Postpartum Psychosocial Adaptations Ch. 18

Knowledge of Infant Needs

*Responding to infant's cry every time does not spoil the child. Their cry indicates hunger, cold, wetness, and a need for cuddling or gentle stimulation* Teach parents that prompt, gentle responses to crying help the infant develop trust in the world as a safe, secure place. Trust is a basic developmental task of infancy and depends on the child learning that caregivers respond consistently and gently in meeting his or her needs.

Maternal Age

Adjustment to parenthood is a challenge for the teenager who has not achieved a strong sense of her own identity. In general, the adolescent may talk less, respond less, and appear more passive or less affectionate with her infant than older parents. She needs special assistance to develop necessary parenting skills that promote optimal development of the infant

Verbal Behaviors

Also important indicators of maternal attachment Most speak to baby in a high-pitched voice Will start calling baby by name, if they haven't already Verbal behaviors may provide clues to a mother's early psychological relationship with her infant. Nurses observe the interactions of mothers and their infants, and if necessary, teach and model interactions that foster early attachment between them.

Preterm or Ill Infant

Although attachment can still occur in these situations, the separation (NICU) may delay the process and create stress on the normally functioning family

Communication

An interpreter should be fluent in the language, of the same religion, and of the same country of origin, if possible. This is particularly important for Middle Eastern families Respect for privacy and modesty of all people is important, but modesty is esp important in Hispanic, Middle Eastern, and Asian cultures Direct communication can be distressing for some Hispanic and Native Americans. These clients may approach a subject only after exchanging polite comments Nodding or saying yes may be a sign of courtesy rather than understanding or agreement. The nurse should ask family members to repeat in their own words what they have been told

Heading toward a new normal

Appreciating the Body: This phase centers on the way the woman feels physically. Must cope with discomfort such as nipple and perineal pain. Sleep is disrupted by excitement, hospital routines, and her physical discomfort, leaving her fatigued. Differences in appearance. This phase also involves dealing with emotional lability and changes in the way women think and retain information. Settling-In: Involves becoming competent, developing confidence, and accommodating and integrating the infant into the parent's lives. A mother's desire to settle into her own environment may lead her to leave the hospital as soon as possible. The mother becomes more secure with her infant. Confidence builds as the infant gains weight and the mother is able to soothe and care for the infant without help from others. A mother must adapt her needs and activities to meet the needs of the infant. Some mothers find a way to integrate the infant into their usual activities with only minor changes. Becoming a New Family: Glad to be on their own and enjoy spending time alone with their newly developed family

Fostering Independence

As she becomes more independent, allow her to schedule her care as much as possible (ambulating, showering etc) Emphasize that the nurse's role at this point is to assist and teach

Involve Parents in Infant Care

Begin with demonstrations and provide assistance while the parents gradually assume all infant care as their confidence in their abilities grow. Demonstrate the simpler tasks such as care of the cord before progressing to more complicated procedures such as bathing. When the parents receive positive reinforcement for simpler tasks, they are more willing to try the more complicated ones Agreement among the entire staff about how to teach basic care is important Suggestions for care must be tactfully phrased to avoid the implication that parents are inept. "You burped that baby like a professional. There are a couple of little hints I can share about diapering."

Major Maternal Concerns

Body Image: Women very concerned about regaining their normal figures. Some mothers have unrealistic expectations about weight loss and the time it takes for the body to regain its nonpregnant shape. Nurses must emphasize that weight loss should be gradual. Rigid restriction of calories can lead to depleted energy and decreased immunity. Nurses should aslo teach the importance of safe activities such as walking and graduated exercises to regain muscle tone Smoking: Majority of women resume smoking at some point during the first 6 months postpartum. Factors that increase likelihood of relapse include weight concerns and failure to breastfeed. Other factors that may cause smoking are depression, living with a smoker, stress, and planning to quit only during pregnancy. Women who breastfeed their infants are less likely to resume smoking by 26 weeks postpartum. Nurses should discuss smoking with postpartum women to offer resources for those who stopped smoking prenatally and are at risk for relapse. Explanations of hazards to the infant from smoking may also be helpful bc some mothers may think that harmful effects occur only during pregnancy. Postpartum Blues: Mild depression is a frequent concern for new mothers. This mild, transient condition affected 60-80% of women who have given birth. This condition begins in the first week, peaks around day 5, and ends within 2 weeks. If it lasts beyond 2 weeks it may be a serious condition. Characterized by insomnia, irritability, fatigue, tearfulness,mood instability, and anxiety. The symptoms are usually unrelated to events, and the condition does not seriously affect the mother's ability to care for the infant. Nurses should prepare women for the occurrence of mild depressed or negative thoughts, let them know it's normal, and offer emotional support and encouragement. Direct cause is unknown, but it may be a result of emotional letdown that occurs after birth, postpartum discomforts, fatigue, anxiety about her ability to care for her baby, and body image concern. Hormonal fluctuations have not been proven to be a cause. Mother s benefit greatly from empthy and support but because the condition is so common caregivers or family members may not be as empathetic.'Mother needs adequate nutrition and rest. She should be encouraged to take time for herself and discuss her feelings. She should also be reassured that such feelings are normal and generally last less than 2 weeks. Must be distinguished from postpartum depression or psychosis. Screening for risk factors or early signs is important during the birth facility stay. Nurse should teach the woman and family to call if depression becomes severe, lasts longer than 2 weeks, or if she is unable to cope with daily life.

