Postpartum physiology. Nursing care of the Postpartum Woman. Transition to parenthood
Prepared by assistant professor N.Petrenko, MD, PhD
• Describe the anatomic and physiologic changes that occur during the postpartum period.
• Identify characteristics of uterine involution and lochial flow and describe ways to measure them.
• List expected values for vital signs and blood pressure, deviations from normal findings, and probable causes of the deviations.
• Identify the priorities of maternal care given during the fourth stage of labor.
• Identify common selection criteria for safe early postpartum discharge.
• Summarize nursing interventions to prevent infection and excessive bleeding, to promote normal bladder and bowel patterns, and to care for the breasts of women who are breastfeeding or bottle-feeding.
• Explain the influence of cultural expectations on postpartum adjustment.
• Identify psychosocial needs of the woman in the early postpartum period.
• Discuss discharge teaching and postpartum home care.
• Discuss ways to facilitate parent-infant adjustment.
• Describe sensual responses that strengthen attachment.
• Identify infant behaviors that facilitate and inhibit parental attachment.
• Differentiate three periods in parental role change after childbirth.
• Identify behaviors of the three phases of maternal adjustment.
• Discuss paternal adjustment.
• Discuss the effects of the following on parental response: parental age (adolescence and over 35 years), social support, culture, socioeconomic conditions, personal aspirations, and sensory impairment.
• Describe sibling adjustment.
• Describe grandparent adaptation.
KEY TERMS AMD DEFINITIONS
afterbirth pains (afterpains) Painful uterine cramps that occur intermittently for approximately 2 or 3 days after birth and that result from contractile efforts of the uterus to return to its normal involuted condition
autolysis The self-destruction of excess hypertrophied tissue
diastasis recti abdominis Separation of the two rectus muscles along the median line of the abdominal wall
involution Reduction in size of the uterus after birth and its return to its nonpregnant condition
lochia Vaginal discharge during the puerperium consisting of blood, tissue, and mucus
lochia alba Thin, yellowish to white, vaginal discharge that follows lochia serosa on approximately the tenth day after birth and that may last from 2 to 6 weeks postpartum
lochia rubra Red, distinctly blood-tinged vaginal flow that follows birth and lasts 2 to 4 days
lochia serosa Serous, pinkish brown, watery vaginal discharge that follows lochia rubra until approximately the tenth day after birth
pelvic relaxation Lengthening and weakening of the fascial supports of pelvic structures
puerperium Period after the third stage of labor and lasting until involution of the uterus takes place, usually approximately 3 to 6 weeks; fourth trimester of pregnancy
subinvolution Failure of the uterus to reduce to its normal size and condition after pregnancy
couplet care One nurse, educated in both mother and infant care, functions as the primary nurse for both mother and infant (also known as mother-baby care or single-room maternity care)
engorgement Swelling of the breast tissue brought about by an increase in blood and lymph supplied to the breast, which precedes true lactation
fourth stage of labor The first 1 or 2 hours after birth
Homans sign Early sign of phlebothrombosis of the deep veins of the calf in which there are complaints of pain when the leg is in extension and the foot is dorsiflexed
thrombus Blood clot obstructing a blood vessel that remains at the place it was formed
uterine atony Relaxation of uterus; leads to postpartum hemorrhage
warm line A help line, or consultation service, for families to access; most often for support of newborn care and postpartum care after hospital discharge
acquaintance Process used by parents to get to know or become familiar with their new infant; an important step in attachment attachment A specific and enduring affective tie to another person
biorhythmicity Cyclic changes that occur with established regularity, such as sleeping and eating patterns
bonding A process by which parents, over time, form an emotional relationship with their infant
claiming process Process by which the parents identify their new baby in terms of likeness to other family members, differences, and uniqueness
en face Face-to-face position in which the parent's and infant's faces are approximately 20 cm apart and on the same plane
engrossment A parent's absorption, preoccupation, and interest in his or her infant; term typically used to describe the father's intense involvement with his newborn
entrainment Phenomenon observed in the microanalysis of sound films in which the speaker moves several parts of the body and the listener responds to the sounds by moving in ways that are coordinated with the rhythm of the sounds (infants have been observed to move in time to the rhythms of adult speech but not to random noises or disconnected words or vowels); believed to be an essential factor in the process of maternal-infant bonding
letting-go phase Interdependent phase after birth in which the mother and family move forward as a system with interacting members
mutuality Parent-infant interaction in which the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics
postpartum blues A let-down feeling, accompanied by irritability and anxiety, which usually begins 2 to 3 days after giving birth and disappears within a week or two; sometimes called "baby blues"
reciprocity Type of body movement or behavior that provides the observer with cues, such as the behavioral cues infants provide to parents and parents' responses to cues
sibling rivalry A sibling's jealousy of and resentment toward a new child in the family
synchrony Fit between the infant's cues and the parent's response
taking-hold phase Period after birth characterized by a woman becoming more independent and more interested in learning infant care skills; learning to be a competent mother is an important task
taking-in phase Period after birth characterized by the woman's dependency; maternal needs are dominant, and talking about the birth is an important task
transition to parenthood Period of time from the preconception parenthood decision through the first months after birth of the baby during which parents define their parental roles and adjust to parenthood
The postpartum period is the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state. This period is sometimes referred to as the puerperium, or fourth trimester of pregnancy. The physiologic changes that occur during the reversal of the processes of pregnancy, though distinctive, are normal. To provide care during the recovery period that is beneficial to the mother, her infant, and her family, the nurse must synthesize knowledge of maternal anatomy and physiology of the recovery period, the newborn's physical and behavioral characteristics, infant care activities, and family response to the birth of the infant. This chapter focuses on anatomic and physiologic changes that occur in the mother during the postpartum period.
REPRODUCTIVE SYSTEM AND ASSOCIATED STRUCTURES
The return of the uterus to a nonpregnant state following birth is known as involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.
At the end of the third stage of labor the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus is approximately the size it was at 16 weeks of gestation (about the size of a grapefruit) and weighs approximately 1000 g.
Fig. 1 Assessment of involution of uterus after childbirth. A, Normal progress, days 1 through 9. B, Size and position of uterus 2 hours after childbirth. C, Two days after childbirth. D, Four days after childbirth. (B, C, D, Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Within 12 hours the fundus may be approximately 1 cm above the umbilicus (Fig. 1). Involution progresses rapidly during the next few days. The fundus descends 1 to 2 cm every 24 hours. By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis. A week after birth the uterus once again lies in the true pelvis. The uterus should not be palpable abdominally after the ninth postpartum day.
The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50 to 60 g (see Fig. 1).
Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.
Postpartum hemostasis is achieved primarily by compression of intramyometrial blood vessels as the uterine muscle contracts rather than by platelet aggregation and clot formation. The hormone oxytocin, released from the pituitary gland, strengthens and coordinates these uterine contractions, which compress blood vessels and promote hemostasis. During the first 1 to 2 postpartum hours, uterine contractions may decrease in intensity and become uncoordinated. Because it is vital that the uterus remain firm and well contracted, exogenous oxytocin (Pitocin) is usually administered intravenously or intramuscularly immediately after expulsion of the placenta. Mothers who plan to breastfeed may also be encouraged to put the baby to breast immediately after birth because suckling stimulates oxytocin release from the posterior pituitary gland.
In first-time mothers, uterine tone is good, the fundus generally remains firm, and the mother does not perceive uterine cramping. Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called afterbirth pains (afterpains), which persist throughout the early puerperium. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.
Immediately after the placenta and membranes are expelled, vascular constriction and thromboses reduce the placental site to an irregular nodular and elevated area. Upward growth of the endometrium causes sloughing of necrotic tissue and prevents the scar formation that is characteristic of normal wound healing. This unique healing process enables the endometrium to resume its usual cycle of changes and to permit implantation and placentation in future pregnancies. Endometrial regeneration is completed by the end of the third postpartum week, except at the placental site. Regeneration at the placental site usually is not complete until 6 weeks after birth.
Postchildbirth uterine discharge, commonly called lochia, initially is bright red and changes later to a pinkish red or reddish brown. It may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.
Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. Approximately 10 days after childbirth the drainage becomes yellow to white (lochia alba). Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia alba may continue for 2 to 6 weeks after the birth.
If the woman receives an oxytocic medication, the flow of lochia is usually scant until the effects of the medication wear off. The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then may experience a gush of blood when she stands. This gush should not be confused with hemorrhage.
Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding approximately 10 days after birth is from the healing placental site. However, any bleeding occurring 3 to 4 weeks after birth may be caused by infection or subinvolution. Continued flow of lochia serosa or lochia alba may indicate endometritis, particularly if fever, pain, or abdominal tenderness is associated with the discharge. Lochia should smell like normal menstrual flow; an offensive odor usually indicates infection.
Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth may be due to unrepaired vaginal or cervical lacerations. Table 1 distinguishes between lochial and nonlochial bleeding.
TABLE 1 LOCHIAL AND NONLOCHIAL BLEEDING
Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts
If the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia.
A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).
If the amount of bleeding continues to be excessive and bright red, a tear may be the source.
The cervix is soft immediately after birth. By 18 hours postpartum it has shortened, become firm, and regained its form. The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth. The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. The cervical os, which dilated to 10 cm during labor, closes gradually. Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks. The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth." Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.
VAGINA AND PERINEUM
Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae. The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened. The mucosa remains atrophic in the lactating woman, at least until menstruation resumes. Thickening of the vaginal mucosa occurs with the return of ovarian function. Estrogen deficiency is also responsible for a decreased amount of vaginal lubrication. Localized dryness and coital discomfort (dyspareunia) may persist until ovarian function returns and menstruation resumes. The use of a water-soluble lubricant during sexual intercourse is usually recommended.
Initially, the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman if lacerations and an episiotomy have been carefully repaired, hematomas are prevented or treated early, and the woman observes good hygiene during the first 2 weeks after birth.
Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. A good light source is essential for visualization of some episiotomies. Healing of an episiotomy is the same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or loss of approximation (separation of the edges of the incision) may occur. Healing should occur within 2 to 3 weeks.
Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.
Pelvic muscular support
The supporting structure of the uterus and vagina may be injured during childbirth and may contribute to later gynecologic problems. Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone. Kegel exercises, which help to strengthen perineal muscles and encourage healing, are recommended after childbirth. Later in life, women can experience pelvic relaxation, the lengthening and weakening of the fascial supports of pelvic structures. These structures include the uterus, upper posterior vaginal wall, urethra, bladder, and rectum.
Significant hormonal changes occur during the postpartal period. Expulsion of the placenta results in dramatic decreases of the hormones produced by that organ. Decreases in human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium. Mothers with type 1 diabetes will be likely to require much less insulin for several days after birth. Because these normal hormonal changes make the puerperium a transitional period for carbohydrate metabolism, it is more difficult to interpret glucose tolerance tests.
Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed (Bowes & Katz, 2002).
β-Human chorionic gonadotropin (/3-hCG) disappears from maternal circulation in 14 days (Resnik, 1999).
PITUITARY HORMONES AND OVARIAN FUNCTION
Lactating and nonlactating women differ considerably in the time when the first ovulation occurs and when menstruation resumes. The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present (Resnik, 1999).
Prolactin levels in blood rise progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth (Rebar, 1999). Serum prolactin levels are influenced by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. Individual differences in the strength of an infant's sucking stimulus probably also affect prolactin levels. In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeks (Rebar, 1999).
Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth. In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns (Resnik, 1999). Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium (Rebar, 1999).
The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume.
When the woman stands up during the first days after birth, her abdomen protrudes and gives her a still-pregnant appearance. During the first 2 weeks after birth the abdominal wall is relaxed. It takes approximately 6 weeks for the abdominal wall to return almost to its nonpregnancy state. The skin regains most of its previous elasticity, but some striae may persist. The return of muscle tone depends on previous tone, proper exercise, and the amount of adipose tissue. Occasionally, with or without overdistention because of a large fetus or multiple fetuses, the abdominal wall muscles separate, a condition termed diastasis recti abdominis (see Fig. 8-13). Persistence of this defect may be disturbing to the woman, but surgical correction rarely is necessary. With time, the defect becomes less apparent.
The hormonal changes of pregnancy (i.e., high steroid levels) contribute to an increase in renal function; diminishing steroid levels after childbirth may partly explain the reduced renal function that occurs during the puerperium. Kidney function returns to normal within 1 month after birth. From 2 to 8 weeks are required for the pregnancy-induced hypotonia and dilation of the ureters and renal pelves to return to the nonpregnant state (Resnik, 1999). In a small percentage of women, dilation of the urinary tract may persist for 3 months, which increases the chance of developing a urinary tract infection.
The renal glycosuria induced by pregnancy disappears, but lactosuria may occur in lactating women. The blood urea nitrogen increases during the puerperium as autolysis of the involuting uterus occurs. This breakdown of excess protein in the uterine muscle cells also results in a mild (+1) proteinuria for 1 to 2 days after childbirth in approximately 50% of women (Simpson & Creehan, 2001). Ketonuria may occur in women with an uncomplicated birth or after a prolonged labor with dehydration.
Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body to rid itself of excess fluid. Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.
URETHRA AND BLADDER
Birth-induced trauma, increased bladder capacity following childbirth, and the effects of conduction anesthesia combine to cause a decreased urge to void. In addition, pelvic soreness caused by the forces of labor, vaginal lacerations, or the episiotomy reduces or alters the voiding reflex. Decreased voiding combined with postpartal diuresis may result in bladder distention. Immediately after birth, excessive bleeding can occur if the bladder becomes distended because it pushes the uterus up and to the side and prevents the uterus from contracting firmly. Later in the puerperium overdistention can make the bladder more susceptible to infection and impede the resumption of normal voiding (Resnik, 1999). With adequate emptying of the bladder, bladder tone is usually restored 5 to 7 days after childbirth.
The mother usually is hungry shortly after the birth and can tolerate a light diet. Most new mothers are very hungry after full recovery from analgesia, anesthesia, and fatigue. Requests for double portions of food and frequent snacks are not uncommon (see Research box).
Weight and Fat Gain During Pregnancy and Postpartum
Obesity is a risk factor for a variety of diseases. Its prevalence is increasing in the United States and at earlier ages. Central obesity, or abdominal fat, as demonstrated by a greater waist-to-hip ratio, is the most valuable predictor of disordered glucose tolerance, which predisposes the patient to diabetes and gestational diabetes. Many women trace weight gain to their pregnancies. Previous studies have documented that most women in developed countries accumulate subcutaneous fat during pregnancy, affecting postpartum weight retention with only minimal effects on infant birth weight.
