Murray: Foundations of Maternal-Newborn and Women's Health Nursing, 5th Edition

Chapter 18: Postpartum Psychosocial Adaptations Instructors Manual

OBJECTIVES
1. Explain the process of bonding and attachment, including maternal touch and verbal

interactions.
2. Describe the progressive phases of maternal adaptation to childbirth and the stages of

maternal role attainment.

3. Identify maternal concerns and the way they change over time. 4. Discuss the cause, manifestations and interventions related to postpartum blues. 5. Describe the processes of family adaptation to the birth of a baby. 6. Discuss factors that affect family adaptation. 7. Discuss cultural influences on family adaptation. 8. Describe assessments and interventions related to postpartum psychosocial adaptations. 9. Discuss the need for additional care of the mother and infant after discharge from the

birth facility.

OUTLINE/LECTURE GUIDE I. Process of Becoming Acquainted A. Bonding 1. Initial attraction for neonate felt by parents 2. Enhanced when parent and infant are permitted to touch and interact 3. Delay procedures that can interfere with this time B. Attachment 1. Bond to a child develops through satisfying interaction 2. Process begins in pregnancy and extends for many months 3. Both parent and child benefit from the formation of irreplaceable links 4. Important concepts a. Process follows a progressive or developmental course that changes over time b. Facilitated by positive feedback from infant c. Occurs through mutually satisfying experiences 5. Attachment is reciprocal between parent and infant
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C. Maternal touch 1. Maternal behavior changes rapidly as mother discovers infant 2. Initially holds baby in a face-to-face position (Figure 18-1) 3. Mother gently explores infant with her fingertips (Figure 18-2) 4. May stroke with palm of her hand 5. Gradually enfolds infant (Figure 18-3) 6. Claiming or binding in as she identifies specific features (Figure 18-4) D. Verbal behaviors 1. Speak in high-pitched voice 2. Provide clues to early psychological relationship to infant 3. Nurses must observe interactions to foster early attachment II. Process of Maternal Adaptation A. Puerperal phases to attain comfort in role of mother 1. Taking-in phase a. Focused on own need for fluid, food, and sleep b. Allows others to make decisions c. Mother is integrating her birth experience into reality d. May be prolonged if complications occur 2. Taking-hold phase a. Mother becomes more independent b. Assumes responsibility for own self-care c. Begins to shift attention to infant d. Welcomes information about newborn behavior e. May verbalize anxiety about her competence as a mother f. Ideal time to provide instructions and demonstrations 3. Letting-go phase a. Couple relinquishes role as a childless couple b. Give up idealized expectations of birth experience c. Relinquish infant of their fantasyaccept real infant d. Allow to verbalize feelings of grief B. Maternal role attainment 1. Mother achieves confidence in her ability and identity as a mother

Instructors Manual 2. Stages of transition a. Anticipatory stage begins during pregnancy b. Formal stage begins with birth of infant and lasts for 4 to 6 weeks c. Informal stage begins when parents learn to respond to infant's cues d. Personal stage attained when parent feels comfortable in parental role C. Heading toward a new normal 1. Appreciating the body 2. Settling in 3. Becoming a new family D. Redefining roles 1. Focuses on maintaining a strong relationship with her partner 2. New parents must share tasks and responsibilities 3. Lack of flexibility can lead to tension and frustration 4. Nurse assists family to express concerns and feelings E. Role conflict 1. Occurs when perception of role differs from reality 2. Parental role may conflict with need for employment a. Help mother acknowledge feelings and recognize as normal b. Develop a schedule that allows maximum time with infant c. Negotiate with other family members to take over household tasks F. Major maternal concerns 1. Body image a. Concerns about regaining normal figure b. May have unrealistic expectations c. Need adequate calories to supply energy and produce milk d. Participate in activities, such as walking, to regain muscle tone 2. Postpartum blues a. Mild depression a frequently expressed concern (1) Condition has an early onset (2) Usually lasts no longer than 2 weeks b. Characterized by fatigue, weeping, mood instability, and anxiety c. Does not usually affect ability of mother to care for infant d. Direct cause unknownmay be hormone-related