Cesarean Birth

Can make parental adjustment more difficult Longer recovery time and additional discomfort for the mother, increased stress for family, and possible financial strain

Maternal Touch

Changes rapidly as the mother progresses through a discovery phase with her infant Initially mother may not reach for infant, but if the infant is placed in her arms, she holds the baby in an en face position with the infant's face in the same vertical plane as her own so they can have eye contact When the infant is awake, the two engage in prolonged, mutual gazing The mother needs time to get acquainted with her baby She may gently explore the infant's face, fingers, and toes with her fingertips only (fingertipping) which is common during early minutes After fingertipping, the mother begins to stroke the baby's chest and legs with her palm. Next, she uses her entire hand and arms to enfold the infant and to bring her baby close to her body. She holds the newborn closer, strokes the baby's hair, presses her cheek against the infant's cheek, and finally feels comfortable enough to engage in a full range of consoling behaviors. The mother next begins to identify specific features of the newborn ("look how bright his eyes are", "he has his father's nose") This identification process is called claiming or binding-in

Identifying Resources

Community Resources Daycare centers, parenting classes, and breast feeding support groups are available Remind the mother that resources are available when she begins to feel isolated and exhausted

Monitor and Protect

Depends on nurses to monitor and protect her Remind her of the need to void and assist her to ambulate Asses her level of comfort frequently and offer analgesia before discomfort is severe and analgesia is less effective Instruct her not to delay requesting analgesia for that reason

Temperament of the Infant

Effects maternal adjustment. Infants who are calm, easily consoled, and enjoy cuddling increase parental confidence and feelings of competence. In contrast, irritable infants who are difficult to console and do not respond to cuddling increase parental frustration and interfere with attachment

Birth of Multiple Infants

Financial strain More complex family relationships Problems of attachment may occur when there is more than one newborn Rooming-in helps parents gain confidence in care-taking and facilitates the attachment process If infants are in NICU, early frequent contacts should be arranged Arranging the parents to interact with each child alone, esp in the early getting acquainted period, is important Mothers may be overwhelmed at the prospect of breastfeeding more than one infant, they need reassurance that they will produce an ample supply of milk for each infant because supply increases with demand.

Helping Father Co-Parent

Include father in teaching Have him participate in diapering, comforting activities, and feeding or helping the mother breastfeed

Promote Body Attachment

Infants often remain in the room with the mother until complications intervene (mother-baby care, couplet care, dyad care) Nursing measures to promote bonding and attachment includes: 1. Assist the parents in unwrapping the baby to inspect the toes, fingers, and body. Inspection fosters identification and allows the parents to become acquainted with the "real" baby, which much replace the fantasy baby that many parents imagined 2. Position the infant in an "en face" position and discuss the infant's ability to see the parent's face. Face-to-face and eye-to-eye contact is a first step in establishing mutual interaction between the infant and parent 3. Point out the reciprocal bonding activities of the infant. "Look how she holds your finger" or "He hasn't taken his eyes off you" 4. Encourage the parents to take as much time as they wish with the infant. This allows them to progress at their own speed through the discovery or getting-acquainted phase. 5. Assist the mother in putting the infant to the breast if she plans to breastfeed. Reassure her that many infants do not latch onto the breast at first. If she is using formula, assist her in positioning the infant securely and reassure her that holding and cuddling the infant provide comfort and security. Answer her questions about feeding. 6. Model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones 7. Point out the characteristics of the infant in a positive way. 8. Provide comfort and ample time for rest because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. A mother who seems uninterested may just need a period rest or pain intervention to be comfortable enough to focus on the infant.