To assess whether patterns of weight and fat gain during pregnancy differed by body mass index (BMI), researchers studied 77 United Kingdom women during pregnancy and 47 of them to 6 months postpartum. The following BMI categories were used: underweight, BMI < 19.8; normal, 19.8 > BMI < 26; overweight, 26 > BMI £ 29; obese, BMI > 29. The BMI in early pregnancy was the baseline. Weight and skinfold thickness at five sites (triceps, biceps, subscapular, suprailiac, and midthigh) were measured at 13, 25, and 36 weeks of gestation and at 6 weeks and 6 months postpartum.
Overall, weight gain was not significant from 13 weeks of gestation to 6 months postpartum, but fat gain was significant. Normal-weight women had little variance in their gain and loss curves. Overweight women had the most dramatic weight gains and weight losses. Obese women showed the highest values for fat mass at 6 months. Whereas other groups lost fat during the postpartum, obese women gained fat.
IMPLICATIONS FOR PRACTICE
In preconception counseling, nurses can advise women why it is important to attain normal body weight before getting pregnant. In prenatal counseling, obese women can be encouraged to try to limit pregnancy weight gain to 15 pounds. After the birth, nurses can offer suggestions and support to postpartum patients, especially those who are obese, about ways to increase exercise and decrease fat intake to lose weight sensibly and safely. Referrals to weight loss programs and support groups may be important interventions to help the woman continue to be successful after the postpartum period.
A spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth. This delay can be explained by decreased muscle tone in the intestines during labor and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration. The mother often anticipates discomfort during the bowel movement because of perineal tenderness as a result of episiotomy, lacerations, or hemorrhoids and resists the urge to defecate. Regular bowel habits should be reestablished when bowel tone returns.
Obstetric trauma (e.g., direct injury to the sphincter muscle, damage to the innervation of the pelvic floor) is perhaps the leading cause of anal incontinence in otherwise healthy women (Toglia, 1996). Women should be taught during pregnancy about episiotomy and its possible sequelae. Pelvic floor (Kegel) exercises should be encouraged.
Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.
As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening.
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.
Changes in blood volume after birth depend on several factors, such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. Blood loss results in an immediate but limited decrease in total blood volume. Thereafter, most of the blood volume increase during pregnancy (1000 to 1500 ml) is eliminated within the first 2 weeks after birth, with return to nonpregnancy values by 6 weeks postpartum (Simpson & Creehan, 2001).
Pregnancy-induced hypervolemia (an increase in blood volume of at least 40% more than prepregnancy values near term) allows most women to tolerate considerable blood loss during childbirth. Many women lose approximately 300 to 400 ml of blood during vaginal birth of a single fetus and approximately twice this much during cesarean birth.
Readjustments in the maternal vasculature after childbirth are dramatic and rapid. The woman's response to blood loss during the early puerperium differs from that in a nonpregnant woman. Three postpartal physiologic changes protect the woman by increasing the blood volume: (1) elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10% to 15%, (2) loss of placental endocrine function removes the stimulus for vasodilation, and (3) mobilization of extravascular water stored during pregnancy occurs. Thus hypovolemic shock usually does not occur in women who experience a normal blood loss.
Pulse rate, stroke volume, and cardiac output increase throughout pregnancy. Immediately after the birth they remain elevated or rise even higher for 30 to 60 minutes as the blood that was shunted through the uteroplacental circuit suddenly returns to the maternal systemic venous circulation. Data regarding the exact time of return of cardiac hemodynamic levels to normal are not available, but cardiac output values remain elevated for at least 48 hours after birth, decrease rapidly in the first 2 weeks postpartum, and return to prepregnancy level by 24 weeks postpartum. Stroke volume, cardiac output, end-diastolic volume, and systemic vascular resistance values have been shown to remain greatly elevated for as long as 12 weeks postpartum (Resnik, 1999).
Few alterations in vital signs are seen under normal circumstances. There may be a small, transient rise in both systolic and diastolic blood pressure that lasts approximately 4 days after the birth (Table 2). Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.
TABLE 2 Vital Signs After Childbirth
DEVIATIONS FROM NORMAL FINDINGS AND PROBABLE CAUSES
During first 24 hours may rise to 38° C as a result of dehydrating effects of labor. After 24 hours the woman should be afebrile.
A diagnosis of puerperal sepsis is suggested if a rise in maternal temperature to 38° C is noted after the first 24 hours after childbirth and recurs or persists for 2 days. Other possibilities are mastitis, endometritis, urinary tract infections, and other systemic infections.
Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. It then begins to decrease. By 8 to 10 weeks after childbirth, the pulse has returned to a nonpregnant rate.
A rapid pulse rate or one that is increasing may indicate hypovolemia as a result of hemorrhage.
Respirations should decrease to within the woman's normal prebirth range by 6 to 8 weeks after birth.
Hypoventilation may follow an unusually high subarachnoid (spinal) block or epidural narcotic after a cesarean birth.
Blood pressure is altered slightly if at all. Orthostatic hypotension, as indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours as a result of the splanchnic engorgement that may occur after birth.
A low or decreasing blood pressure may reflect hypovolemia secondary to hemorrhage. However, it is a late sign, and other symptoms of hemorrhage usually alert the staff. An increased reading may result from excessive use of vasopressor or oxytocic medications. Because pregnancyinduced hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is needed. If a woman complains of headache, hypertension must be ruled out as a cause before analgesics are administered.
Hematocrit and hemoglobin
During the first 72 hours after childbirth, there is a greater loss of plasma volume than in the number of blood cells. This results in a rise in hematocrit and hemoglobin levels by the seventh day after the birth. There is no increased red blood cell (RBC) destruction during the puerperium, but any excess will disappear gradually in accordance with the life span of the RBC. The exact time at which RBC volume returns to prepregnancy values is not known, but it is within normal limits when measured 8 weeks after childbirth (Bowes & Katz, 2002).
White blood cell count
Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common. Neutrophils are the most numerous white blood cells. Leukocytosis coupled with the normal increase in erythrocyte sedimentation rate that occurs may obscure the diagnosis of acute infections at this time.
Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first few days after childbirth (Bowes & Katz, 2002). Factors I, II, VIII, IX, and X decrease within a few days to nonpregnant levels. Fibrin split products, probably released from the placental site, can also be found in maternal blood.
Varicosities (varices) of the legs and around the anus (hemorrhoids) are common during pregnancy. Varices, even the less common vulvar varices, regress (empty) rapidly immediately after childbirth. Surgical repair of varicosities is not considered during pregnancy. Total or nearly total regression of varicosities is expected after childbirth.
Neurologic changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth.
Pregnancy-induced neurologic discomforts abate after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve. The periodic numbness and tingling of fingers that afflicts 5% of pregnant women usually disappears after the birth unless lifting and carrying the baby aggravates the condition. Headache requires careful assessment. Postpartum headaches may be caused by various conditions, including pregnancy-induced hypertension, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for epidural or spinal anesthesia. Depending on the cause and effectiveness of the treatment, the duration of the headaches can vary from 1 to 3 days to several weeks.
Adaptations of the mother's musculoskeletal system that occur during pregnancy are reversed in the puerperium. These adaptations include the relaxation and subsequent hypermobility of the joints and the change in the mother's center of gravity in response to the enlarging uterus. The joints are completely stabilized by 6 to 8 weeks after birth. However, although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not. The new mother may notice a permanent increase in her shoe size.
Chloasma of pregnancy usually disappears at the end of pregnancy. Hyperpigmentation of the areolae and linea nigra may not regress completely after childbirth. Some women will have permanent darker pigmentation of those areas. Striae gravidarum (stretch marks) on the breasts, abdomen, and thighs may fade but usually do not disappear.
Vascular abnormalities such as spider angiomas (nevi), palmar erythema, and epulis generally regress in response to the rapid decline in estrogens after the end of pregnancy. For some woman, spider nevi persist indefinitely.
The abundance of fine hair seen during pregnancy usually disappears after giving birth; however, any coarse or bristly hair that appears during pregnancy usually remains. Fingernails return to their prepregnancy consistency and strength.
Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system.
No significant changes in the maternal immune system occur during the postpartum period. The mother's need for a rubella vaccination or for prevention of Rh isoimmunization is determined.
Nursing Care During the Fourth Trimester
The goal of nursing care in the immediate postpartum period is to assist women and their partners during their initial transition to parenting. The approach to the care of women after birth has changed from one modeled on sick care to one that is wellness-oriented. Consequently, in the United States most women remain hospitalized no more than 1 or 2 days after giving birth and some for as few as 6 hours. Because there is so much important information to be shared with these women in a very short time, it is vital that their care be thoughtfully planned and provided. Care is focused on the woman's physiologic recovery, her psychologic well-being, and her ability to care for herself and her new baby, and includes other family members.
FOURTH STAGE OF LABOR
The first 1 to 2 hours after birth, sometimes called the fourth stage of labor, is a crucial time for mother and newborn. Both are not only recovering from the physical process of birth but are also becoming acquainted with each other and additional family members. During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence.
The fourth stage of labor is an excellent time to begin breastfeeding because the infant is in an alert state and ready to nurse. Breastfeeding at this time also aids in the contraction of the uterus and the prevention of maternal hemorrhage. In most centers the mother remains in the labor and birth area during this recovery time. In an institution where labor, delivery, and recovery (LDR) rooms are used, the woman stays in the same room where she gave birth. In traditional settings, women are taken from the delivery room to a separate recovery area for observation. Arrangements for care of the newborn vary during the fourth stage of labor. In many settings, the baby remains at the mother's bedside and the labor/birth nurse cares for both of them. In other institutions the baby is taken to the nursery for several hours of observation after an initial bonding period with the parents (Fig. 1).
Fig. 1 Mother and father get acquainted with their newborn. (Courtesy Michael S. Clement, MD, Mesa, AZ.)
If the recovery nurse has not previously cared for the new mother, her assessment begins with an oral report from the nurse who attended the woman during labor and birth and a review of the prenatal, labor, and birth records. Of primary importance are conditions that could predispose the mother to hemorrhage, such as precipitous labor, large baby, grand multiparity (i.e., having given birth to six or more viable infants), or induced labor. For healthy women, hemorrhage is probably the most dangerous potential complication during the fourth stage of labor.
During the first hour in the recovery room, physical assessments of the mother are frequent. All factors except temperature are assessed every 15 minutes for 1 hour. Temperature is assessed at the beginning and end of the recovery period. After the fourth 15-minute assessment, if all parameters have stabilized within the normal range, the process is usually repeated once in the second hour. Box 1 and Fig. 2 describe the physical assessment of the mother during the fourth stage of labor. Fig. 3 demonstrates an easy to-use flow sheet that combines the essential immediate postpartum and anesthesia recovery assessments.
BOX 1 Assessment During Fourth Stage of Labor
Before beginning the assessment, wash hands thoroughly, assemble necessary equipment, and explain the procedure to the patient.
Measure blood pressure per assessment schedule.
Assess rate and regularity.
Put on clean examination gloves.
Position woman with knees flexed and head flat.
Just below umbilicus, cup hand and press firmly into abdomen. At the same time, stabilize the uterus at the symphysis with the opposite hand.
If fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to woman's umbilicus. Lay fingers flat on abdomen under umbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between umbilicus and top of fundus. If the fundus is above the umbilicus, this is recorded as plus fb or cm; if below, as minus fb or cm.
If fundus is not firm, massage it gently to contract and expel any clots before measuring distance from umbilicus.
Place hands appropriately; massage gently only until firm.
Expel clots while keeping hands placed as in Fig. 2. With upper hand, firmly apply pressure downward toward vagina; observe perineum for amount and size of expelled clots.
Assess distention by noting location and firmness of uterine fundus and by observing and palpating bladder. Distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a waterfilled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the woman's right side.
Assist woman to void spontaneously. Measure amount of urine voided.
Catheterize as necessary.
Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline.
Observe lochia on perineal pads and on linen under the mother's buttocks. Determine amount and color, note size and number of clots; note odor.
Observe perineum for source of bleeding (e.g., episiotomy, lacerations).
Ask or assist woman to turn on her side and flex upper leg on hip.
Lift upper buttock.
Observe perineum in good lighting.
Assess episiotomy site or laceration repair for intactness, hematoma, edema, bruising, redness, and drainage.
Assess for presence of hemorrhoids.
Fig. 2 Palpating fundus of uterus during the fourth stage of labor. Note that upper hand is cupped over fundus; lower hand dips in above symphysis pubis and supports uterus while it is massaged gently.
Fig. 3 An example of a maternity recovery room record. (Courtesy The Regional Medical Center at Memphis [The Med], Memphis, TN.)
During the fourth stage of labor, intense tremors that resemble shivering from a chill are commonly seen; they are not related to infection. Several theories have been offered to explain these tremors or shivering, such as their being the result of a sudden release of pressure on pelvic nerves after birth, a response to a fetus-to-mother transfusion that occurred during placental separation, a reaction to maternal adrenaline production during labor and birth, or a reaction to epidural anesthesia. Warm blankets and reassurance that the chills or tremors are common, self-limiting, and last only a short while are useful interventions.
The nutritional status of the woman is assessed. Restriction of food and fluid intake and the loss of fluids (blood, perspiration, or emesis) during labor cause many women to express a strong desire to eat or drink soon after birth. In the absence of complications, a woman who has given birth vaginally; has recovered from the effects of the anesthetic; and has stable vital signs, a firm uterus, and small to moderate lochial flow may have fluids and a regular diet as desired (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 1997).
The woman who has given birth by cesarean or has received regional anesthesia for a vaginal birth requires special attention during the recovery period. Recovery from anesthesia requires that cardiopulmonary support and emergency supplies (e.g., resuscitation bag, face mask) be available (Johnson & Johnson, 1996). A postanesthesia recovery (PAR) score is determined for each patient on arrival and updated as part of every 15-minute assessment. Components of the PAR score include activity, respirations, blood pressure, level of consciousness, and color.
NURSE ALERT Regardless of her obstetric status, no woman should be discharged from the recovery area until she has completely recovered from the effects of anesthesia.
If the woman received general anesthesia, she should be awake and alert and oriented to time, place, and person. Her respiratory rate should be within normal limits, and her oxygen saturation levels at least 95%, as measured by a pulse oximeter. If the woman received epidural or spinal anesthesia, she should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.