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e. Self-limiting, but mother needs support of family and health care workers III. The Process of Family Adaptation A. Fathers 1. Developing bond to newborn called engrossment 2. Characterized by intense interest in infant's looks and ways the infant responds 3. Desire to touch and hold baby 4. Experience strong attraction to infant 5. Many variables contribute to the development of a strong tie to the newborn 6. Look forward to parenting but lack confidence 7. Want to be included in learning about infant care 8. Need information about child care after the child is born B. Siblings 1. Response to new baby depends on age and developmental level a. Toddlers not usually aware of impending birth (1) May view infant as competition (2) Negative behaviors may surface and indicate stress (3) Jealousy and frustration may manifest as hostile behaviors toward mother b. Preschoolers engage in more looking than touching (Figure 18-6) 2. Parents need to affirm their continued love and affection 3. Parents and visitors must pay attention to the sibling C. Grandparents 1. Grandparents living nearby develop a strong attachment 2. May live many miles away and it is difficult to form a close attachment 3. Expectations of the role of grandparents differ 4. Often are a major part of the support system of the new parents IV. Factors Affecting Family Adaptation A. Discomfort and fatigue 1. May make it difficult to focus on needs of newborn 2. Remain a problem since infant's schedule is erratic B. Knowledge of infant needs

Instructors Manual 1. May become anxious if unable to console crying infant 2. Have many concerns about specific procedures 3. Want to know if infant is adequately nourished a. Breast-feeding adds to stress experienced 4. Concerns about spoiling the infant C. Previous experience with newborns affects family adjustment D. Expectations for the newborn 1. Unprepared for normal characteristics of newborn's appearance 2. May have anticipated different newborn behaviors 3. Nurses need to teach normal growth and development 4. Parent may be disappointed with sex of child a. Must acknowledge these feelings b. Must deal with these feelings before attachment can take place E. Maternal age 1. Parenthood a challenge for teenager 2. Teenagers need special assistance to develop necessary parenting skills F. Maternal temperament 1. Personality traits a major influence on attachment a. Calm, secure mother adjusts more easily b. Excitable and insecure mother has more difficulty G. Temperament of the infant 1. Infant who is calm and easily consoled increases parental confidence 2. Irritable infants who do not respond to cuddling increase parental frustration H. Availability of strong support system is a major factor in maternal adjustment I. Unanticipated events 1. Cesarean birth can make parental adjustment more difficult a. Financial strain b. Longer recovery time c. Additional discomfort d. Increased stress for family 2. Preterm or ill infant a. Prolonged separation b. Delay attachment

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3. Birth of multiple infants a. Can present problems of attachment b. Must interact with each child individually c. Encourage parents to relate to each infant as an individual d. Early, frequent contacts help parents gain confidence e. May be overwhelmed at prospect of breast-feeding multiple infants V. Cultural Influences on Adaptation A. Provide nursing care that is culture specific 1. Fits health beliefs, values, and practices of a particular culture 2. Becoming difficult because of increasing ethnic diversity 3. Be aware of cultural beliefs and acknowledge importance B. Communication 1. Verbal communication may be difficult 2. Provide an interpreter if possible 3. Privacy and modesty are especially important in some cultures 4. Tactfulness and warmth are important C. Health beliefs 1. Cultural beliefs and practices provide a sense of security 2. Health beliefs related to breast-feeding and hygiene can cause conflict postpartum 3. Specific practices should be accepted and supported D. Dietary practices 1. Encourage bringing foods from home VI. Home Care and Community-Based Care A. Assessments and interventions often occur in the home B. May leave birth facility while still in taking-in phase 1. May not have fully recovered from childbirth 2. Psychosocial concerns may surface later when support is inadequate C. Review methods to provide care for mothers after discharge D. Communication between nurses in home and hospital is extremely important

