Timely Cord Clamping
Early cord clamping (prior to 30 seconds before birth) has been discouraged in the last decade, instead, the umbilical cord is recommended to be clamped in the first 60 to 180 seconds after birth and preferably before the first 2 minutes of life [20]. Delayed cord clamping (after the cord still has a pulse) is about 3 minutes [21] and delayed cord clamping for 2-3 minutes increases neonatal blood by 30-40% or 25-30 mL/kg. With the onset of physiological hemolysis, iron is stored in the infant’s body, which is sufficient for at least 3-11 months [22].
Although delayed cord clamping is effective in infants’ health and reduces their mortality, prolonged delay may result in polycythemia [23] and hyperbilirubinemia [23, 24]. It should be noted that hyperbilirubinemia requiring phototherapy and polycythemia are not significant when the umbilical cord is clamped during the first 180 seconds after birth and may lead to complications such as hyperbilirubinemia and neonatal icterus if it is clamped up to 3 minutes and more [25]. Therefore, the best cord clamping time is reported to be between 30 seconds to 2 minutes after birth. Cord clamping between 30 second and 2 min allows for most of the blood transfer from the placenta to the infant.
Infection Control Practices
Nosocomial infections are common adverse events that can have irreparable consequences for care recipients in the operating room [3, 26]. Infants are more vulnerable to infection and hence much care should be taken to prevent infection transmission [27], and infection control standards should be strictly observed [28, 29]. This is especially important in premature infants with low birth weight [27, 29, 30].
Adequate Operating Room Temperature and Humidity
Hypothermia can cause cardiac arrhythmias and cardiovascular collapse in infants [31], and it can lead to dehydration or even burns [32, 33]. Hypothermia can result in cerebral hypoxia and encephalopathy and even infant death [12]. The WHO recommends a room temperature of 24-26 °C that can reduce cold stress in infants [34]. It has been emphasized that infants should be dried and their back should be covered to prevent hypothermia during skin to skin contact [12]. On the other hand, hyperthermia and placing infants in front of a high temperature source with no control may lead to their dehydration or even burns [32, 33]. Adequate Operating Room Temperature is essential for prevention of hypothermia and hyperthermia in infants during C-section surgery [35].
Fall
Falls can cause irreparable injuries and even death due to brain hemorrhage [13]. Infants should be transported in special beds with safety bed rails, and when they are carried in the arms by everyone, such as nurse or parent, their head and neck should be securely supported and their body should be firmly attached to the nurse or parent body to minimize the risk of falling. Education on proper carrying of an infant should be taught to parents, family members, and all caregivers of the infant. Skin to skin contact (SSC) should not be performed when the mother is unconscious or sleepy and infants should be placed in their bed; in case of SSC, infants should be fully supported by the nurse or another person and be watched at all times [12].
Safe Sleep
Safe position results in hemodynamic, physiological and neurological stability in neonates [36]. Inappropriate positioning and improper sleeping can lead to irreparable injuries; therefore, correct sleeping position of infants has been emphasized [37]. Infants should preferably be in the supine position on firm and secure beds with non-saggy mattress without a pillow. Unprotected and unsuitable beds should not be used [38]. Under special conditions, infants can be positioned in lateral or prone positions. Their neck should be supported and their body should be aligned [36]. In the prone position, food remains less in the stomach and it is suggested to place infants in the prone position in the first half hour after feeding [39].
However, it is emphasized that infants should not be in the prone position when sleeping because this increases the incidence of sudden death during sleep [38]. During SSC, infants should be positioned safely while their shoulder and chest are in front of the mother’s face, their head should be properly positioned and turned to one side, their face should be visible all the time, their nose and mouth should be un covered, and their legs should be slightly flexed [12].
Medication Error
The choice of medication and the right dosage of medication are significantly important in infants [40]. Medication error and wrong dosage and infusion are preventable adverse events [3]. In order to avoid the possibility of errors in stressful conditions during neonatal surgeries and C-section, updating the knowledge of medication selection and right dosage by physicians [40], employing experienced and committed staff [4, 41], continuous group training [42] and interdisciplinary training [13] through simulation [5] are necessary, and the staff should be prepared for real situations in high-risk infants requiring mechanical resuscitation and ventilation [5]. Other considerations for reducing the possibility of medication error include the use of intact equipment [14].
Perioperative Injuries in Infants
The possibility of perioperative injuries, such as unwanted incisions during opening of the uterus [3], can be reduced through teamwork [43, 44], employing experienced and dedicated staff [4, 41], continuous team training [42] as well as interdisciplinary training [13] through simulation [5], and using proper and intact equipment and checking equipment before use to ensure their proper functioning [14].
Error in Registering Infants' Identity
Error in registering infants' identity should be a never event. Stavroudis, Miller et al (2008) reported that 11% of NICU errors involved misidentification [14]. Patient misidentification can occur among neonates given the high rate of multiple births and the practice of using ‘‘BB’’ (baby boy) or ‘‘BG’’ (baby girl) instead of her or his mother name. With correct registration of the mother and infant identities on the newborn identification band and using safe surgical checklist could prevent infants' misidentification and a decrease in medication errors [11, 45].
Implications for Practice
Neonates are at further risk for harm from medication errors because of inability to communicate with providers; and changing developmental systems affecting drug absorption, distribution, metabolism, and excretion. So for improvement in infant’s safety during C-section, it is important that teamwork and additional measures such as operating interdisciplinary training through simulation and employing experienced and committed staff for prevention of nosocomial infection and Perioperative Injuries. Safety measures such as consider cord time clamping to decrease hyperbilirubinemia and anemia. Additional measures such as operating room temperature for prevention hyperthermia and hypothermia as well as neonatal transport, safe sleep and caregiver education for prevention of falls and sudden death. Error in registering infants' identity should be a never event for prevention of medication error.