TRANSFER FROM THE RECOVERY AREA
After the initial recovery period of 1 to 2 hours has been completed, he woman may be transferred to a postpartum room in the same or another nursing unit. In facilities with labor, delivery, recovery, postpartum (LDRP) rooms, the nurse who provides care during the recovery period usually continues caring for the woman. Women who have received general or regional anesthesia must be cleared for transfer from the recovery area by a member of the anesthesia care team.
In preparing the transfer report, the recovery nurse uses information from the records of admission, birth, and recovery. Information that must be communicated to the postpartum nurse includes identity of the health care provider; gravidity and parity; age; anesthetic used; any medications given; duration of labor and time of rapture of membranes; oxytocin induction or augmentation; type of birth and repair; blood type and Rh status; group B streptococci status; status of rubella immunity; syphilis and hepatitis serology test results; intravenous infusion of any fluids; physiologic status since birth; description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of pediatrician or pediatric nurse practitioner; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.
Most of this information is also documented for the nursing staff in the newborn nursery. In addition, specific information should be provided regarding the infant's Apgar scores, weight, voiding, stooling, and whether fed since birth. Nursing interventions that have been completed (e.g., eye prophylaxis, vitamin K injection) must also be recorded.
Women who give birth in birthing centers may go home within a few hours, after the woman's and infant's conditions are stable.
DISCHARGE—BEFORE 24 HOURS AND AFTER 48 HOURS
Early postparturn discharge, shortened hospital stay, and 1-day maternity stay are all terms for the decreasing length of hospital stays of mothers and their babies after a low risk birth. The trend of shortened hospital stays is based largely on efforts to reduce health care costs coupled with consumer demands to have less medical intervention and more family-focused experiences (Ferguson & Englehard, 1997; Wilkerson, 1996).
LAWS RELATING TO DISCHARGE
Health care providers have expressed concern with shortened stays because some medical problems do not show up in the first 24 hours after birth and new mothers have not had sufficient time to learn how to care for their newborns and identify newborn health problems such as jaundice and dehydration related to breastfeeding difficulties (Havens & Hannan, 1996).
The concern for the potential increase in adverse maternalinfant outcomes from hospital early discharge practices led the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other professional health care organizations to promote the enactment of federal and state maternity length-of-stay bills to ensure adequate care for both the mother and the newborn. The passage of the Newborns' and Mothers' Health Protection Act of 1996 provides minimum federal standards for health plan coverage for mothers and their newborns (Ferguson & Engelhard, 1997). Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow the new mother and newborn to remain in the hospital for a minimum of 48 hours after a normal vaginal birth and for 96 hours after a cesarean birth unless the attending provider, in consultation with the mother, decides on early discharge.
CRITERIA FOR DISCHARGE
Early discharge with postpartum home care can be a safe and satisfying option for women and their families when it is comprehensive and based on individual needs (Wilkerson, 1996). Hospital stays must be long enough to identify problems and to ensure that the woman is sufficiently recovered and prepared to care for herself and the baby at home.
It is essential that nurses consider the medical needs of the woman and her baby and provide care that is coordinated to meet those needs in order to provide timely physiologic interventions and treatment to prevent morbidity and hospital readmission. With predetermined criteria for identifying low risk in the mothers and newborns (Box 2), the length of hospitalization can be based on medical need for care in an acute care setting or in consideration of the ongoing care needed in the home environment (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 1997; Weekly & Neumann, 1997).
BOX 2 Criteria for Early Discharge
Uncomplicated pregnancy, labor, vaginal birth, and postpartum course
No evidence of premature rupture of membranes
Blood pressure, temperature stable and within normal limits
Voiding adequate amounts without difficulty
Hemoglobin >10 g
No significant vaginal bleeding; perineum intact or no more than second-degree episiotomy or laceration repair; uterus is firm
Received instructions on postpartum self-care
Term infant (38 to 42 weeks) with weight appropriate for gestational age
Normal findings on physical assessment
Temperature, respirations, and heart rate within normal limits and stable for the 12 hours preceding discharge
At least two successful feedings completed (normal sucking and swallowing)
Urination and stooling have occurred at least once
No evidence of significant jaundice in the first 24 hours after the birth
No excessive bleeding at the circumcision site for at least 2 hours
Screening tests performed according to state regulations; tests to be repeated at follow-up visit if done before the infant is 24 hours old
Initial hepatitis B vaccine given or scheduled for first follow-up visit
Laboratory data reviewed: maternal syphilis and hepatitis B status; infant or cord blood type and Coombs test results if indicated
No social, family, or environmental risk factors identified
Family or support person available to assist mother and infant at home
Follow-up scheduled within 1 week if discharged before 48 hours after the birth
Documentation of skill of mother in feeding (breast or bottle), cord care, skin care, perineal care, infant safety (use of car seat, sleeping positions), and recognizing signs of illness and common infant problems
Care paths provide the nurse with an organize
d approach toward meeting essential maternal-newborn care and teaching goals within a limited time frame (see Care Path). Care paths can be developed for vaginal or cesarean births. Other methods such as postpartum order sets and maternal-newborn teaching checklists (Fig. 4) can be used to accomplish patient care and educational outcomes.
CARE PATH 24-Hour Vaginal Birth Without Complications
Date of Birth: ____________________
Hour of Birth: ____________________
The uncomplicated vaginal birth patient's admission/discharge is based on a 24-hour length of stay postbirth based on individual needs.
PULMONARY PHYSIOLOGIC FOCUS
ADM. TO PP UNIT—8 HOUR
Woman will have normal vital signs (VS) as documented on flowsheet
NA MET VARIANCE
Woman will have normal VS and moderate lochia rubra
NA MET VARIANCE
Woman will have normal VS and minimal lochia rubra
NA MET VARIANCE
Woman will have normal VS and minimal lochia rubra
NA MET VARIANCE
Vital signs every 15 min x 1 hour, then hourly Assess perineum/episiotomy Ice pack prn Assess lochia
Vital signs every 4 hours
Ice pack prn
ADM. TO PP UNIT—8 HOURS
Vital signs every shift
Ice pack prn
Vital signs every shift
Ice pack prn
Woman will have appropriate lab work done and medication given by time of transfer to mother/baby unit
NA MET VARIANCE
Woman will begin to verbalize understanding of hepatitis status and medication requirements
NA MET VARIANCE
Woman will have appropriate lab work done by 16 hours PP
NA MET VARIANCE
Woman will have appropriate lab work done and appropriate meds initiated
NA MET VARIANCE
CBC, if not done before birth Urine drug screen if ordered U/A—dipstick (Send to lab, if abnormal)
Review hepatitis B status
Medication regimen initiated
ADM. TO PP UNIT—8 HOURS
Review rubella status
Review Hgb and Hct
Rubella vaccine, if appropriate
RhoGAM, if indicated
Parent will be up to bathroom before transfer
NA MET VARIANCE
Woman will resume normal nutritional status and bladder function
NA MET VARIANCE
Woman will resume normal nutritional status
and bladder function
NA MET VARIANCE
Woman will have normal bowel and bladder function
NA MET VARIANCE
Assess bladder fullness
Assist to bathroom
Assess for tolerance of PO intake
Encourage PO fluids
Assist to bathroom as needed
Assess bladder function
Encourage PO intake
ADM. TO PP UNIT—8 HOURS
Encourage PO fluids
Assist to bathroom as needed
Assess bladder function
Encourage PO intake
Encourage PO fluids
Assist to bathroom as needed
Woman/family will begin attachment behaviors with newborn
NA MET VARIANCE
Woman/family will demonstrate appropriate attachment behaviors
NA MET VARIANCE
Family will verbalize comfort with new infant
NA MET VARIANCE
Family will verbalize comfort with new infant
NA MET VARIANCE
Encourage mother/family members to hold and touch infant
Provide skin-to-skin contact of mother/infant
Provide mother the opportunity to breastfeed, if
Offer flexible rooming-in with infant
Allow for verbalization of woman's feelings
Assess discharge needs and need for Social
Completion of birth certificate
Arrange for home visit
Woman will begin self-care activities as tolerated
NA MET VARIANCE
Woman will be up to bathroom/shower with assistance
NA MET VARIANCE
Woman will be up to bathroom/shower independently
NA MET VARIANCE
Woman will be up to bathroom/shower independently
NA MET VARIANCE
Instruct woman in pericare and pad changes
Reinforce proper pericare
Instruct on use of sitz bath
Encourage woman to shower
ADM. TO PP UNIT—8 HOURS
Reinforce proper pericare
Reinforce use of sitz bath
Reinforce proper pericare
Reinforce use of sitz bath
Woman will begin to verbalize and/or demonstrate self-care and infant care activities
NA MET VARIANCE
Woman will begin to verbalize and/or demonstrate infant and selfcare activities
NA MET VARIANCE
Woman/family will demonstrate appropriate infant care activities
NA MET VARIANCE
Woman/family will demonstrate appropriate infant care activities
NA MET VARIANCE
Teaching to include:
Breastfeeding latch-on and positioning, if applicable
Appropriate handwashing techniques
Cough and deep breathing exercises
Instruct in pain relief techniques/medication
Teaching to include:
Breastfeeding/formula initial feeding information
Safety issues reviewed
Teaching to include:
Attendance at mother/baby care class
Breast care or formula information
Lactation consult prn
Appropriate handwashing techniques
Teaching to include:
Reinforcement of teaching from mother/baby class
Plans for self/infant follow-up
Review Baby Net program
Telephone number for follow-up questions
Home-going meds and purposes
Fig. 4 Self/family learning checklist. (Copyright Abbott Northwestern Hospital of Allina Health System, Minneapolis and St. Paul, MN.)
Hospital-based maternity nurses continue to play invaluable roles as caregivers, teachers, and patient and family advocates in developing and implementing effective home care strategies. The nurse participates in the determination of whether the mother and newborn meet the criteria for early discharge.
LEGAL TIP Early Discharge
Whether or not the woman and her family have chosen early discharge, the nurse and the primary health care provider are held responsible if the woman is discharged before her condition has stabilized within normal limits. If complications occur, the medical and nursing staff could be sued for abandonment.
CARE MANAGEMENT—PHYSICAL NEEDS
Assessment and Nursing Diagnoses
A complete physical assessment, including measurement of vital signs, is performed on admission to the postpartum unit. If the woman's vital signs are within normal limits, they are usually assessed every 4 to 8 hours for the remainder of her hospitalization. Other components of the initial assessment include the mother's emotional status, energy level, degree of physical discomfort, hunger, and thirst. Intake and output assessments should always be included if an intravenous infusion or a urinary catheter is in place. If the woman gave birth by cesarean, her incisional dressing should also be assessed. To some degree, her knowledge level concerning self-care and infant care can also be determined at this time.
Ongoing physical assessment
The new mother should be evaluated thoroughly each shift throughout hospitalization. Physical assessments include evaluation of the breasts, uterine fundus, lochia, perineum, bladder and bowel function, vital signs, and legs. If a woman has an intravenous line in place, her fluid and hematologic status should be evaluated before it is removed. Signs of potential problems that may be identified during the assessment process are listed in the Signs of Potential Complications box.
SIGNS OF POTENTIAL COMPLICATIONS
More than 38° C after the first 24 hr
Tachycardia or marked bradycardia
Hypotension or hypertension
Lethargy, extreme fatigue
Deviated from the midline, boggy consistency, remains above the umbilicus after 24 hr
Heavy, foul odor, bright red bleeding that is not lochia
Pronounced edema, not intact, signs of infection, marked discomfort
Homans sign positive; painful, reddened area; warmth on posterior aspect of calf
Redness, heat, pain, cracked and fissured nipples, inverted nipples, palpable mass
Lack of appetite
Urine: inability to void, urgency, frequency, dysuria; bowel; constipation, diarrhea
Inability to rest or sleep
Routine laboratory tests
Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit values are often evaluated on the first postpartum day to assess blood loss during childbirth, especially after cesarean birth. In some hospitals a clean-catch or catheterized urine specimen may be obtained and sent for routine urinalysis or culture and sensitivity, especially if an indwelling urinary catheter was inserted during the intrapartum period. In addition, if the woman's rubella and Rh status are unknown, tests to determine her status and need for possible treatment should be performed at this time.
Although all women experience similar physiologic changes during the postpartum period, certain factors act to make each woman's experience unique. From a physiologic standpoint the length and difficulty of the labor, type of birth (i.e., vaginal or cesarean), presence of episiotomy or lacerations, parity, and whether the mother plans to breastfeed or bottle-feed are factors to be considered with each woman. After analyzing the data obtained during the assessment process, the nurse establishes nursing diagnoses that will provide a guide for planning care. Examples of nursing diagnoses commonly established for the postpartum patient include the following:
• Risk for deficient fluid volume (hemorrhage) related to
-uterine atony after childbirth
• Urinary retention or constipation related to
-childbirth trauma to tissues
• Acute pain related to
-trauma to perineum
• Disturbed sleep pattern related to
-discomforts of postpartum period
-long labor process
-infant care and hospital routine
• Ineffective breastfeeding related to
Expected Outcomes of Care
The nursing plan of care includes both the postpartum woman and her infant, even if the nursery nurse retains primary responsibility for the infant. In many hospitals, couplet care (also called mother-baby care or single-room maternity care) is practiced. Nurses in these settings have been educated in both mother and infant care and function as primary nurses for both mother and infant, even if the infant is kept in the nursery. This approach is a variation of rooming-in, in which the mother and infant room together and mother and nurse share the care of the infant. The organization of the mother's care must take the newborn into consideration. The day actually revolves around the baby's feeding and care times.
Once the nursing diagnoses are formulated, the nurse plans with the woman what nursing measures are appropriate and which are to be given priority.
The nursing plan of care includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort or pain, safety measures to prevent injury or infection, and teaching and counseling measures designed to promote the woman's feelings of competence in self-care and baby care. Family members are included in the teaching. The nurse evaluates continuously and is ready to change the plan if indicated. Almost all hospitals use standardized care plans or care paths as a basis for planning. The nurse's adaptation of the standardized plan to specific medical and nursing diagnoses results in individualized patient care.
