The following is a detailed description extracted from my “Speaker Information” document. It describes the preparations, requirements and procedure. With longer training times in the NICU, supporting breastfeeding of prematures, sensory environment and developmental care components are integrated into the learning experience.
A key aspect of this is the safe technique provided by the Kangacarrier (see details), the parents get to keep this for continued use !
SKIN-TO-SKIN CONTACT TECHNIQUE DEMONSTRATION
Purpose: to provide all practicing health professionals with direct “hands-on” skills development in techniques to initiate safe continuous skin-to-skin contact. As this may be a daunting and novel idea, I provide some details as to what is entailed below.
Time required 60 – 120 minutes
In the workshop environment I regularly use a manikin to demonstrate the technique for the KangaCarrier. Such demonstration does however not compare with the real life situation. The very concept of removing a baby from the incubator may in real life be frightening for some staff, and sufficient preparation of and knowledge transmission to staff is required beforehand. Careful preparation for the actual demonstration is also essential.
Staff issues: The neonatologist in charge must give his consent, both to my presence in his unit, and to working with any particular mother-infant dyad. His actual presence during the demonstration is desirable but not essential. Likewise the nurse-in-charge of the unit must be consenting, and willing to apply the techniques in the future. A practical way of doing so is to identify one or two key members of staff who can function as “trainers”, whom I will then also train to train, (the nurse in charge can obviously be one herself). Finally, the specific nurse in charge of the baby must be willing. She will remain responsible for the baby’s wellbeing throughout the demonstration, and (along with neonatologist and nurse in charge) has the expressed right to “bail out” and return to routine if she is at all unhappy or uncomfortable at any stage. The actual baby transfer and equipment handling will be done by the nurse-in-charge, with myself in direct support.
Equipment requirements: A recliner chair that allows for fixing of the backrest, or a hospital bed that allows for changing the angle of rest are preferable. Alternatively a comfortable sofa or divan, with pillows that can achieve different angles is adequate. Rocking chairs are not suitable. The chair or bed needs to be positioned so that the required technology is equally accessible to them as to the incubator.
Baby: I am prepared to work with almost any gestation and weight of baby, but I will make my own assessment of the general condition and current state organization of the baby. For this, appropriate consent for me to peruse the patient charts and folder is required. A NICU wishing to implement such changes should start an incremental process with bigger, more stable and less technologically dependent babies, and develop from there. I am therefore happy to start with a completely normal healthy fullterm baby, for which the technique is also applicable. But for the Unit’s sense of confidence, just having witnessed a very small baby in SSC may be helpful to launch the incremental change process. There are some practical details with the positioning of very small infants, and the management of the technology, which I like to point out.
Mother: The mother is the most important! She should be able to give informed consent, which requires that she has some knowledge of what she is consenting to. This may be difficult, but attending a GR or other lecture works fine. Consent should also be obtained by a “third party”, someone the mother does not feel beholden to such that she feels she ought to agree even if she is unhappy. I also prefer that from the outset the father (spouse or partner) be included in the request for consent, and that he be present for the demonstration. (Father’s can and should do SSC, and I am happy to demonstrate on fathers also!) The mother should be told that her consent is preliminary, and that she and her partner will be interviewed by me before any demonstration, and that she may refuse after finding out more details from me.
(It is very valuable for the change process to have media support and coverage, and media generally love the idea. Particular care and sensitivity should however be taken in selecting mothers for such exposure, a particular personality is required ! )
At such an interview, I will introduce myself, and I will ask if mother wants the nurse in charge of her baby to be present or not. I will explain briefly the purpose of the demonstration, and at an early stage explain that skin-to-skin contact requires no brassiere and therefore some very brief exposure of her breasts to me as the doctor doing the technique, and to any audience that she is willing to allow. I attempt to corroborate her sensitivity with partner, and invite refusal of consent. If she does consent, I ask specifically if she is prepared to be photographed, and undertake to convey and enforce her refusal. I establish the size of audience she will tolerate. (Issues about purpose of demonstration, exposure, photos, audience, refusal and bailout can all be covered by staff eliciting preliminary consent, but I will nevertheless go over those again.)
I explain the role of the nurse in charge, including the “right of bail-out”, and extend that right also to the mother to exercise at any time. I establish when she last fed her baby, and how she feels about the baby at that moment in time. The skin-to-skin demonstration should preferably be timed to follow immediately after a feed, the worst time is just before a scheduled feed. The mother should be prepared to spend longer than one hour providing SSC. I then use a manikin to explain what I will do, in terms of the baby, the wrapper, the shirt, the technology and her own reactions. I do the actual demo while speaking through all the stages, from equipment preparation, chest preparation, baby preparation, placement, securing of baby, positioning of baby and mother, and mobilization of mother. Mother is exposed for two brief moments only, and baby is not exposed to any cold stress at any stage.
For a single dyad, this takes less than one hour. Preferably there should be three or more dyads, allowing for “time juggling” for feeds, state organization, procedures, refusals, decompensations and other unforeseen events. Part of the demo does involve observations during the SSC time, during which time simple psychological support (e.g. allowing crying) to the mother (and or father) should be available. The technique requires regular changing of position timed to feeds, such a change can be included, but can also be managed by the nurse. Such a change can also entail changing to father or other primary caregiver. A minimum time for the demonstration is therefore three hours, but can be extended to 8 if different clinical areas and more staff want the benefit of the demonstration.
At the end of the time it is useful to have a debriefing session with staff involved, and perhaps with parents also. Reflections and impressions can be shared, but also practical detail questions and clinical concerns. Initial thoughts to planning ahead can be shared. Making such formal plans to change practice should however be a subsequent and separate exercise, far too much is involved just to start, without allowing for an extensive and responsible change process.