Information about Newborn

Internet Mail Text: A free service from National Healthy Mothers, Healthy Babies Coalition provides texts with information about pregnancy and infants through one year. Infants must be fed every 2-4 hours and will not sleep through the night for 12-16 weeks Help parents recognize signals that indicate when the infant has had enough interaction and wants to avoid further stimulation. These avoidance cues (looking away, splaying fingers, arching back, fussiness) indicate that the infant needs a quiet time

Grandparents

Involvement depends on many factors, the most important factor is proximity. Grandparents who live near child develop a strong attachment. This evolves into unconditional love and a special relationship that brings grandparents joy and an added sense of security to the grandchildren. Forming a close attachment is more difficult when grandparents live many miles away, Grandparents are often a major part of the support system that new parents need, Grandmother provide assistance with household tasks and infant care, which helps the mother recover from childbirth and make the transition to parenthood. Grandfathers who were very busy providing for their own children may enjoy the opportunity to nurture their grandchildren.

Listen to the Birth Experience

Listen and offer sincere praise for her efforts during labor. Use open-ended questions to determine the woman's perception of the birth Mother's are often busy on the phone telling loved ones about the birth "Excuse me for a moment. I need to check you soon, I can do it now or come back in 10 minutes"

Cultural Influences on Adaptation p.360 read

Major goal of nursing practice in the postpartum period is to provide culture-specific nursing care that fits the health beliefs, values, and practices of each woman

Maternal Temperament

Maternal personality traits greatly influence attachment Mothers who are calm, secure in their ability to learn, and free from unnecessary anxiety adjust more easily to the demands of motherhood. Conversely, mothers who are excitable, insecure, and anxious have more difficulty.

Home and Community-Based Care

Methods currently used to provide care for mothers and infants after discharge include phone calls, nurse-managed postpartum clinics, home visits, and baby lines staffed by nurses who provide info and guidance for callers Psychosocial support including phone calls, home and clinic visits, and breastfeeding and parenting education has been shown to decrease the incidence of hospital readmission of normal newborns Nurses in the birth facility should make nursing diagnoses available to other nurses for follow up care

Redefined Roles

Mother focuses on maintaining a strong, adaptive relationship with her partner. She observes him for any change in behavior and is acutely sensitive to his interaction with the infant. From father's perspective: Anxieties about succeeding in his new role put added pressure on the family. Conflicting demands between work and home, feelings of exclusion, and concerns about his relationship with his partner present additional challenges. The new parents may need to agree on a division of tasks and responsibilities that was not necessary before the birth of the infant. Role assignment can be accomplished quickly in some families and create tension in other families. Nurses can use their communication skills to assist the family in expressing their feelings and concerns so that the changes can be accomplished with minimal stress.

Previous Experience

Multiparas are more comfortable with the infants and exhibit attachment behavior earlier than primiparas , who typically spend many more hours in the early discovery phase

Nonverbal Behavior

Nonverbal behavior is equally as important Validate impressions and conclusions during a psychosocial assessment. Ask how much experience they have had with newborns, what their plans are when they go home etc Intersperse questions over time during normal care-giving. The mother should not feel as if she is being interrogated

Discomfort and Fatigue

Normally discomfort assoc with childbirth resolves within the first days after birth but may make it difficult to focus on the newborn's needs Fatigue often remains a problem during the first few weeks and months, when the infant's schedule is erratic and the chance for uninterrupted sleep is minimal. When the infant begins to sleep through the night (3-4 months), the parent can reestablish familiar patterns, and fatigue often becomes less of a factor

Role Conflict

Occurs when a person's perception of role responsibilities differs significantly from reality Ex.) If mother perceives her responsibility as providing most of the care and comfort for the infant, but reality dictates that she must place the infant with a care-giver and return to full time employment, role conflict may occur If possible, woman should not return to work until they are comfortable in the parenting role and understand the infant's unique needs. Primiparas often do not realize how strong their attachment to the infant will be or how difficult it will be to leave the infant and return to work Intense "separation grief", some may feel jealous of the caregiver, whom they fear will supplant them in the infant's affection Nurse can help by acknowledging these feelings and reassuring the mother that her emotions are normal. Anticipatory guidance from the nurse is important. The mother needs to plan for time to reestablish feelings of closeness when she comes home from work. She needs to develop a schedule that allows max time with the baby when she is at home. She may have to negotiate with another fam member to take over some of the household tasks until she feels more comfortable with the situation

Expectations about the Newborn

Parents may be unprepared for normal newborn characteristics such as cranial molding, blotchy skin, and newborn rash. Nurses must teach them normal newborn characteristics and early growth and development. For example, an infant's stomach is small and the infant must be fed frequently. Also infants are neurologically unable to sleep through the night during the early weeks. Feelings of disappointment regarding gender etc must be resolved before attachment can take place.