Expected outcomes for the postpartum period are based on the nursing diagnoses identified for the individual patient. Examples of common expected outcomes for physiologic needs are that the woman will do the following:
• Demonstrate normal involution and lochial characteristics
• Remain comfortable and injury free
• Demonstrate normal bladder and bowel patterns
• Demonstrate knowledge of breast care, whether breastfeeding or bottle-feeding
• Integrate the newborn into the family
Plan of Care and Interventions
Nurses assume many roles while implementing the nursing care plan. They provide direct physical care, teach motherbaby care, and provide anticipatory guidance and counseling. Perhaps most important of all, they nurture the woman by providing encouragement and support as the woman begins to assume the many tasks of motherhood. Nurses who take the time to "mother the mother" do much to increase feelings of self-confidence in new mothers.
The first step in providing individualized care is to confirm the woman's identity by checking her wristband. At the same time the infant's identification number is matched with the corresponding band on the mother's wrist and, in some instances, the father's wrist. The nurse determines how the mother wishes to be addressed and then notes her preference in her record and in her nursing care plan.
The woman and her family are oriented to their surroundings. Familiarity with the unit, routines, resources, and personnel reduces one potential source of anxiety—the unknown. The mother is reassured through knowing whom and how she can call for assistance and what she can expect in the way of supplies and services. If the woman's usual daily routine before admission differs from the facility's routine, the nurse works with the woman to develop a mutually acceptable routine.
Infant abduction from hospitals in the United States has increased over the past few years. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification badges. On some units, all staff members wear matching scrubs or special badges. Other units use closed-circuit television, computer monitoring systems, or fingerprint identification pads. As a rule, the baby is never carried in a staff member's arms between the mother's room and the nursery but is always wheeled in a bassinet, which also contains baby care supplies. Patients and nurses must work together to ensure the safety of newborns in the hospital environment (see Plan of Care).
PLAN OF CARE POSTPARTUM CARE—VAGINAL BIRTH
NURSING DIAGNOSIS Risk for deficient fluid volume related to uterine atony/hemorrhage
Expected Outcomes Fundus is firm, lochia is moderate, and there is no evidence of hemorrhage.
Monitor lochia (color, amount, consistency) and count and weigh sanitary pads if lochia is heavy to evaluate amount of bleeding.
Monitor and palpate fundus for location and tone to determine status of uterus and dictate further interventions because atonic uterus is most common cause of postpartum hemorrhage.
Monitor intake and output, assess for bladder fullness, and encourage voiding because a full bladder interferes with involution of the uterus.
Monitor vital signs (increased pulse and respirations, decreased blood pressure) and skin temperature and color to detect signs of hemorrhage/shock.
Monitor postpartum hematology studies to assess effects of blood loss.
If fundus is boggy, apply gentle massage and assess tone response to promote uterine contractions and increase uterine tone. (Do not overstimulate because doing so can cause fundal relaxation.)
Express uterine clots to promote uterine contraction.
Explain to the woman the process of involution and teach her to assess and massage the fundus and to report any persistent bogginess to involve her in self-care and increase sense of self-control.
Administer oxytocic agents per physician/nurse-midwife order and evaluate effectiveness to promote continuing uterine contraction.
Administer fluids, blood, blood products, or plasma expanders as ordered to replace lost fluid and lost blood volume.
NURSING DIAGNOSIS Acute pain related to postpartum physiologic changes (hemorrhoids, episiotomy, breast engorgement, cracked/sore nipples)
Expected Outcome Patient exhibits signs of decreased discomfort.
Assess location, type, and quality of pain to direct intervention.
Explain to the woman the source and reasons for the pain, its expected duration, and treatments to decrease anxiety and increase sense of control.
Administer prescribed pain medications to provide pain relief.
If pain is perineal (episiotomy, hemorrhoids), apply ice packs in the first 24 hours to reduce edema and vulvar irritation and reduce discomfort; encourage sitz baths using cool water first 24 hours to reduce edema and warm water thereafter to promote circulation; apply witch hazel compresses to reduce edema; teach woman to use prescribed perineal creams, sprays, or ointments to depress response of peripheral nerves; teach woman to tighten buttocks before sitting and to sit on flat, hard surfaces to compress buttocks and reduce pressure on the perineum. (Avoid donuts and soft pillows as they separate the buttocks and decrease venous blood flow, increasing pain.)
If pain is from breasts and woman is breastfeeding, encourage use of a supportive bra to increase comfort; ascertain that infant has latched on correctly to prevent sore nipples; vary infant position during feeding to prevent sore nipples.
If breasts are engorged, have woman use warm compresses or take a warm shower before breastfeeding to stimulate milk flow and relieve stasis.
If nipples are sore, have woman air-dry nipples after feeding to toughen nipples, apply breast creams as prescribed to soften nipples and relieve irritation and wear breast shields in her bra to relieve irritation.
If pain is from breast and woman is not breastfeeding, encourage use of a tight supportive bra or breast binder and application of ice packs to reduce lactation and decrease heaviness
NURSING DIAGNOSIS Disturbed sleep pattern related to excitement, discomfort, and environmental interruptions
Expected Outcome Patient sleeps for uninterrupted periods of time and feels rested after waking.
Establish woman's routine sleep patterns and compare with current sleep pattern, exploring things that interfere with sleep, to determine scope of problem and direct interventions.
Individualize nursing routines to fit woman's natural body rhythms (i.e., wake/sleep cycles), provide a sleep-promoting environment (i.e., darkness, quiet, adequate ventilation, appropriate room temperature), prepare for sleep using woman's usual routines (i.e., back rub, soothing music, warm milk), teach use of guided imagery and relaxation techniques to promote optimum conditions for sleep.
Avoid things or routines (i.e., caffeine, foods that induce heartburn, fluids, strenuous mental/physical activity) that may interfere with sleep.
Administer sedation or pain medication as prescribed to enhance quality of sleep.
Advise woman/partner to limit visitors and activities to avoid further taxation and fatigue.
Teach woman to use infant nap time as a time for her also to nap and replenish energy and decrease fatigue.
Prevention of infection
One important means of preventing infection is maintenance of a clean environment. Bed linens should be changed as needed. Disposable pads and draw sheets may need to be changed frequently. By not walking about bare foot, women avoid contaminating the linens when they return to bed. A sitz bath or heat lamp used in common must be scrubbed after each woman's use. Personnel must be conscientious about their handwashing techniques to prevent cross-infection. Standard Precautions must be practiced. Staff members with colds, coughs, or skin infections (e.g., a cold sore on the lips [herpes simplex virus type 1]) must follow hospital protocol when in contact with postpartum patients. In many hospitals, staff members with open herpetic lesions, strep throat, conjunctivitis, upper respiratory infections, or diarrhea are encouraged to avoid contact with mothers and infants by staying home until the condition is no longer contagious.
Proper care of the episiotomy site and any perineal lacerations prevents infection in the genitourinary area and aids the healing process. Educating the woman to wipe from front to back (urethra to anus) after voiding or defecating is a simple first step. In many hospitals a squeeze bottle filled with warm water or an antiseptic solution is used after each voiding to cleanse the perineal area (Box 3). The woman should change her perineal pad from front to back each time she voids or defecates and wash her hands thoroughly before and after doing so.
BOX 3 Interventions for Episiotomy, Lacerations, and Hemorrhoids
Explain both procedure and rationale before implementation.
Wash hands before and after cleansing perineum and changing pads.
Wash perineum with mild soap and warm water at least once daily.
Cleanse from symphysis pubis to anal area.
Apply peripad from front to back, protecting inner surface of pad from contamination.
Wrap soiled pad and place in covered waste container.
Change pad with each void or defecation or at least 4 times per day.
Assess amount and character of lochia with each pad change.
Apply a covered ice pack to perineum from front to back
1. During first 2 hours to decrease edema formation and increase comfort
2. After the first 2 hours following the birth to provide anesthetic effect
Demonstrate for and assist woman; explain rationale.
Fill bottle with tap water warmed to approximately 38° C (comfortably warm on the wrist).
Instruct woman to position nozzle between her legs so that squirts of water reach perineum as she sits on toilet seat.
Explain that it will take whole bottle of water to cleanse perineum.
Remind her to blot dry with toilet paper or clean wipes.
Remind her to avoid contamination from anal area.
Apply clean pad.
Prepare bath by thoroughly scrubbing with cleaning agent and rinsing.
Pad with towel before filling.
Fill one-half to one-third full with water of correct temperature 38° to 40.6° C. Some women prefer cool sitz baths.
Ice is added to water to lower the temperature to the level comfortable for the woman.
Encourage woman to use at least twice a day for 20 minutes.
Place call bell within easy reach.
Teach woman to enter bath by tightening gluteal muscles and keeping them tightened and then relaxing them after she is in the bath.
Place dry towels within reach.
Check woman in 15 minutes; assess pulse as needed.
Clamp tubing and fill bag with warm water.
Raise toilet seat, place bath in bowl with overflow opening directed toward back of toilet.
Place container above toilet bowl.
Attach tube into groove at front of bath.
Loosen tube clamp to regulate rate of flow: fill bath to about one-half full; continue as above for built-in sitz bath.
Assemble Surgi-Gator (see Fig. 6).
Instruct woman regarding use and rationale.
Follow package directions.
Instruct woman to sit on toilet with legs apart and to put nozzle so tip is just past the perineum, adjusting placement as needed.
Remind her to return her applicator to her bedside stand.
Inspect lamp for defects.
Cover lamp with towels.
Position lamp 50 cm from perineum; use 3 times a day for 20-minute periods.
Teach regarding use of 40-W bulb at home.
Provide draping over woman.
If same lamp is being used by several women, clean it carefully between uses.
Apply anesthetic cream or spray: use sparingly 3 to 4 times per day.
Offer witch hazel pads (Tucks) after voiding or defecating; woman pats perineum dry from front to back, then applies witch hazel pads.
Prevention of excessive bleeding
The most common cause of excessive bleeding following birth is uterine atony, failure of the uterine muscle to contract firmly. The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.
If uterine atony occurs, the relaxed uterus distends with blood and clots, blood vessels in the placental site are not clamped off, and excessive bleeding results.
Excessive blood loss following childbirth may also be caused by vaginal or vulvar hematomas, unrepaired lacerations of the vagina or cervix, and retained placental fragments.
NURSE ALERT A perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks are indications of excessive blood loss, requiring immediate assessment, intervention, and notification of the physician or nurse-midwife.
Accurate visual estimation of blood loss is an important nursing responsibility. Blood loss is usually described subjectively as scant, light, moderate, or heavy (profuse). Fig. 5 shows examples of perineal pad saturation corresponding to each of these descriptions.
Fig. 5 Blood loss after birth is assessed by the extent of perineal pad saturation as (from left to right) scant (<2.5 cm), light (<10 cm), moderate (>10 cm), or heavy (one pad saturated within 2 hours).
It is difficult to judge the amount of lochial flow based only on observation of perineal pads. Postpartal blood loss may be estimated by observing the amount of staining on a perineal pad. More objective estimates of blood loss include weighing blood clots and items saturated with blood (1 ml equals 1 g); using devices that catch and measure blood flowing from the vagina; and establishing how many milliliters it takes to saturate perineal pads being used (Johnson &Johnson, 1996; Luegenbiehl, 1997); however, these methods are not common in practice.
Any estimation of lochial flow is inaccurate and incomplete without consideration of the time factor. The woman who saturates a perineal pad in 1 hour or less is bleeding much more than the woman who saturates one perineal pad in 8 hours.
Luegenbiehl (1997) found that nurses in general tend to overestimate, rather than underestimate, blood loss. Different brands of perineal pads vary in their saturation volume and soaking appearance. For example, blood placed on some brands tends to soak down into the pad, whereas on other brands it tends to spread outward. Nurses should determine saturation volume and soaking appearance for the brands used in their institution so that they may improve accuracy of blood loss estimation.
Blood pressure is not a reliable indicator of impending shock from early hemorrhage. More sensitive means of identifying shock are provided by respirations, pulse, skin condition, urinary output, and level of consciousness. The frequent physical assessments performed during the fourth stage of labor are designed to provide prompt identification of excessive bleeding (see Emergency box).
EMERGENCY HYPOVOLEMIC SHOCK
Signs and Symptoms
Persistent significant bleeding —perineal pad soaked within 15 minutes; may not be accompanied by a change in vital signs or maternal color or behavior.
Woman states she feels weak, light-headed, "funny," "sick to my stomach," or "sees stars."
Woman begins to act anxious or exhibits air hunger.
Woman's skin turns ashen or grayish.
Skin feels cool and clammy.
Pulse rate increases.
Blood pressure declines.
Notify primary health care provider.
If uterus is atonic, massage gently and expel clots to cause uterus to contract; compress uterus manually, as needed, using two hands. Add oxytocic agent to IV drip, as ordered.
Give oxygen by face mask or nasal prongs at 8 to 10 L/min.
Tilt the woman to her side or elevate the right hip; elevate her legs to at least a 30-degree angle.
Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume.
Administer blood or blood products, as ordered.
Monitor vital signs.
Insert an indwelling urinary catheter to monitor perfusion of kidneys.
Administer emergency drugs, as ordered.
Prepare for possible surgery or other emergency treatments or procedures.
Chart incident, medical and nursing interventions instituted, and results of treatments.
MAINTENANCE OF UTERINE TONE
A major intervention to restore good tone is stimulation by gently massaging the uterine fundus until firm (see Fig. 2). Fundal massage may cause a temporary increase in the amount of vaginal bleeding seen as pooled blood leaves the uterus. Clots may also be expelled. The uterus may remain boggy even after massage and expulsion of clots.
Fundal massage can be a very uncomfortable procedure. Understanding the causes and dangers of uterine atony and the purpose of fundal massage can help the woman to be more cooperative. Teaching the patient to massage her own fundus enables her to maintain some control and decreases her anxiety.
Additional interventions likely to be used are administration of intravenous fluids and oxytocic medications (drugs that stimulate contraction of the uterine smooth muscle).
Prevention of bladder distention. A full bladder causes the uterus to be displaced above the umbilicus and well to one side of midline in the abdomen. It also prevents the uterus from contracting normally. Nursing interventions focus on helping the woman to empty her bladder spontaneously as soon as possible. The first priority is to assist the woman to the bathroom or onto a bedpan if she is unable to ambulate. Having the woman listen to running water, placing her hands in warm water, or pouring water from a squeeze bottle over her perineum may stimulate voiding. Other techniques include assisting the woman into the shower or sitz bath and encouraging her to void, or placing oil of peppermint in a bedpan under the woman (the vapors may relax the urinary meatus and trigger spontaneous voiding). Administering analgesics, if ordered, may be indicated because some women may fear voiding because of anticipated pain. If these measures are unsuccessful, a sterile catheter may be inserted to drain the urine.
