Study overview

This study was a single-center prospective randomized (1:1 allocation) controlled trial. The pregnant women were randomly divided into EENC and conventional groups by using a random number table automatically generated by a computer. The staff who performed at least 90 minutes of SSC during and after cesarean were blinded to the randomization procedure. The study coordinator placed allocation details in a non-transparent, sealed envelope and concealed them from recruiters, data collectors, and allocators. After recruitment and baseline data collection, another study coordinator opened the envelopes and assigned participants to the EENC group and the conventional groups, which with the ending number is an odd number were in the EENC group and an even number of women were in the conventional group. Recruitment, data collection and data analysis were carried out by the corresponding assistant researchers, researchers and statisticians. Due to the nature of the study, participants were not blinded to the group’s intervention, but both physicians and Doulas were blinded.

Establishment of an intraoperative EENC team for cesarean delivery

Doulas are trained professionals that provide comprehensive support during the cesarean delivery. Only full-time obstetric nurses with 3 years of experience, good communication skills, intraoperative EENC theory and skills training, and who passed the examination to ensure the homogenization of intraoperative SSC implementation steps were assigned to implement intraoperative EENC during cesarean delivery. Meanwhile, they were volunteered to perform intraoperative SSC as a doulas. Doulas in the two groups were identically qualified, which in the two groups helped the mother to make eyes contact with the newborn, and the routine nursing and psychological counseling were the same. Differing in mother-infant SSC, the EENC group, the skin contact between mother and newborn was carried out in strict accordance with the requirements of basic health care technology for newborns at early stage, and the skin contact lasted for 90 minutes immediately after the umbilical cord was cut off.

Intervention methods

The following steps were performed in the conventional group: thorough drying of the newborn after delivery, delayed umbilical cord weaning, early mother–infant SSC (the guide nurse started SSC within 10–30 minutes after birth, and the duration of intraoperative SSC was at least 30 minutes, and the cessation of SSC at the latest postoperatively), and returning to the ward for routine care.

Moreover, the following steps were performed in the EENC group: After delivery of a newborn by cesarean section, the neonate was immediately placed supine on a dry towel on the mother’s abdomen, and drying of the neonate was started within 5 seconds. The drying maneuver was completed within 20 to 30 seconds and the newborn was thoroughly dried. During the drying of the newborn, the assistant touches the umbilical artery, waits for the umbilical artery pulsation to stop, and ties the umbilical cord approximately 1 to 3 minutes after birth. After ligating the umbilical cord, the operator hands the newborn to the guide nurse. Doulas initiated SSC within 5–10 minutes after birth until surgery is completed. At the end of the cesarean section, in order to ensure the safety of the newborn, the newborn was temporarily separated from the mother, and when the mother was moved to the surgical cart postoperatively, the newborn was placed on the mother’s chest to continue the SSC was continued, returning to the ward to continue SSC to accumulate ≧ 90 minutes, reaching the time when the newborn can stop breastfeeding on their own, and after-care routine similar to the conventional group.

Intraoperative immediate SSC safety management points include the correct procedure of performing chest–skin warming; the newborn should be in a prone position on their mother’s bare chest after cutting the umbilical cord; the newborn’s chest and abdomen should touch their mother’s chest for maximum skin contact; they should face toward the breast; pay attention to warmth; when the newborn starts using their tongue, the head should be turned or lifted, and other breastfeeding signals should be performed to help complete the first breastfeeding; intraoperative SSC should continue until surgery is completed. Meanwhile, doulas should always observe the newborn’s skin color, breathing, sucking response and the routine check-up and weighing should be recorded and completed before returning to the ward.

Observed indicators (1)

Breastfeeding indicators: ① Breastfeeding initiation and the duration of first breastfeeding: initiation of direct skin contact of the mother’s chest and abdomen against the newborn’s chest and abdomen skin contact after delivery of the newborn [11], the newborn correctly latches the nipple and most of the areola, and the establishment of regular effective sucking and swallowing [12] for the start of breastfeeding time and duration. ② Onset of lactogenesis II: the time point approximately 72 hours after delivery when large quantities of breast milk starts to be secreted, at which time the mother perceives that the milk rises and the breast is full [13]. Timing of initiation of initiation of lactation phase II by a combination of maternal report and staff assessment. Staff will informed the phenomenon of the onset of lactogenesis II. to mother advancely. And around 48–72 hours postpartum, most women feel that their breasts were fullness or swelling and their breasts products abundant milk. When they felt the above-mentioned situation, they should informed the staff immediately. To ascertain the onset of the lactogenesis II. staff will observe and squeeze both sides of the areola,and then assess milk spillage. ③ Breastfeeding self-efficacy score: the breastfeeding self-efficacy scale (BSES) was scored [14] between 30 and 150, with higher scores representing higher breastfeeding self-efficacy and higher self-confidence in independent breastfeeding skills. ④ Exclusive breastfeeding rate during hospitalization: newborns were exclusively breastfed, except for administration of vitamins and minerals. The rate of exclusive breastfeeding for mothers who underwent cesarean delivery during hospitalization was calculated for both groups. ⑤ Maternal satisfaction scores: a self-designed cesarean delivery satisfaction questionnaire was distributed before discharge, including 10 items (cesarean delivery maternal and infant care, first maternal and infant SSC, breastfeeding, maternal and infant cesarean delivery outcome), with each item scored on a Likert 5-point scale (total score of 5 to 20), with higher scores indicating higher maternal perceptions. The questionnaire’s Cronbach alpha coefficient was 0.839 after the pre-survey.

(2)

Maternal and infant health indicators: ① Incidence of neonatal hypothermia: the axillary temperature of the newborn is < 36.0 °C at any time within 24 hours after birth. ② Incidence of neonatal hypoglycemia: neonatal heel blood glucose of < 2.2 mmol/L at any time within 24 hours after birth. We only monitor blood glucose in newborns at high risk for hypoglycemia. ③ Cumulative blood loss within 24 hours postpartum:it was measured by weighing the weight of the immersion pad and then minus the weight of the dry pad. The weight of 100 g is about equal to 100 ml(ml) of blood.