Why Immediate Skin-to-Skin After Caesarean Births Still Isn’t Routine (And Why That Needs to Change)

What if I told you one of the simplest, safest, most powerful things you can do for your baby after birth… still isn’t routine in many hospitals?

Even with decades of research behind it.

Even when the birth is planned.

Even when everyone is healthy.

I’m talking about skin-to-skin after a caesarean birth.

This is not a luxury. It’s evidence-based care. And it’s time we made it standard.

 

Skin-to-Skin: Why It Matters So Much

Skin-to-skin contact is not just a lovely bonding moment (though it is that too). It’s biologically expected care.

When babies are placed directly on a mother’s bare chest after birth, their breathing, heart rate, temperature, blood sugar, and stress levels all stabilise more quickly than if they’re placed in a cot or warmer. They cry less, settle more easily, and are less likely to require NICU admission. Mothers have lower anxiety and pain scores, more oxytocin, and improved breastfeeding outcomes.

Skin-to-skin also helps with microbiome seeding—that means your baby is being colonised by your friendly bacteria, which helps train their immune system and protect them from harmful bugs. This is especially important after a caesarean birth, when babies don’t pass through the birth canal and might miss that first exposure.

“Holding the newborn in skin-to-skin contact immediately after birth and continuing without interruptions for the first hour or more is now recognised as more than simply physical contact at the beginning of a new life—it is also the start of the psychosocial attachment process and the optimal physical transition mechanism for the newborn and mother.”

— Brimdyr et al., 2023

 

Timing Is Critical

 

In 2023, global experts published a new guideline in Acta Paediatrica clearly stating that SSC should be immediate, uninterrupted, and continuous—for all mothers and all babies, including those born by caesarean and those born preterm.

This means starting SSC within seconds, not minutes, after birth. And yes, it can be done safely—right there on the operating table—with the right support.

The guideline also stressed that routine newborn procedures (like weighing, measuring, and even resuscitation in many cases) can be safely delayed until after SSC. The evidence is clear: babies do better when they stay with their mothers. And if SSC is delayed unnecessarily, the evidence shows we risk missing a sensitive period for bonding, breastfeeding, and neurological development.

 

 

The Long-Term Impact: New Evidence From the IPISTOSS Trial

Also in 2023, The IPISTOSS trial, published in JAMA Network Open (2023), found that very preterm babies (28–33 weeks gestation) who received SSC in the first 6 hours of life with either parent showed significantly better social and communicative behaviours at 4 months of age.

These weren’t small differences—babies who experienced early SSC were more engaged, more interactive, and displayed greater positive affect at age 4 months. The effect size was moderate to large. And interestingly, in most cases, it was the fathers who provided that early skin-to-skin contact—especially after caesarean birth.

This is huge. It tells us that even just a few hours of close contact, at the very start of life, can shape how a baby interacts with the world months later. These aren’t just short-term benefits—we’re talking about brain development, attachment, and emotional wellbeing.

 

What About Safety?

A 2020 systematic review by Frederick, Fry and Clowtis looked at the outcomes of intraoperative SSC during caesarean birth. Across multiple studies, they found no significant differences in vital newborn measures like:

• Temperature
• Apgar scores
• Oxygen saturation
• Heart rate

In other words: immediate skin-to-skin after a caesarean does not compromise newborn safety.

Instead, the review highlighted clear benefits—like improved bonding, better breastfeeding outcomes, and greater maternal satisfaction. The authors encouraged clinicians to treat SSC as standard, evidence-based practice, not a luxury.

In fact, the Acta Paediatrica 2023 guideline states that SSC is safe even for babies as small as 1000 grams, provided they are breathing and have stable heart rates. That’s preterm babies, surgical babies, and tiny babies—all included.

 

 

What Women Say They Want

In 2019, a study by Stevens and colleagues explored what women want after caesarean birth—and what happens when they don’t get it.

Women shared that:

• They felt disconnected, sorrowful, and even angry when they were separated from their babies after birth
• They wanted to explore their naked baby, even if they felt unsure or nervous
• They wanted their partner involved in theatre and recovery, to witness bonding and feel close as a family
• Most importantly—they said holding their baby close “just felt right”

 

This is a powerful reminder that clinical care isn’t just about safety. It’s about helping mothers feel emotionally connected and present at the start of their parenting journey.

 

Skin-to-Skin and Delayed Cord Clamping: The Dynamic Duo

It’s worth noting that immediate skin-to-skin contact and delayed cord clamping are like two peas in a pod—both are vital parts of a gentle, physiology-respecting start to life.

And like SSC this isn’t just a nice idea—it’s now recommended by the World Health Organization for all babies, at all births, including caesarean births.