Promotion of comfort, rest, ambulation, and exercise
Comfort. Most women experience some degree of discomfort during the postpartum period. Common causes of discomfort include afterbirth pains (afterpains), episiotomy or perineal lacerations, hemorrhoids, and breast engorgement. The woman's description of the type and everity of her pain is the best guide in choosing an appropriate intervention. To confirm the location and extent of discomfort, the nurse inspects and palpates areas of pain as appropriate for redness, swelling, discharge, and heat and observes for body tension, guarded movements, and facial tension. Blood pressure, pulse, and respirations may be elevated in response to acute pain. Diaphoresis may accompany severe pain. A lack of objective signs does not necessarily mean there is no pain, because there may also be a cultural component to the expression of pain. Nursing interventions are intended to eliminate the pain sensation entirely or reduce it to a tolerable level that allows the woman to care for herself and her baby. Nurses may use both nonpharmacologic and pharmacologic interventions to promote comfort. Pain relief is enhanced by using more than one method or route.
Nonpharmacologic interventions. Warmth, distraction, imagery, therapeutic touch, relaxation, and interaction with the infant may decrease the discomfort associated with afterbirth pain. Simple interventions that can decrease the discomfort associated with an episiotomy or perineal lacerations include encouraging the woman to lie on her side whenever possible and to use a pillow when sitting. Other interventions include application of an ice pack; topical application (if ordered); dry heat; cleansing with a squeeze bottle; and a cleansing shower, tub bath, or sitz bath (Fig. 6). Many of these interventions are also effective for hemorrhoids, especially ice packs, sitz baths, and topical applications (such as witch hazel pads). Box 3 gives more specific information about these interventions.
Fig, 6 Hygienic sitz bath (Surgi-Gator) for perineal care. (Courtesy Andermac, Inc., Yuba City, CA.)
The discomfort associated with engorged breasts may be lessened by applying either ice, heat, or cabbage leaves to the breasts and wearing a well-fitted support bra. Decisions about specific interventions for engorgement are based on whether the woman chooses breastfeeding or bottle-feeding .
Pharmacologic interventions. Most health care providers routinely order a variety of analgesics to be administered as needed, including both narcotic and nonnarcotic (nonsteroidal antiinflammatory medications) choices, with their dosage and time frequency ranges. Topical application of antiseptic or anesthetic ointment or spray is a common pharmacologic intervention for perineal pain. Patient-controlled analgesia pumps and epidural analgesia are technologies commonly used to provide pain relief after cesarean birth.
NURSE ALERT The nurse should carefully monitor all women receiving opioids because respiratory depression and decreased intestinal motility are side effects.
Many women want to participate in decisions about analgesia. Severe pain, however, may interfere with active participation in choosing pain relief measures. If an analgesic is to be given, the nurse must make a clinical judgment of the type, dosage, and frequency from the medications ordered. The woman is informed of the prescribed analgesic and its common side effects; this teaching is documented.
Breastfeeding mothers often have concerns about the effects of an analgesic on the infant. Although nearly all drugs present in maternal circulation are also found in breast milk, many analgesics commonly used during the postpartum period are considered relatively safe for breastfeeding mothers. Often, the timing of medications can be adjusted to minimize infant exposure. A mother may be given pain medication immediately after breastfeeding so that the interval between medication administration and the next nursing period is as long as possible. The decision to administer medications of any type to a breastfeeding mother must always be made by carefully weighing the woman's need against actual or potential risks to the infant.
If acceptable pain relief has not been obtained in 1 hour and there has been no change in the initial assessment, the nurse may need to contact the primary care provider for additional pain relief orders or further directions. Unrelieved pain results in fatigue, anxiety, and a worsening perception of the pain. It might also indicate the presence of a previously unidentified or untreated problem.
Rest. The excitement and exhilaration experienced after the birth of the infant may make rest difficult. The new mother, who is often anxious about her ability to care for her infant or is uncomfortable, may also have difficulty sleeping. The demands of the infant, the hospital environment and routines, and the presence of frequent visitors contribute to alterations in her sleep pattern.
Fatigue. Fatigue is common in the postpartum period (Pugh et al., 1999) and involves both physiologic components, associated with long labors, cesarean birth, anemia, and breastfeeding, and psychologic components, related to depression and anxiety. Infant behavior may also contribute to fatigue, particularly for mothers of more difficult infants.
Interventions must be planned to meet the woman's individual needs for sleep and rest. Back rubs, other comfort measures, and medication for sleep for the first few nights may be necessary. The side-lying position for breastfeeding minimizes fatigue in nursing mothers (Milligan, Flenniken, & Pugh, 1996). Support and encouragement in mothering behaviors help reduce anxiety. Hospital and nursing routines may be adjusted to meet individual needs. In addition, the nurse can help the family limit visitors and provide a comfortable chair or bed for the partner.
Ambulation. Early ambulation is successful in reducing the incidence of thromboembolism and in promoting the woman's more rapid recovery of strength. Free movement is encouraged once anesthesia wears off unless an analgesic has been administered. After the initial recovery period is over, the mother is encouraged to ambulate frequently.
NURSE ALERT Having a hospital staff or family member present the first time the woman gets out of bed after birth is wise because she may feel weak, dizzy, faint, or light-headed.
The rapid decrease in intraabdominal pressure after birth results in a dilation of blood vessels supplying the intestines (splanchnic engorgement) and causes blood to pool m the viscera. This condition contributes to the development of orthostatic hypotension when the woman who has recently given birth sits or stands up, first ambulates, or takes a warm shower or sitz bath. The nurse also needs to consider the baseline blood pressure; amount of blood loss; and type, amount, and timing of analgesic or anesthetic medications administered when assisting a woman to ambulate.
Prevention of clot formation is important. Women who must remain in bed after giving birth are at increased risk for the development of a thrombus. If a woman remains in bed longer than 8 hours (e.g., for postpartum MgSO4 therapy for preeclampsia), exercise to promote circulation in the legs is indicated using the following routine:
• Alternate flexion and extension of feet.
• Rotate ankle in circular motion.
• Alternate flexion and extension of legs.
• Press back of knee to bed surface; relax.
If the woman is susceptible to thromboembolism, she is encouraged to walk about actively for true ambulation and is discouraged from sitting immobile in a chair. Women with varicosities are advised to wear support hose. If a thrombus is suspected, as evidenced by complaint of pain in calf muscles, or warmth, redness, or tenderness in the suspected leg (positive Homans sign), the primary health care provider should be notified immediately; meanwhile the woman should be confined to bed, with the affected limb elevated on pillows.
Exercise. Most women who have just given birth are extremely interested in regaining their nonpregnant figures. Postpartum exercise can begin soon after birth, although the woman should be encouraged to start with simple exercises and gradually progress to more strenuous ones. Fig. 7 illustrates a number of exercises appropriate for the new mother. Abdominal exercises are postponed until approximately 4 weeks after cesarean birth.
Fig. 7 Postpartum exercise should begin as soon as possible. The woman should start with simple exercises and gradually progress to more strenuous ones
Kegel exercises to strengthen pelvic muscle tone are extremely important, particularly after vaginal birth. Kegel exercises help women regain the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later by maintaining urinary continence. It is essential that women learn to perform Kegel exercises correctly. Approximately one fourth of all women who learn Kegel exercises do them incorrectly and may increase their risk of incontinence (Sampselle & Miller, 1996). This may occur when women inadvertently bear down on the pelvic floor muscles, thrusting the perineum outward. The woman's technique can be assessed during the pelvic examination at the 6-week checkup by inserting two fingers intravaginally and checking whether the pelvic floor muscles correctly contract and relax.
Promotion of nutrition
During the hospital stay, most women display a good appetite and eat well; nutritious snacks are usually welcomed. Women may request that family members bring to the hospital favorite or culturally appropriate foods (Fig. 8). Cultural dietary preferences must be respected. This interest in food presents an ideal opportunity for nutritional counseling on dietary needs after pregnancy, such as for breastfeeding, preventing constipation and anemia, promoting weight loss, and promoting healing and well-being. Prenatal vitamins and iron supplements are often continued until 6 weeks postpartum or until the ordered supply has been used.
Fig. 8 Special foods are considered essential for recovery in the Asian culture. (Courtesy Concept Media, Irvine, CA.)
Promotion of normal bladder and bowel patterns
Bladder function. After giving birth the mother should void spontaneously within 6 to 8 hours. The first several voidings should be measured to document adequate emptying of the bladder. A volume of at least 150 ml is expected for each voiding. Some women experience difficulty in emptying the bladder, possibly a result of diminished bladder tone, edema from trauma, or fear of discomfort.
Bowel function. Interventions to promote normal bowel elimination include educating the woman about measures to avoid constipation, such as ensuring adequate roughage and fluid intake and promoting exercise. Alerting the woman to side effects of medications such as narcotic analgesics (e.g., decreased gastrointestinal tract motility) may encourage her to implement measures to reduce the risk of constipation. Stool softeners or laxatives may be necessary during the early postpartum period. With early discharge a new mother may be home before having a bowel movement. Some mothers experience gas pains. Antigas medications may be ordered. Ambulation or rocking in a rocking chair may stimulate passage of flatus and relief of discomfort.
Breastfeeding promotion and lactation suppression
Breastfeeding promotion. The first 2 hours after childbirth are an excellent time to encourage the mother to breastfeed. The infant is in an alert state and ready to breastfeed. Breastfeeding aids in the contraction of the uterus and prevention of maternal hemorrhage. This is an opportune time to instruct the mother in breastfeeding and to assess the physical appearance of the breasts.
Lactation suppression. Suppression of lactation is necessary when the woman has decided not to breastfeed or in the case of neonatal death. Wearing a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth is important. Women should avoid breast stimulation, including running warm water over the breasts, newborn suckling, or pumping of the breasts. A few nonbreastfeeding mothers experience severe breast engorgement (swelling of breast tissue caused by increased blood and lymph supply to the breasts preceding lactation). If breast engorgement occurs, it can usually be managed satisfactorily with nonpharmacologic interventions.
Ice packs to the breasts are helpful in decreasing the discomfort associated with engorgement. The woman should use a 15 minutes on-45 minutes off schedule (to prevent the rebound swelling that can occur if ice is used continuously), or she can place fresh cabbage leaves inside her bra. Cabbage leaves have been used to treat swelling in other cultures for years (Roberts, 1995). The exact mechanism of action is not known, but it is thought that naturally occurring plant estrogens or salicylates may be responsible for the effects. The leaves are replaced each time they wilt. A mild analgesic may also be necessary to help the mother through this uncomfortable time. Medications that were once prescribed for lactation suppression (e.g., estrogen, estrogen and testosterone, bromocriptine) are no longer used.
Health promotion of future pregnancies and children
Rubella vaccination. For women who have not had rubella (10% to 20% of all women) or women who are serologically not immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. Seroconversion occurs in approximately 90% of women vaccinated after birth. The live attenuated rubella virus is not communicable in breast milk; therefore breastfeeding mothers can be vaccinated. However, because the virus is shed in urine and other body fluids, the vaccine should not be given if the mother or other household members are immunocompromised. Rubella vaccine is made from duck eggs, so women who have allergies to these eggs may develop a hypersensitivity reaction to the vaccine, for which they will need adrenaline. A transient arthralgia or rash is common in vaccinated women but is benign. Because the vaccine may be teratogenic, women who receive the vaccine must be informed about this fact.
LEGAL TIP Rubella Vaccination informed consent for rubella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. Women must understand that they must practice contraception to avoid pregnancy for 2 to 3 months after being vaccinated.
Prevention of Rh Isoimmunization. Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) (see Medication Guide). Rh immune globulin promotes lysis of fetal Rh-positive blood cells before the mother forms her own antibodies against them.
Rh Immune Globulin, RhoGAM, Gamulin Rh, HypRho-D
Suppression of immune response in nonsensitized women with Rh-negative blood who receive Rhpositive blood cells because of fetomaternal hemorrhage, transfusion, or accident
Suppress antibody formation in women with Rh-negative blood after birth, miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villi sampling
Standard dose 1 vial (300 jjig) IM in deltoid or gluteal muscle; microdose 1 vial (50 ^g) IM in deltoid muscle
Myalgia, lethargy, localized tenderness and stiffness at injection site, possible allergic response
• Give standard dose to mother within 72 hours after birth if baby is Rh positive, at 28 weeks of gestation as prophylaxis, or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g., amniocentesis, second trimester miscarriage or abortion, after version).
• Give microdose for first trimester miscarriage or abortion, ectopic pregnancy, chorionic villi sampling.
• Verify that the woman is Rh negative and has not been sensitized, that Coombs' test is negative, and that baby is Rh positive. Provide explanation to the woman about procedure, including the purpose, possible side effects, and effect on future pregnancies. Have the woman sign a consent form if required by agency. Verify correct dosage and confirm lot number and woman's identity before giving injection (verify with another RN or other procedure per agency policy); document administration per agency policy.
NURSE ALERT After birth, Rh immune globulin is administered to all Rh-negative, antibody (Coombs'jnegative women who give birth to Rh-positive infants. Rh immune globulin is administered to the mother intramuscularly. It should never be given to an infant.
The administration of 300 /j,g (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. If a large fetomaternal transfusion is suspected, however, the dosage needed should be determined by performing a Kleihauer-Betke test, which detects the amount of fetal blood in the maternal circulation. If more than 15 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased.
A 1:1000 dilution of Rh immune globulin is crossmatched to the mother's RBCs to ensure compatibility. Because Rh immune globulin is usually considered a blood product, precautions similar to those used for transfusing blood are necessary when it is given. The identification number on the patient's hospital wristband should correspond to the identification number found on the laboratory slip. The nurse must also check to see that the lot number of the laboratory slip corresponds to the lot number on the vial. Finally, the expiration date on the vial should be checked to ensure a usable product.
Rh immune globulin suppresses the immune response. Therefore the woman who receives both Rh immune globulin and rubella vaccine must be tested at 3 months to see if she has developed rubella immunity. If not, the woman will need another dose of rubella vaccine.
There is some disagreement about whether Rh immune globulin should be considered a blood product. Health care providers need to discuss the most current information about this issue with women whose religious beliefs conflict with having blood products administered to them.
The nurse can be reasonably assured that care was effective when the expected outcomes of care for physical needs have been achieved.