Instructors Manual VII. Application of the Nursing Process: Maternal Adaptation A. Assessment (Table 18-1) B. Analysis (Box 18-1) 1. Determine parents' ability to create or continue a nurturing environment 2. Risk for altered parenting can be related to many factors a. Fatigue b. Discomfort c. Lack of knowledge C. Planning: expected outcomes 1. Verbalize feelings of comfort and support 2. Demonstrate progressive attachment behaviors 3. Participate in care of the newborn D. Interventions 1. Assisting the mother through recovery phases a. Care for mother so she can move on to more complex tasks b. Provide physical care and comfort c. Meet food and fluid needs 2. Monitor and protect a. Assist to ambulate and remind her to void b. Assess level of comfort, offer analgesia 3. Listen to the birth experience a. Mother will want to recount the details of her experience b. Offer praise for her efforts during labor 4. Fostering independence a. Allow her to schedule her care if possible b. Encourage her to assume responsibility for self-care 5. Promoting bonding and attachment a. Early, unlimited contact is of primary importance b. Nurses providing mother-baby care helps parents be more prepared for discharge c. Research emphasizes value of infant remaining in the mother's room (1) Prolonged contact leads to more touching (2) Mother has more time to learn newborn's needs

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d. Assist parents to inspect the infant e. Position the infant in an en face position f. Point out reciprocal bonding activities g. Allow infant to remain with parents as long as they wish h. Assist with positioning for feeding i. Model behaviors j. Point out positive characteristics of the infant k. Provide comfort and ample time for rest 6. Involving parents in infant care a. Providing care is an important component of attachment b. Helps parents to develop confidence in their ability c. Review and demonstrate infant care procedures d. Provide teaching that is consistent for all the staff e. Allow time for practice f. Offer repeated praise and encouragement E. Evaluation VIII. Application of the Nursing Process: Family Adaptation A. Assessment 1. Fathers a. Assess father's emotional status and interaction with infant b. Assess father's role as the primary support person c. Help father develop realistic expectations of newborn behavior d. Provide information about mother's needs during recovery period 2. Observe reactions of siblings to the newborn 3. Observe involvement of other family members 4. Assess nonverbal behavior B. Analysis 1. Identify family strengths and problem areas (Table 18-2) 2. Identify areas where nursing intervention can promote family adaptation 3. Altered family processes can be related to a number of factors C. Planning: goals and outcomes 1. Family will verbalize understanding of infant needs and behaviors

Instructors Manual 2. Family will identify methods for reducing stress 3. Family will describe measures to reduce sibling rivalry 4. Family will identify external resources and support systems D. Interventions 1. Teaching the family about the newborn a. Provide information about infant behavior b. Provide information about physical and psychological needs c. Discuss importance of responding to infant cues d. Also need to recognize signals that stimulation should be avoided 2. Helping the family adapt a. Provide anticipatory guidance about stress reduction b. Emphasize priority of caring for mother and baby c. Establish a relaxed home atmosphere and a flexible schedule d. Recommend that mother conserve energy for infant care e. Do not let visitors interfere with adequate rest for mother f. Instruct family about need to restrict intake of caffeine g. Teach relaxation exercises h. Delay tiring projects until infant is more predictable i. Encourage open expression of feelings j. Parents need health, nutrition, and recreation k. Enlist others to help with meals and shopping 3. Helping the father co-parent 4. Providing ways to reduce sibling rivalry a. Plan time alone with older sibling b. Reassure older children of their place in the family c. Offer frequent expressions of love and affection d. Guide visitors not to focus exclusively on infant e. Respond calmly if older child shows regressive behavior or hostility f. Include older children in infant care 5. Identify family and/or community sources of support E. Evaluation 1. Parents learn appropriate response to infant behavior 2. Mother obtains adequate rest

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3. Parents are able to reduce stress of anxiety in siblings 4. Parents identify and use external resources