, visit our resource bibliography.


Hung, K. J., & Berg, O. (2011). Early skin-to-skin after cesarean to improve breastfeeding. MCN The American Journal of Maternal Child Nursing, doi:10.1097/NMC.0b013e3182266314 (abstract)


San Francisco General Hospital, an urban, acute-care hospital with Baby-Friendly designation


To alter the process of care in the operating room to enable routine, early skin-to-skin contact after cesarean birth, with the aim of increasing the success of breastfeeding initiation.


This quality improvement project used the “Plan, Do, Study, Act” method.

Plan: The improvement team surveyed the nursing staff to identify opportunities and barriers, and to find the nurses interested in becoming champions of the improvement project. They also surveyed obstetric, anesthesia, and neonatology staff to determine how the process of care in the operating room could be altered to enable safe skin-to-skin care. The team gained further insights by visiting other hospitals where STS care in the operating room had been implemented and consulting the published literature on the subject.

Do: The improvement team developed a flow chart to identify babies eligible for STS care (vigorous with and adequate pulse and color and no signs of respiratory distress) and standardize the procedure for moving drapes, untying the mother’s arm and gown, placing the baby transverse on the mother’s chest, and covering the baby with blankets and a hat.

Study: Early piloting of the flow chart allowed the improvement team to make refinements the process. These included placement of the baby in a manner that allowed observation, moving unnecessary equipment, and allowing STS care before the baby went to the nursery.

Act: When the flow chart was finalized, the improvement team offered an in-service to staff, posted the flow chart in the OR, and actively encouraged staff to continue STS care in the OR and monitor results.


During the first 3 months after implementation, the rate of STS within 90 minutes of cesarean birth in healthy babies increased from 20% to 68%, and the rate of infants who did not get any STS contact within 4 hours decreased from 40% to 9%. Rates were reevaluated at 9 months and remained similarly elevated. Babies who experienced STS in the operating room had better LATCH scores (measure of breastfeeding effectiveness) and were less likely to have supplemental formula during their hospital stay compared with infants who had STS contact later or not at all.



Filed in Blueprint, Care coordination, Clinical practice guideline/policy change, Educational materials for health professionals, Performance measurement/reporting, Team building on Thu., Aug 11, 2011

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