CARE MANAGEMENT—PSYCHOSOCIAL NEEDS
Meeting the psychosocial needs of new mothers involves assessing the parents' reactions to the birth experience, feelings about themselves, and interactions with the new baby and other family members (Fig. 9). Specific inter ventions are then planned to increase the parents' knowledge and self-confidence as they assume the care and responsibility of the new baby and integrate a new member into their existing family structure in a way that meets their cultural expectations.
Fig. 9 Bonding and attachment begun early after birth are fostered in the postpartum period. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Assessment and Nursing Diagnoses
Impact of the birth experience
Many women indicate a need to examine the birth process itself and look at their own intrapartal behavior in retrospect. Their partners may express similar desires. If their birth experience was different from that included in their birth plan (e.g., induction, epidural anesthesia, cesarean birth), both partners may need to mourn the loss of their expectations before they can adjust to the reality of their birth experience. Inviting them to review the events and describe how they feel helps the nurse assess how well they understand what happened and how well they have been able to put their childbirth experience into perspective.
An important assessment concerns the woman's selfconcept, body image, and sexuality. How this new mother feels about herself and her body during the puerperium may affect her behavior and adaptation to parenting. The woman's self-concept and body image may also affect her sexuality. Overweight women experience depressive and anxiety symptoms up to 14 months postpartum (Carter, Baker, & Brownell, 2000).
Feelings related to sexual adjustment after childbirth are often a cause of concern for new parents. Women who have recently given birth may be reluctant to resume sexual intercourse for fear of pain or may worry that coitus could damage healing perineal tissue. Because many new parents are anxious for information but reluctant to bring up the subject, postpartum nurses should matter-of-factly include the topic of postpartum sexuality during their routine physical assessment. While examining the episiotomy site, for example, the nurse can say, "I know you're sore right now, but it probably won't be long until you (or you and your partner) are ready to make love again. Have you thought about what that might be like? Would you like to ask me questions?" This approach assures the woman and her partner that resuming sexual activity is a legitimate concern for new parents and indicates the nurse's willingness to answer questions and share information.
Adaptation to parenthood/parent-infant interactions
The psychosocial assessment also includes evaluating adaptation to parenthood, as evidenced by mother's and father's reactions to and interactions with the new baby. Clues indicating successful adaptation begin to appear early in the postbirth period as parents react positively to the newborn infant and continue the process of establishing a relationship with him or her.
Parents are adapting well to their new role when they exhibit a realistic perception and acceptance of their newborn's needs and his or her limited abilities, immature social responses, and helplessness. Examples of positive parent-infant interactions include taking pleasure in their infant and in the tasks done for and with her or him, understanding their infant's emotional states and providing comfort, and reading their infant's cues for new experiences and sensing the infant's fatigue level.
Family structure and functioning
A woman's adjustment to her role as mother is affected greatly by her relationships with her partner, her mother and other relatives, and any other children. Nurses can help ease the new mother's return home by identifying possible conflicts among family members and helping the woman plan strategies for dealing with these problems before discharge. Such a conflict could arise when couples have very different ideas about parenting. Dealing with the stresses of sibling rivalry and unsolicited grandparent advice can also affect the woman's transition to motherhood. Only by asking about other nuclear and extended family members can the nurse discover potential problems in such relationships and help plan workable solutions for them.
Impact of cultural diversity
The final component of a complete psychosocial assessment is the woman's cultural beliefs and values. Much of a woman's behavior during the postpartum period is strongly influenced by her cultural background. Nurses are likely to come into contact with women from many different countries and cultures. All cultures have developed safe and satisfying methods of caring for new mothers and babies. Only by understanding and respecting the values and beliefs of each woman can the nurse design a plan of care to meet their individual needs.
Sometimes the psychosocial assessment indicates serious actual or potential problems that must be addressed. The Signs of Potential Complications box lists several psychosocial needs that, at a minimum, warrant ongoing evaluation following hospital discharge. Patients exhibiting these needs should be referred to appropriate community resources for assessment and management.
SIGN OF NOTENTIAL COMPLICATIONS
Unable or unwilling to discuss labor and birth experience.
Refers to self as ugly and useless.
Excessively preoccupied with self (body image).
Lacks a support system.
Partner or other family members react negatively to the baby.
Refuses to interact with or care for baby. For example, does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or dirty diapers. (Cultural appropriateness of actions needs to be considered.)
Expresses disappointment over baby's sex.
Sees baby as messy or unattractive.
Baby reminds mother of family member or friend she does not like.
After analyzing the data obtained during the assessment process, the nurse establishes nursing diagnoses to provide a guide for planning care. Nursing diagnoses related to psychosocial issues that are frequently established for the postpartum patient include the following:
• Interrupted family processes related to
-unexpected birth of twins
• Impaired verbal communication related to
-patient's hearing impairment
-nurse's language not the same as patient's
• Impaired parenting related to
-long, difficult labor
-unmet expectations of labor and birth
• Anxiety related to
-newness of parenting role, sibling rivalry, or response of grandparent
• Risk for situational low self-esteem related to
-body image changes
Expected Outcomes of Care
Expected psychosocial outcomes during the postpartum period are based on the nursing diagnoses identified for the individual woman and her family. Examples of common expected outcomes include that the woman (family) will do the following:
• Identify measures that promote a healthy personal adjustment in the postpartum period
• Maintain healthy family functioning based on cultural norms and personal expectations
Plan of Care and Interventions
The nurse functions in the roles of teacher, encourager, and supporter rather than doer while implementing the psychosocial plan of care for a postpartum woman. Implementation of the psychosocial care plan involves carrying out specific activities to achieve the expected outcome of care planned for each individual woman. Topics that should be included in the psychosocial plan of care include promotion of parenting skills and family member adjustment to the newest member.
Cultural issues must also be considered when planning care. There are many traditional health beliefs and practices among the different cultures within the American population. Traditional health practices that are used to maintain health or to avoid illnesses deal with the whole person (i.e., body, mind, and spirit) and tend to be culturally based.
Women from various cultures may view health as a balance between opposing forces (e.g., yin versus yang), being in harmony with nature, or just "feeling good." Traditional practices may include the observance of certain dietary restrictions, clothing, or taboos for balancing the body; participation in certain activities such as sports and art for maintaining mental health; and use of silence, prayer, or meditation for developing spiritually. Practices (e.g., using religious objects or eating garlic) are used to protect oneself from illness and may involve avoiding people who are believed to create hexes, spells, or who have an "evil eye." Restoration of health may involve a person taking folk medicines (e.g., herbs, animal substances) or using a traditional healer.
Childbirth occurs within this sociocultural context. Rest, seclusion, dietary restraints, and ceremonies honoring the mother are all common traditional practices that are followed for the promotion of the health and well-being of the mother and baby.
There are several common traditional health practices used and beliefs held by women and their families during the postpartum period. In Asia, for example, pregnancy is considered to be a hot (yang) condition, and childbirth results in a sudden loss of yang forces (Mattson, 1995). Therefore balance must be restored by increasing the return of yang forces present physically or symbolically in hot food, hot water, and warm air.
Another common belief is that the mother and baby remain in a weak and vulnerable state for a period of several weeks following birth. During this time the mother may remain in a passive role, take no baths or showers, and stay in bed to prevent cold air from entering her body.
Women who have immigrated to the United States or other Western nations without their extended families may not have much help at home, making it difficult for them to observe these activity restrictions. The Cultural Considerations box lists some common cultural beliefs about the postpartum period and family planning.
Postpartum Period and Family Planning
Chinese, Mexican, Korean, and Southeast Asian women may wish to eat only warm foods and drink hot drinks to replace blood loss and to restore the balance of hot and cold in their bodies. These women may also wish to stay warm and avoid bathing, exercises, and hair washing for 7 to 30 days after childbirth. Self-care may not be a priority; care by family members is preferred. The woman has respect for elders and authority. These woman may wear abdominal binders. They may prefer not to give their babies colostrum.
Haitian women may request to take the placenta home to bury or burn.
Muslim women follow strict religious laws on modesty and diet. A Muslim woman must keep her hair, body, arms to the wrist, and legs to the ankles covered at all times. She cannot be alone in the presence of a man other than her husband or a male relative. Observant Muslims will not eat pork or pork products and are obligated to eat meat slaughtered according to Islamic laws (halal meat). If halal meat is not available, kosher meat, seafood, or a vegetarian diet is usually accepted.
Birth control is government mandated in mainland China. Most Chinese women will have an IUD inserted after the birth of their first child. Women do not want hormonal methods of contraception because they fear putting these medications in their bodies.
Hispanic women will likely choose the rhythm method because most are Catholic.
(East) Indian men are encouraged to have voluntary sterilization by vasectomy.
Muslim couples may practice contraception by mutual consent as long as its use is not harmful to the woman. Acceptable contraceptive methods include foam and condoms, the diaphragm, and natural family planning.
Hmong women highly value and desire large families, which limits birth control practices.
It is important that nurses consider all cultural aspects when planning care and not use their own cultural beliefs as the framework for that care. Although the beliefs and behaviors of other cultures may seem different or strange, they should be encouraged as long as the mother wants to conform to them and she and the baby suffer no ill effects. The nurse needs to determine whether a woman is using any folk medicine during the postpartum period because active ingredients in folk medicine may have adverse physiologic effects on the woman when ingested with prescribed medicines. The nurse should not assume that a mother desires to use traditional health practices that represent a particular cultural group merely because she is a member of that culture. Many young women who are first or second-generation Americans follow their cultural traditions only when older family members are present or not at all.
The nurse can be reasonably assured that care was effective if expected outcomes of care for psychosocial needs have been met.
SELF-CARE, SIGNS OF COMPLICATIONS
Discharge planning begins at the time of admission to the unit and should be reflected in the plan of care developed for each individual woman. For example, a great deal of time during the hospital stay is usually spent in teaching about maternal and newborn care, because all women must be capable of providing basic care for themselves and their infants at the time of discharge. It is also crucial that every woman be taught to recognize the physical signs and symptoms that might indicate problems and how to obtain advice and assistance quickly if these signs appear. Before discharge, women need basic instruction regarding the resumption of sexual intercourse, prescribed medications, routine mother-baby checkups, and contraception.
Just before the time of discharge the nurse reviews the woman's chart to see that laboratory reports, medications, signatures, and other items are in order. Some hospitals have a checklist to use before the woman's discharge. The nurse verifies that medications, if ordered, have arrived on the unit; that any valuables kept secured during the woman's stay have been returned to her and that she has signed a receipt for them; and that the infant is ready to be discharged.
No medication that would make the mother sleepy should be administered if she is the one who will be holding the baby on the way out of the hospital. In most instances the woman is seated in a wheelchair and is given the baby to hold. Some families leave unescorted and ambulatory, depending on hospital protocol. The woman's possessions are gathered and taken out with her and her family. The woman's and the baby's identification bands are carefully checked. Babies must be secured in a car seat for the drive home.
Many couples resume sexual activity before the traditional postpartum checkup 6 weeks after childbirth. Risk of hemorrhage and infection are minimal by approximately 2 weeks postpartum. Couples may be anxious about the topic but uncomfortable and unwilling to bring it up. It is important that the nurse discuss the physical and psychologic effects that giving birth can have on sexual activity (see Self-Care box). Contraceptive options should also be discussed with women (and their partners if present) be fore discharge so that they can make informed decisions about fertility management before resuming sexual activity. Waiting to discuss contraception at the 6-week checkup may be too late. It is possible, particularly in women who bottle-feed, for ovulation to occur as soon as 1 month after birth. A woman who engages in unprotected sex risks becoming pregnant. Current contraceptive options are discussed in detail in Chapter 6. Women who are undecided about contraception at the time of discharge need information about using condoms with foam or creams until the first postpartum checkup.
Patient Instructions for Self-Care
Resumption of Sexual Intercourse
You can safely resume sexual intercourse by the second to fourth week after birth when bleeding has stopped and the episiotomy has healed. For the first 6 weeks to 6 months, the vagina does not lubricate well.
Your physiologic reactions to sexual stimulation for the first 3 months after birth will be slower and less intense. The strength of the orgasm is reduced.
A water-soluble gel, cocoa butter, or a contraceptive cream or jelly might be recommended for lubrication. If some vaginal tenderness is present, your partner can be instructed to insert one or more clean, lubricated fingers into the vagina and rotate them within the vagina to help relax it and to identify possible areas of discomfort. A position in which you have control of the depth of the insertion of the penis also is useful. The side-by-side or female-on-top position may be more comfortable.
The presence of the baby influences postbirth lovemaking. Parents hear every sound made by the baby; conversely you may be concerned that the baby hears every sound you make. In either case, any phase of the sexual response cycle may be interrupted by hearing the baby cry or move, leaving both of you frustrated and unsatisfied. In addition, the amount of psychologic energy expended by you in child care activities may lead to fatigue. Newborns require a great deal of attention and time.
Some women have reported feeling sexual stimulation and orgasms when breastfeeding their babies. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers.
You should be instructed to correctly perform the Kegel exercises to strengthen your pubococcygeal muscle. This muscle is associated with bowel and bladder function and with vaginal feeling during intercourse.
Women routinely continue to take their prenatal vitamins and iron during the postpartum period. It is especially important that women who are breastfeeding or who are discharged with a lower than normal hematocrit take these medications as prescribed. Women with extensive episiotomies or vaginal lacerations (third or fourth degree) are usually prescribed stool softeners to take at home. Pain relief medications (analgesics or nonsteroidal anti-inflammatory medications) may be prescribed, especially for women who had cesarean birth. The nurse should make certain that the woman knows the route, dosage, frequency, and common side effects of all ordered medications.
ROUTINE MOTHER AND BABY CHECKUPS
Women who have experienced uncomplicated vaginal births are still commonly scheduled for the traditional 6-week postpartum examination. Women who have had a cesarean birth are often seen in the physician's or nursemidwife's office or clinic 2 weeks after hospital discharge. The date and time for the follow-up appointment should be included in the discharge instructions. If an appointment has not been made before the woman leaves the hospital, she should be encouraged to call the physician's or nurse-midwife's office or clinic and schedule an appointment.
Parents who have not already done so need to make plans for newborn follow-up at the time of discharge. Most offices and clinics like to see newborns for an initial examination within the first week or by 2 weeks of age. If an appointment for a specific date and time was not made for the infant before leaving the hospital, the parents should be encouraged to call the office or clinic right away.