Reducing Sibling Rivalry

Plan time with older children Frequent praise and expressions of love and affection help reassure older children of their places in the family Emphasize importance of responding calmly with understanding when a sibling regresses to more infantile behaviors or expresses hostility toward the infant Children older than 3 enjoy being a big brother or big sister and respond well when they are included in infant care Setting aside separate time with children under 3 is important

Helping the Family Adapt

Priority for the first 4-6 weeks should be caring for the mother and the baby Flexible meal schedule Mother sleeps when infant sleeps Limit coffee, teas, colas, and chocolate because they contain caffeine Teach breathing exercises to reduce stress and promote relaxation Infant's behavior is more predictable around 12-16 weeks Encourage having loved ones help with chores etc

Maternal Role Attainment

Process by which mother acheives confidence in her ability to care for her infant and becomes comfortable with her identity as a mother. Process begins during pregnancy and continues for several months after childbirth. The transition to maternal or paternal role includes four stages 1. Anticipatory Stage: Begins during pregnancy when the pregnant woman chooses a physician and location for infant's birth. She may attend childbirth classes to be prepared and feel she has some control over the birth experience. She seeks out role models to help her learn the mother role. 2. Formal Stage: Begins with birth of infant and cont for approx 4-6 weeks. Behaviors are largely guided by others such as health professionals, close friends, and parents. Major task during this stage is for parents to become acquainted with their infants so that the parents can mesh their care-giving with infant cues. 3. Informal Stage: May overlap the formal stage. Begins when mothers have learned appropriate responses to their infant's cues and signals. The mothers begin to respond according to the unique needs of their infants and develop maternal role that fits them rather following textbooks or health professionals directives. 4. Personal Stage: Attained when the mother feels a sense of harmony in the role, enjoys the infant, sees the infant as a central person in her life, and has internalized the parental role. The mother accepts the role of parent and feels comfortable in this role. The range of time for achieving the maternal role is highly variable, with some mothers reaching that point in the first month and others taking much longer. Maternal role attainment implies an end point when the woman adjusts to motherhood. Continues throughout motherhood (becoming a mother) Mothers do not feel competent and self-confident in the mothering role until about 4 months after childbirth

Siblings

Response depends on their age and developmental level Toddlers are usually not completely aware of the impending birth. When the baby arrives , they may see the infant as competition and fear they will be replaced in the parent's affection. Toddler may have feelings of jealousy and resentment when they must share time and attention with a baby. Some toddlers exhibit hostile behaviors toward mother, particularly when she holds or feeds the newborn. Sleep problems, an increase in attention-seeking efforts, and regression to more infantile behaviors such as renewed bed-wetting and thumbsucking are common. These behaviors show jealousy and frustration young children feel as they observe the mother's attention being given to another The parents can be taught how to accept without judgment the strong feelings expressed by the toddler and to continue to reinforce the child's feelings of being loved. Plans for changes in routine, such as beginning toilet training, should be postponed until family adjustments have been made. Preschool siblings may engage in more looking than touching. Most spend at least some time in proximity to the infant and talk to the mother about the infant. Older children may adapt more easily. Sibling classes may help ease the transition At home a relaxed approach without time constraints may facilitate interactions between young children and infants. Special care must be taken by the parents, visitors, and nurses to pay as much attention to the sibling as the new baby. Parents can emphasize the advantages of being an older sibling and can allow siblings to participate in age appropriate aspects of infant care

Puerperal Phases

Should not be used as strict guidelines for maternal assessment, but the phases can help the nurse anticipate maternal needs and intervene to meet those needs Taking In: Mother is primarily focused on her own need for fluid, food, and sleep. Inexperienced nurses may be puzzled by the mother's passive, dependent behavior as she takes in or receives attention and physical care. She also takes in every detail of the neonate but seems content to allow others to make decisions. A major task for the mother during this time is to integrate her birth experience into reality. To do this, she discusses her labor and delivery many times on the phone or for visitors. This process helps the mother recognize that the pregnancy is over and the newborn is now a separate individual. This phase lasts 1 day or less. This phase may be prolonged with cesarean birth, especially in an emergency (these women may have difficulty assimilating the unfamiliar and intrusive procedures that occurred and may have negative perception of birth experience. Women who have had a c-section need continued attention and sensitive care Taking Hold: Mother becomes more independent during this phase. She exhibits concern about managing her own body functions and assumes responsibility for her own care. When she feels comfortable and in control of her body, she shifts her attention to the behaviors of the infant. She compares her infant with other infants to validate wellness and wholeness. She welcomes information about the wide variety of behaviors exhibited in newborns. Mother may verbalize anxiety about her competence as a mother. She may compare her care-taking skills unfavorably with those of the nurse. This phase lasts several days. This phase has been called the teachable, reachable, referable moment. Nurses can take advantage of this ideal time to review previously taught material and provide additional instructions and demonstrations. Letting Go: Time of relinquishment for the mother and often the father. If first child, couple must give up their previous role as a childless couple and acknowledge the loss of the more carefree lifestyle. Many mothers must also give up idealized expectations of the birth. Some parents are disappointed in the size, gender, or characteristics of the infant who does not "match up" with the fantasy baby of pregnancy. They must relinquish the infant of their fantasies and accept the real infant. These losses often provoke feelings of grief that are so subtle they may be unexamined or unacknowledged. Both parents may benefit from discussing these feelings and realize these feelings are common. If mother is very young or pregnancy was unplanned, the feelings of loss and grief may be acute. During this phase, mother refocuses on her relationship with her partner. She may also return to work at this time. This requires relinquishing part of the care of the infant to a caretaker