 

Here’s what the research shows it can do:

 

For all babies:

Increased blood volume

Improved iron stores

Reduced risk of anaemia

Smoother transition to life outside the womb

More stem cells

Less chance of needing a blood transfusion

 

For Preterm Babies, It’s Even More Important:

Better circulation as they adapt

Fewer blood transfusions

Lower risk of NEC (necrotising enterocolitis, a serious gut condition that preemies are more vulnerable to).

Lower risk of brain bleeds (IVH) (intraventricular haemorrhage, a type of bleeding in the brain that’s more common in very early babies)

Lower risk of death

Higher haemoglobin levels

(Yan et al, 2023)

And the good news? According to recent research, this can absolutely be done safely during both elective and nonelective caesarean births, without increasing maternal blood loss or causing harm to babies. In fact, one study even found that severe postpartum haemorrhage was significantly lower in the delayed clamping group.

When combined with uninterrupted skin-to-skin contact, babies not only benefit from improved thermoregulation and colonisation with their parent’s microbiome, but they also remain more physiologically stable while transitioning to life outside the womb.

The frustrating part? Neither practice is routine in many theatres. But that’s a whole other blog…

 

 

So What’s Getting in the Way?

The Kelly & Harper-McDonald (2021) review looked at exactly this question—why, despite all the benefits, is immediate skin-to-skin contact still not happening after caesarean section in many hospitals?

 

Here’s what they—and many others—are seeing in practice:

 

 1. Outdated Theatre Routines

In many hospitals, babies are still routinely taken to a warmer after caesarean, even when they’re vigorous and crying. —just because “that’s how it’s always been done.” But the evidence clearly supports assessing babies on the mother’s chest unless there’s a clear clinical need for separation.

✔ SSC supports physiological stability, even in preterm babies (IPISTOSS, 2023).
✔ No differences in vital signs (including temperature) when SSC is started in theatre (Frederick et al., 2020).

 

2. Paediatricians Still Saying No

In some cases, it’s the attending paediatrician who calls the shots. They may prefer to check baby on a separate surface, even if there’s no urgent concern. But we now have strong evidence—including the Acta Paediatrica guideline—that skin-to-skin is safe and beneficial, and routine checks can be done with baby on their mother’s chest.

✔ Global guidelines support immediate SSC as safe and beneficial (Brimdyr et al., 2023).

 

3. Anaesthetists Feeling Unsure

Some anaesthetists are reluctant to support SSC in theatre, citing concerns about drips, ECG leads, monitoring, or theatre sterility. These are legitimate considerations—but they’re not deal-breakers. Many hospitals around the world safely support skin-to-skin in theatre every day with a cooperative, well-trained team.

 

4. Lack of Policy or Protocol

Without a clear protocol, whether SSC happens often depends on who’s on shift. A supportive midwife might make it happen, but if the anaesthetist or paediatrician says no, parents miss out. This is where hospital policies, staff education, and leadership are key.

 

 5. Physical Layout of Theatres

Some operating rooms simply aren’t set up for SSC. There may be no space for a midwife to support mum and baby, or no privacy for parents. But again, this is a system issue—not a safety one—and it’s fixable. These are logistical issues that can absolutely be addressed with planning.

 

 6. Staff Shortages and Time Pressures

When staff are stretched thin, SSC is often seen as an “extra” rather than essential. Facilitating it can feel too hard when there aren’t enough hands on deck to support the process safely.

However, SSC helps babies stabilise faster, potentially reducing NICU admission and the need for extra staff.

 

7. Lack of Training and Confidence

Many staff simply haven’t been trained to support SSC after caesarean. Without hands-on education, they may worry about baby’s position, maternal safety, or interrupting theatre workflow. This is fixable with education and simulation training.

 

8. Cultural Beliefs or Misunderstandings

Some staff still believe SSC is only for vaginal births or think it’s optional. Others may come from care models where separation is routine. Shifting culture takes education, leadership, and listening to women. SSC should be the default for all births,

 

9. The Assumption That Mum Can’t Hold Baby

There’s a common belief that after a spinal or epidural, a woman won’t be able to safely hold her baby. But research shows that most women can—with gentle positioning and someone nearby to keep watch. Women aren’t fragile. They can do this.

 

10. No One Thinks to Offer It to the Partner

When mum can’t do skin-to-skin—due to a general anaesthetic or complications—often, no one offers it to the partner. But as the IPISTOSS study showed, SSC with the other parent still leads to measurable developmental benefits. Dads, partners, co-parents—they all matter too.

 

11. Interdepartmental Disconnect

Without coordination between maternity, neonatal, anaesthetic, and theatre teams, SSC can fall through the cracks. Communication is key, and multidisciplinary protocols make all the difference.