FOLLOW-UP AFTER DISCHARGE
Home visits to new mothers and babies within a few days of discharge can help bridge the gap between hospital care and routine visits to health care providers. Nurses are able to assess the mother, infant, and home environment; answer questions and provide education; and make referrals to community resources if necessary. Home visits may also help reduce the need for more expensive health care, such as nonroutine health care visits and rehospitalization, and decrease stress in new families (Brown & Johnson, 1998). Immediate follow-up contact and home visits ideally are available 7 days a week.
Home nursing care many not be available even if needed because there are no agencies providing the service or there is no coverage for payment by third-party payers. If care is available, a referral form containing information about both mother and baby should be completed at hospital discharge and sent immediately to the home care agency. Fig. 10 is an example of such a referral form.
Fig. 10 Referral form. (Courtesy OB Homecare of Allina Hospitals and Clinics, Minneapolis, MN.)
The home visit is most commonly scheduled on the woman's second day home from the hospital, but it may be scheduled on any of the first 4 days at home, depending on the individual family's situation and needs. Additional visits are planned throughout the first week, as needed. The home visits may be extended beyond that time if the family's needs warrant it and if a home visit is the most appropriate option for carrying out the follow-up care required to meet the specific needs identified.
During the home visit the nurse conducts a systematic assessment of mother and newborn to determine physiologic adjustment, identify any existing complications, and answer any questions the mother has for herself and the mother or family has about the newborn or newborn care. Conducting the assessment in a separate room provides private time for the mother to ask questions on topics such as breast care, family planning, and constipation. The assessment focuses on the mother's emotional adjustment and her knowledge of self-care and infant care.
During the newborn assessment, the nurse can demonstrate and explain normal newborn behavior and capabilities and encourage the mother and family to ask questions or express concerns they may have. The home care nurse must verify if the newborn screen for phenylketonuria and other inborn errors of metabolism has been drawn. If the baby was discharged from the hospital before 24 hours of age, the newborn screen may be done by the home care nurse or the family will need to take the infant to the clinic or physician's office.
As part of the routine follow-up of a woman and her infant after discharge from the hospital, many providers are implementing one or more postpartum telephone followup calls to their patients for assessment, health teaching, identification of complications to effect timely intervention, and referrals. Telephone follow-up may be part of the services offered by the hospital, private physician or clinic, or a private agency; it may be either a separate service, or combined with other strategies for extending postpartum care. Telephonic nursing assessments are frequently used after a postpartum home care visit to reassess a woman's knowledge about the signs and symptoms of adequate hydration in breastfeeding or, after initiating home phototherapy, to assess the caregiver's knowledge regarding equipment complications.
The "warm line" is another type of telephone link between the new family and concerned caregivers or experienced parent volunteers. A warm line is a help line or consultation service, not a crisis intervention line. The warm line is appropriately used for dealing with less extreme concerns that may seem urgent at the time the call is placed but are not actual emergencies. Calls to warm lines commonly relate to infant feeding, prolonged crying, or sibling rivalry. Warm line services may extend beyond the fourth trimester. Families need to call when concerns arise and be given phone numbers for easy access to answers to their questions.
A special group experience is sometimes sought by the woman adjusting to motherhood. On occasion, postpartum women who have met earlier in prenatal clinics or on the hospital unit may begin to associate for mutual support. Members of childbirth classes who attend a postpartum reunion may decide to extend their relationship during the fourth trimester.
A postpartum support group enables mothers and fathers to share with and support each other as they adjust to parenting. Many new parents find it reassuring to discover that they are not alone in their feelings of confusion and uncertainty. An experienced parent can often impart concrete information that can be valuable to other members in a postpartum support group. Inexperienced parents may find themselves imitating the behavior of others in the group whom they perceive as particularly capable.
Referral to community resources
To develop an effective referral system, it is important that the nurse have an understanding of the needs of the woman and family and of the organization and community resources available for meeting those needs. Locating and compiling information about available community services contributes to the development of a referral system. It is important for the nurse to develop his or her own resource file of local and national services that are used commonly by health care providers (see Resources at the end of this chapter).
TRANSITION TO PARENTHOOD
Becoming a parent creates a period of change 'and instability for men and women who decide to have children. This occurs whether parenthood is biologic or adoptive and whether the parents are married husband-wife couples, cohabiting couples, single mothers, single fathers, lesbian couples with one woman as biologic mother, or gay male couples who adopt a child. Parenting may be described as a process of role attainment and role transition that begins during pregnancy. The transition ends when the parent develops a sense of comfort and confidence in performing the parental role.
PARENTAL ATTACHMENT, BONDING, AND ACQUAINTANCE
The process by which a parent comes to love and accept a child and a child comes to love and accept a parent is referred to as attachment Using the terms attachment and bonding, Klaus and colleagues (1972) proposed that the period shortly after birth is important to mother-to-infant attachment. They defined the phenomenon of bonding as a sensitive period in the first minutes and hours after birth when mothers and fathers must have close contact with their infants for optimal later development (Klaus & Kennell, 1976). Klaus and Kennell (1982) later revised their theory of parent-infant bonding, modifying their claim of the critical nature of immediate contact with the infant after birth. They acknowledged the adaptability of human parents, stating that it took longer than minutes or hours for parents to form an emotional relationship with their infants. The terms attachment and bonding continue to be used interchangeably.
Attachment is developed and maintained by proximity and interaction with the infant, through which the parent becomes acquainted with the infant, identifies the infant as an individual, and claims the infant as a member of the family. Attachment is facilitated by positive feedback (i.e., social, verbal, and nonverbal responses, whether real or perceived, that indicate acceptance of one partner by the other). Attachment occurs through a mutually satisfying experience. A mother commented on her son's grasp reflex, "I put my finger in his hand, and he grabbed right on. It is just a reflex, I know, but it felt good anyway" (Fig. 1).
Fig. 1 Hands. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
The concept of attachment has been extended to include mutuality; that is, the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. The infant displays signaling behaviors such as crying, smiling, and cooing that initiate the contact and bring the caregiver to the child. These behaviors are followed by executive behaviors such as rooting, grasping, and postural adjustments that maintain the contact. The caregiver is attracted to an alert, responsive, cuddly infant and repelled by an irritable, apparently disinterested infant. Attachment occurs more readily with the infant whose temperament, social capabilities, appearance, and sex fit the parent's expectations. If the child does not meet these expectations, resolution of the parent's disappointment can delay the attachment process. A list of infant behaviors affecting parental attachment that continues to be a classic comprehensive reference is presented in Table 1. A corresponding list of parental behaviors that affect infant attachment is presented in Table 2.
TABLE 1 Infant Behaviors Affecting Parental Attachment
Visually alert; eye-to-eye contact; tracking or following of parent's face
Appealing facial appearance; randomness of body movements reflecting helplessness
Vocalization; crying only when hungry or wet
Anticipatory approach behaviors for feedings; sucks well; feeds easily
Enjoys being cuddled, held
Activity and regularity somewhat predictable
Attention span sufficient to focus on parents
Differential crying, smiling, and vocalizing; recognizes and prefers parents
Approaches through locomotion
Clings to parent; puts arms around parent's neck
Lifts arms to parents in greeting
Sleepy; eyes closed most of the time; gaze aversion
Resemblance to person parent dislikes; hyperirritability or jerky body movements when touched
Bland facial expression; infrequent smiles
Crying for hours on end; colicky
Exaggerated motor reflex
Feeds poorly; regurgitates; vomits often
Resists holding and cuddling by crying, stiffening body
Inconsolable; unresponsive to parenting, caretaking tasks
Unpredictable feeding and sleeping schedule
Inability to attend to parent's face or offered stimulation
Shows no preference for parents over others
Unresponsive to parent's approaches
Seeks attention from any adult in room
TABLE 2 Parental Behaviors Affecting Infant Attachment
Looks; gazes; takes in physical characteristics of infant; assumes en face position; eye contact
Hovers; maintains proximity; directs attention to, points to infant
Identifies infant as unique individual
Claims infant as family member; names infant
Touches; progresses from fingertip to fingers to palms to encompassing contact
Smiles at infant
Talks to, coos, or sings to infant
Expresses pride in infant
Relates infant's behavior to familiar events
Assigns meaning to infant's actions and sensitively interprets infant's needs
Views infant's behaviors and appearance in positive light
Turns away from infant; ignores infant's presence
Avoids infant; does not seek proximity; refuses to hold infant when given opportunity
Identifies infant with someone parent dislikes; fails to discern any of infant's unique features
Fails to place infant in family context or identify infant with family member; has difficulty naming
Fails to move from fingertip touch to palmar contact and holding
Maintains bland countenance or frowns at infant
Wakes infant when infant is sleeping; handles roughly; hurries feeding by moving nipple continuously
Expresses disappointment, displeasure in infant
Does not incorporate infant into life
Makes no effort to interpret infant's actions or needs
Views infant's behavior as exploiting, deliberately uncooperative; views appearance as distasteful, ugly
An important part of attachment is acquaintance (Klaus & Kennell, 1983). Parents use eye contact (Fig. 2), touching, talking, and exploring to become acquainted with their infant during the immediate postpartum period. Adoptive parents undergo the same process when they first meet their new child. During this period families engage in the claiming process, which is the identification of the new baby (Fig. 3). The child is first identified in terms of "likeness" to other family members, then in terms of "differences," and finally in terms of "uniqueness." The unique newcomer is thus incorporated into the family. Mothers and fathers scrutinize their infant carefully and point out characteristics that the child shares with other family members and that are indicative of a relationship between them. The claiming process is revealed by maternal comments such as the following: "Russ held him close and said, 'He's the image of his father,' but I found one part like me—his toes are shaped like mine."
Fig. 2 Mother and baby make eye contact in en face position. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Fig. 3 Family members examine the new baby. They discuss how she resembles them and other family members. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
On the other hand, some mothers react negatively. They "claim" the infant in terms of the discomfort or pain the baby causes. The mother interprets the infant's normal responses as being negative toward her and reacts to her child with dislike or indifference. She does not hold the child close or touch the child to be comforting; for example, "The nurse put the baby into Marie's arms. She promptly laid him across her knees and glanced up at the television. 'Stay still until I finish watching—you've been enough trouble already.'"
Nursing interventions related to the promotion of parentinfant attachment are numerous and varied (Table 3). They can enhance positive parent-infant contacts by heightening parental awareness of an infant's responses and ability to communicate. As the parent attempts to become competent and loving in that role, nurses can bolster the parent's self-confidence and ego. Nurses are in prime positions to identify actual and potential problems and collaborate with other health care professionals who will provide care for the parents after discharge. Nursing considerations for fostering maternal-infant bonding among special populations may vary (see Cultural Considerations box).
Table 3 Examples of Parent-Infant Attachment Interventions
Facilitation of development of parentinfant relationship
Give parents opportunity to hold infant soon after birth
Keep infant with parents after birth when possible
Provide rooming-in in hospital
Provide pain relief for mother
Provide opportunity for parents to see, hold, and examine newborn immediately after birth
ENVIRONMENTAL MANAGEMENT: ATTACHMENT PROCESS
Manipulation of environment that facilitates development of parentinfant relationship
Allow for family visitation as desired
Create environment that fosters privacy
Permit father/significant other to sleep in room with mother
Provide rocking chair
FAMILY INTEGRITY PROMOTION: CHILDBEARING FAMILY
Facilitation of growth of individuals or families who are adding infant to family
Convey accepting attitude (for nonthreatening environment for family to express feelings)
Reinforce parenting behaviors
Offer to be listener for significant other
Discuss sibling's reaction to newborn, as appropriate
Use of interactive helping process to assist in maintenance of successful breastfeeding
Educate parents about infant feeding for informed decision making
Give parents recommended education material, as needed
Provide information about advantages and disadvantages of breastfeeding
Inform parents about appropriate classes or groups for breastfeeding
PARENT EDUCATION: CHILDBEARING FAMILY
Preparation of individuals to perform their role as parents
Reinforce skills parent does well in caring for infant to promote confidence
Assist parents in interpreting infant cues
Monitor learning needs of family
Appraise parents' learning styles (how they learn best)
RISK IDENTIFICATION: CHILDBEARING FAMILY
Identification of individuals or families who are likely to have difficulties in parenting and prioritization of strategies to prevent parenting problems
Review maternal history of chemical dependency, noting duration, type of drug(s), and time and strength of last dose before birth
Monitor behaviors indicative of problem with attachment
Determine parents' feelings about unplanned pregnancy
Determine economic, marital, and educational status of parents
Fostering Bonding Among Specific Populations
WOMEN IN ECONOMICALLY DISADVANTAGED SITUATIONS
Low-income mothers may have to contend with stressors that distract them from developing a relationship with their babies. Inability to pay for infant supplies or child care, chaotic home situations, and worry over eligibility for social and health care services deplete these women's psychologic energy.
Nurses need to conduct nonjudgmental, individual assessments of resources and social networks to avoid inaccurate and stereotypical assumptions. Nurses can help economically disadvantaged mothers access social services, such as the Women, Infants, and Children (WIC) program and Medicaid. For mothers whose home environments provide little or no support and multiple stressors, early discharge may not be optimal. Nurses can advocate for longer hospital stays for these mothers when the hospital environment is more conducive to bonding.
Economically disadvantaged mothers, especially adolescents, are not as likely to be aware of the benefits of bonding or to be knowledgeable of normal infant behaviors. These women may not be aware of maternity care options, such as rooming-in, or may be less assertive in asking for such options. The nurse needs to be a patient educator and advocate, explaining the choices and the potential benefits. The nurse should ensure a supportive, encouraging environment that will help mothers engage in positive interactions with their infants. By use of the Brazelton Neonatal Behavioral Assessment Scale, the nurse can capture the mother's attention with a mother-infant interactional experience and, at the same time, increase the mother's knowledge of infant behavior. Written material can be provided after the assessment to reinforce the behavioral concepts.
Examples, from sections of an individualized handout written as if from the baby, include "My strengths: great motor maturity—I stretch my arms way up over my head" and "How you can help: swaddle my arms so I can suck on my hands" (Tedder, 1991).
WOMEN OF VARYING ETHNIC AND CULTURAL GROUPS
Childbearing practices and rituals of other cultures may not be congruent with standard practices associated with bonding in the Anglo-American culture. For example, Chinese families traditionally use extended family members to care for the newborn so that the mother can rest and recover, especially after a cesarean birth. Some Native American, Asian, and Hispanic women do not initiate breastfeeding until their breast milk comes in. Haitian families do not name their babies until after the confinement month. Amount of eye contact varies among cultures, too. Yup'ik Eskimo mothers almost always position their babies so that eye contact can be made.