By Discharge Mother Should

Show progressive attachment behaviors, including enfolding the infant, calling by name, and responding gently when the infant cries. Participation in care should include: diapering, feeding and care of the umbilical cord and circumcision

Dietary Practices

Some cultural dietary practices to consider center on the hot-cold theory of health and diet. This theory refers to the intrinsic properties of certain foods instead of the temperature or spiciness of foods. Although ice water is commonly given to hospital clients, it is not acceptable to many Asians (they may prefer hot or warm beverages to keep warm) Nurses should encourage food brought from home and discuss any dietary restrictions with family.

Assisting the Mother Through Recovery Phases

The early "taking in" phase is a time to "mother" the mother to help her transition to more complex tasks of maternal adjustment Provide ample fluids and favorite foods Keep linens dry, tuck warm blankets around her until chilling has stopped, and use warm water for perineal care

Fathers

The father's developing bond with the newborn is facilitated by engrossment Engrossment: An intense fascination and face-to-face observation between the father and newborn Characterized by father's intense interest in how the infant looks and responds and a desire to touch and hold the baby Many fathers comment on the baby's distinctive features and view the baby as perfect. They experience strong attraction to the infant and elation after the birth The father's attachment behaviors increase when the infant is awake, makes eye contact, and responds to father's voice Fathers may lack confidence in providing infant care and are sensitive to being left out of instructions and demonstrations of infant care The nurse can assist the new father by involving him in child care activities soon after birth to help him feel more confident and competent Often need more information about normal growth and development during infancy Parents should be encouraged to negotiate the division of household chores during pregnancy or shortly after delivery

"Fourth Trimester"

The first 12 weeks at home As the family makes the transition to parenthood and adapts to changes

Attachment

The process by which an enduring bond between a parent and child developed through pleasurable, satisfying interaction. The process begins in pregnancy and extends for many months after childbirth The infant receives warmth, food, and security from parent The parent, usually mother, accepts responsibility for the infant's care and places the child's needs above her own for years to come. In return she receives enjoyment and establishes her identity as a mother. Both benefit from the formation of irreplaceable links that continue long after the child ceases to be dependent. Attachment follows a progressive or developmental course that changes over time. It is rarely instantaneous Attachment behaviors of inexperienced or first-time mothers do not differ significantly from those of experienced mothers Occurs through mutually satisfying experiences, therefore if mother is in pain or physically exhausted, she needs pain relief and assistance so she is able to enjoy the early experiences with baby *Unlike bonding, attachment is reciprocal* it occurs in both directions between parent and infant Facilitated by positive feedback, either real or perceived, from the infant. For example, an infants grasp around mothers finger means "I love you" to the -parent. Alert infants have a repertoire of responses called reciprocal attachment behaviors. These behaviors are the infant's part in the process of early attachment that progresses to lifelong, mutual devotion *(table p. 352)*

Bonding

The rapid initial attraction felt by parents for their infant It is undirectional, from parent to child, and is enhanced when parents and infants are permitted to touch and interact during the first 30-60 minutes after birth During this time, the infant is in a quiet, alert state and seems to gaze directly at the parents Infants are often placed skin-to-skin on mom's chest or abdomen for bonding time immediately after delivery Nurses frequently delay procedures, such as measurements and medication administration that would interfere with this time Early and sustained contact between parents and infant can enhance bonding and attachment. However, if early contact between parent and infant is limited bc of an obstetric emergency or neonatal illness, bonding and attachment can still occur at a later time

Availability of a Strong Support System

p. 360 Self- explanitory

Health Beliefs

p. 361 READ