 

12. Fear From Previous Incidents

If a unit has had a previous scare or adverse event during SSC—regardless of cause—it can lead to blanket restrictions. We need thoughtful reflection and evidence-based responses, not knee-jerk reactions.

 

 

So, Where Do We Go From Here?

 

This isn’t about placing blame on individual staff. This is about systems, training, and culture. If we want babies to have the best start, we need:

• Clear protocols for immediate SSC after caesarean
• Multidisciplinary education, including paediatricians and anaesthetists
• Parent preparation so they can advocate for SSC in their birth preferences
• Flexible theatre practices that prioritise bonding, not just efficiency

 

And above all—we need to stop treating this as optional.

“Women wanted their baby to stay with them and have skin-to-skin contact, even if they felt apprehensive about providing this care.”

— Stevens et al., 2019

 

 

 If You’re Planning a Caesarean…

Here are some things you can do:

• Ask your care provider if they support immediate skin-to-skin in theatre
• Include your SSC preferences in your birth plan
• Discuss practical ways of facilitating SSC (eg gown on backwards, ECG leads on your back, IV in non-dominant arm, etc)
• Discuss with your partner who will provide SSC if you’re unable
• Let your midwife know you’d like your baby assessed on your chest if well

 

Because those first moments matter—for bonding, breastfeeding, and long-term wellbeing.

This excellent blog by the wonderful Dr Sarah Buckley will help you create your caesarean birth plan: How to Have the Best Cesarean

 

Final Thoughts

Skin-to-skin is not just a warm and fuzzy extra—it’s a critical part of newborn care. The science is in. The benefits are clear. And the time to act is now.

Let’s stop letting theatre routines and outdated policies rob families of this golden time, that they will never get back.

Let’s make immediate skin-to-skin after caesarean birth the standard of care—not the exception.

 

A Personal Note…

I’ve been banging on about skin-to-skin for years—because the evidence has been there for years. In fact, I first wrote about this back in 2016 when a prominent obstetrician told the media that skin-to-skin was “just a fad.” 🙄

I wrote this blog in response:

👉 Skin-to-Skin: Not a Fad

I hope he’s kept up with the research since then.

 

 

 

📚 References:

Brimdyr, K., Stevens, J., Svensson, K., Blair, A., Turner-Maffei, C., Grady, J., Bastarache, L., Al Alfy, A., Crenshaw, J., Giugliani, E., Ewald, U., Haider, R., Jonas, W., Kagawa, M., Lilliesköld, S., Maastrup, R., Sinclair, R., Swift, E., Takahashi, Y., & Cadwell, K. (2023). Skin-to-skin contact after birth: Developing a research and practice guideline. Acta Paediatrica, 112(8), 1633–1643. https://doi.org/10.1111/apa.16842

Frederick, A., Fry, T., & Clowtis, L. (2020). Intraoperative mother and baby skin-to-skin contact during cesarean birth: A systematic review. MCN: The American Journal of Maternal/Child Nursing, 45(6), 332–339. https://doi.org/10.1097/NMC.0000000000000659

Kelly, L., & Harper-McDonald, B. (2021). Challenges in achieving immediate skin-to-skin contact following birth by elective caesarean section: A narrative review of the literature. MIDIRS Midwifery Digest, 31(1), 96–100.

Lilliesköld, S., Lode-Kolz, K., Rettedal, S., Lindstedt, J., Linnér, A., Pike, H. M., Ahlqvist-Björkroth, S., Ådén, U., & Jonas, W. (2023). Skin-to-skin contact at birth for very preterm infants and mother-infant interaction quality at 4 months: A secondary analysis of the IPISTOSS randomised clinical trial. JAMA Network Open, 6(11), e2344469. https://doi.org/10.1001/jamanetworkopen.2023.44469

Stevens, J., Schmied, V., Burns, E., & Dahlen, H. G. (2019). Skin-to-skin contact and what women want in the first hours after a caesarean section. Midwifery, 74, 140–146. https://doi.org/10.1016/j.midw.2019.03.020

World Health Organization (WHO), & United Nations Children’s Fund (UNICEF). (2018). Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – The revised Baby-friendly Hospital Initiative. WHO. https://www.who.int/publications/i/item/9789241513807

Purisch, S. E., Ananth, C. V., Rouse, D. J., Tita, A. T. N., Werner, E. F., Rice, M. M., Saade, G. R., & Grobman, W. A. (2023). Association of Delayed Cord Clamping With Maternal and Neonatal Outcomes in Cesarean Delivery. AJOG Global Reports, 3(4), 100269. https://doi.org/10.1016/j.xagr.2023.100269