Nurses should become knowledgeable of the childbearing beliefs and practices of diverse cultural and ethnic groups. Because individual cultural variations exist within groups, nurses need to clarify with the patient and family members or friends what cultural norms the woman follows. Incorrect judgments may be made about mother-infant bonding if nurses do not practice culturally sensitive care.
ASSESSMENT OF ATTACHMENT BEHAVIORS
One of the most important areas of assessment is careful observation of those behaviors thought to indicate the formation of emotional bonds between the newborn and family, especially the mother. Unlike physical assessment of the neonate, which has concrete guidelines to follow, assessment of parent-infant attachment requires much more skill in terms of observation and interviewing. Rooming-in of mother and infant and liberal visiting privileges for father, siblings, and grandparents facilitate recognition of behaviors that demonstrate positive or negative attachment. An excellent opportunity exists during feeding. Guidelines for assessment of attachment behaviors are presented in Box 1.
BOX 1 Assessing Attachment Behavior
When the infant is brought to the parents, do they reach out for the infant and call the infant by name? (Recognize that in some cultures, parents may not name the infant in the early newborn period.)
Do the parents speak about the infant in terms of identification—whom the infant looks like; what appears special about their infant over other infants?
When parents are holding the infant, what kind of body contact is there—do parents feel at ease in changing the infant's position; are fingertips or whole hands used; are there parts of the body they avoid touching or parts of the body they investigate and scrutinize?
When the infant is awake, what kinds of stimulation do the parents provide—do they talk to the infant, to each other, or to no one; how do they look at the infant—direct visual contact, avoidance of eye contact, or looking at other people or objects?
How comfortable do the parents appear in terms of caring for the infant? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers?
What type of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking?
If the infant is fussy, what kinds of comforting techniques do the parents use, such as rocking, swaddling, talking, or stroking?
During pregnancy, and often even before conception occurs, parents develop an image of the "ideal" or "fantasy" infant. At birth the fantasy infant becomes the real infant. How closely the dream child resembles the real child influences the bonding process. Assessing such expectations during pregnancy and at the time of the infant's birth allows identification of discrepancies in the parents' view of the fantasy child versus the real child.
The labor process significantly affects the immediate attachment of mothers to their newborn infants. Factors such as a long labor, feeling tired or "drugged" after birth, and problems with breastfeeding can delay the development of initial positive feelings toward the newborn.
Early close contact may facilitate the attachment process between parent and child. This does not mean that a delay will inhibit this process (humans are too resilient for that), but additional psychologic energy may be needed to achieve the same effect. To date, no scientific evidence has demonstrated that immediate contact after birth is essential for the human parent-child relationship.
Parents who desire but are unable to have early contact with their newborn (e.g., the infant was transferred to the intensive care nursery) can be reassured that such contact is not essential for optimal parent-infant interactions. Otherwise, adopted infants would not form the usual affecttional ties with their parents. Nor does the mode of infant mother contact after birth (skin-to-skin versus wrapped) appear to have any important effect. Nurses need to stress that the parent-infant relationship is a process that occurs over time.
The provision of rooming-in facilities for the mother and her baby is common in family-centered care. The infant is transferred to the area from the transitional nursery (if the facility uses one) after showing satisfactory extrauterine adjustment. The father is encouraged to participate in the care of the infant, and siblings and grandparents are also encouraged to visit and become acquainted with the infant. Whether the method of family-centered care is rooming-in, mother-baby or couplet care, or a family birth unit, mothers and their partners are considered equal and integral parts of the developing family. Partners are encouraged to take as active a role as they wish.
Extended contact with the infant should be available for all parents but especially for those at risk for parenting inadequacies, such as adolescents and low-income women. Any activity that optimizes family-centered care is worthy of serious consideration by postpartum nurses.
COMMUNICATION BETWEEN PARENT AND INFANT
The parent-infant relationship is strengthened through the use of sensual responses and abilities by both partners in the interaction. The nurse should keep in mind that there may be cultural variations in these interactive behaviors.
Touch, or the tactile sense, is used extensively by parents and other caregivers as a means of becoming acquainted with the newborn. Many mothers reach out for their infants as soon as they are born and the cord is cut. They lift them to their breasts, enfold them in their arms, and cradle them. Once the infant is close to them, they begin the exploration process with their fingertips, one of the most touch-sensitive areas of the body. Within a short time the caregiver uses the palm to caress the baby's trunk and eventually enfolds the infant. Gentle stroking motions are used to soothe and quiet the infant; patting or gently rubbing the infant's back is a comfort after feedings. Infants also pat the mother's breast as they nurse. Both seem to enjoy sharing each other's body warmth. There is a desire in parents to touch, pick up, and hold the infant (Fig. 4). They comment on the softness of the baby's skin and are aware of milia and rashes. As parents become increasingly sensitive to the infant's like or dislike of different types of touch, they draw closer to their baby.
Fig. 4 Mother interacts Judy Bamber, San Jose, CA.) with newborn.
Variations in touching behaviors have been noted in mothers from different cultural groups (Galanti, 1991; Inman, 1996; Jambunathan & Stewart, 1995; Jimenez, 1995). For example, minimal touching and cuddling is a traditional Southeast Asian practice thought to protect the infant from evil spirits. Because of tradition and spiritual beliefs, women in India and Bali have practiced infant massage since ancient times.
Interest in having eye contact with the baby has been demonstrated repeatedly by parents. Some mothers remark that once their babies have looked at them, they feel much closer to them. Parents spend much time getting their babies to open their eyes and look at them. In American culture, eye contact appears to cement the development of a trusting relationship and is an important factor in human relationships at all ages. In other cultures, eyeto-eye contact may be perceived differently. For example, in Mexican culture, sustained direct eye contact is considered to be rude, immodest, and dangerous for some. This danger may arise from the malojo (evil eye), resulting from excessive admiration. Women and children are thought to be more susceptible to the mal ojo (Geissler, 1999).
As newborns become functionally able to sustain eye contact with their parents, time is spent in mutual gazing, often in the en face position, a position in which the parent's face and the infant's face are approximately 20 cm apart and on the same plane (see Fig. 2). Nursing and medical practices should be implemented that encourage this interaction. Immediately after birth, for example, the infant can be positioned on the mother's abdomen or breasts with the mother's and the infant's faces on the same plane so that they can easily make eye contact. Lights can be dimmed so that the infant's eyes will open. Instillation of prophylactic antibiotic ointment in the infant's eyes can be delayed until the infant and parents have had some time together in the first hour after birth.
The shared response of parents and infants to each other's voices is also remarkable. Parents wait tensely for the first cry. Once that cry has reassured them of the baby's health, they begin comforting behaviors. As the parents talk in high-pitched voices, the infant is alerted and turns toward them.
Infants respond to higher-pitched voices and can distinguish their mother's voice from others soon after birth. Infants use their cries to signal hunger, pain, boredom, and tiredness. With experience, parents learn to distinguish among such cries.
Another behavior shared by parents and infants is a response to each other's odor. Mothers comment on the smell of their babies when first born and have noted that each infant has a unique odor. Infants learn rapidly to distinguish the odor of their mother's breast milk.
Newborns move in time with the structure of adult speech (entrainment). They wave their arms, lift their heads, and kick their legs, seemingly "dancing in tune" to a parent's voice. Culturally determined rhythms of speech are ingrained in the infant long before spoken language is used to communicate. This shared rhythm also gives the parent positive feedback and establishes a positive setting for effective communication.
The fetus is in tune with the mother's natural rhythms (biorhythmicity), such as heartbeats. After birth a crying infant may be soothed by being held in a position where the mother's heartbeat can be heard or by hearing a recording of a heartbeat. One of the newborn's tasks is to establish a personal biorhythm. Parents can help in this process by giving consistent loving care and using their infant's alert state to develop responsive behavior and thereby increase social interactions and opportunities for learning (Fig. 5). The more quickly parents become competent in child care activities, the more quickly their psychologic energy can be directed toward observing the communication cues the infant gives them.
Fig. 5 Infant in alert state. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
RECIPROCITY AND SYNCHRONY
Reciprocity is a type of body movement or behavior that provides the observer with cues. The observer or receiver interprets those cues and responds to them. Reciprocity often takes several weeks to develop with a new baby. For example, when the newborn fusses and cries, the mother responds by picking up and cradling the infant; the baby becomes quiet and alert and establishes eye contact; the mother verbalizes, sings, and coos while the baby maintains eye contact. The baby then averts the eyes and yawns; the mother decreases her active response (Fig. 6). If the parent continues to stimulate the infant, the baby may become fussy.
Fig, 6 Holding newborn in en face position, mother works to alert her daughter, 6 hours old. A, Infant is quiet and alert. B, Mother begins talking to daughter. C, Infant responds, opens mouth like her mother. D, Infant gazes at her mother. E, Infant waves hand. F, Infant glances away, resting. Hand relaxes. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Synchrony refers to the "fit" between the infant's cues and the parent's response. When parent and infant experience a synchronous interaction, it is mutually rewarding (Fig. 7). Parents need time to interpret the infant's cues correctly. For example, after a certain time the infant develops a specific cry in response to different situations such as boredom, loneliness, hunger, and discomfort. The parent may need assistance in deciphering these cries, along with trial and error interventions, before synchrony develops.
Fig. 7 Sharing a smile: example of synchrony. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
PARENTAL ROLE AFTER CHILDBIRTH
Adaptation involves a stabilizing of tasks, a coming to terms with commitments. Parents demonstrate growing competence in child care activities and are more attuned to their infant's behavior. Typically, the period from the decision to conceive through the first months of having a child is termed the transition to parenthood.
TRANSITION TO PARENTHOOD
Historically, the transition to parenthood was viewed as a crisis. The current perspective is that parenthood is a developmental transition (Tomlinson, 1996) rather than a major life crisis for the majority of families. The transition to parenthood is described as a time of disorder and disequilibrium, as well as satisfaction, for mothers and their partners (Rogan et al., 1997; Sethi, 1995; Tomlinson, 1996). Usual methods of coping often seem ineffective. Some parents can be so distressed that they are unable to be supportive of each other. Because men typically identify their spouses as their primary or only source of support, the transition can be harder for the fathers, who feel deprived when the mothers, who are also experiencing stress, cannot provide their usual level of support. Strong emotions such as helplessness, inadequacy, and anger that arise when dealing with a crying infant catch many parents unprepared. On the other hand, parenthood allows adults to develop and display a selfless, warm, and caring side of themselves, which may not be expressed in other adult roles.
For the majority of mothers and their partners, the transition to parenthood is viewed as an opportunity rather than a time of danger. Parents are stimulated to try new coping strategies as they work to master their new roles and reach new developmental levels. As they work through the transition, personal strength and resourcefulness are revealed (Rogan et al, 1997).
PARENTAL TASKS AND RESPONSIBILITIES
Parents need to reconcile the actual child with the fantasy and dream child. This means coming to terms with the infant's physical appearance, sex, innate temperament, and physical status. If the real child differs greatly from the fantasy child, parents may delay acceptance of the child. In some instances, they may never accept the child.
Some parents are startled by the normal appearance of the neonate—size, color, molding of the head, or bowed appearance of the legs. Many fathers have commented that they thought the odd shape of the infant's head (molding) meant the infant would be mentally retarded.
Many parents know the sex of the infant before birth because of the use of ultrasound assessments; for those who do not have this information, disappointment over the sex of the infant can take time to resolve. The parents may provide adequate physical care but find it difficult to be sincerely involved with the infant until this internal conflict has been resolved. As one mother remarked, "I really wanted a boy. I know it is silly and irrational, but when they said, 'She's a lovely little girl,' I was so disappointed and angry—yes, angry—I could hardly look at her. Oh, I looked after her okay, her feedings and baths and things, but I couldn't feel excited. To tell the truth, I felt like a monster not liking my child. Then one day she was lying there and she turned her head and looked right at me. I felt a flooding of love for her come over me, and we looked at each other a long time. It's okay now. I wouldn't change her for all the boys in the world."
Parents need to become adept in the care of the infant, including caregiving activities, noting the communication cues given by the infant to indicate needs, and responding appropriately to the infant's needs. Self-esteem grows with competence. Breastfeeding makes mothers feel they are contributing in a unique way to the welfare of the infant. The infant's response to the parental care and attention may be interpreted by the parent as a comment on the quality of that care. Infant behaviors that are interpreted by parents as positive responses to their care include being consoled easily, enjoying being cuddled, and making eye contact. Spitting up frequently after feedings, crying, and being unpredictable may be perceived as negative responses to parental care. Continuation of these infant responses that are viewed as negative by the parent can result in alienation of parent and infant to the detriment of the infant.
Assistance, including advice by husbands, partners, wives, mothers, mothers-in-law, and professional workers, can either be seen as supportive or an indication of how inept these people have judged the new parents to be. Criticism, real or imagined, of the new parents' ability to provide adequate physical care, nutrition, or social stimulation for the infant can prove devastating. By providing encouragement and praise for parenting efforts, nurses can bolster the new parents' confidence.
Parents must establish a place for the newborn within the family group. Whether the infant is the firstborn or the last born, all family members must adjust their roles to accommodate the newcomer. The firstborn child needs support to accept a rival for parental affections. An older child needs help dealing with losing a favored position in the family hierarchy. The parents are expected to negotiate these changes.
Three phases are evident as the mother adjusts to her parental role. These phases are characterized by dependent behavior, dependent-independent behavior, and interdependent behavior.
During the first 24 to 48 hours after childbirth the mother's dependency needs predominate. To the extent that these needs are met by others, the mother is able to divert her psychologic energy to her infant rather than to focus on herself. She needs "mothering" herself to "mother." Rubin (1961) aptly described these few days as the taking-in phase, a time when nurturing and protective care are required by the new mother. In Rubin's classic description the taking-in phase lasted 2 to 3 days. Later studies found that women move more rapidly through the taking-in phase (Ament, 1990; Wrasper, 1996). Evans and colleagues (1998), in a study of women giving birth vaginally, found that both taking-in and taking-hold were present on the evening of birth.
This dependent phase is a time of great excitement during which parents need to verbalize their experience of pregnancy and birth. Focusing on, analyzing, and accepting these experiences help the parents move on to the next phase. Some parents use staff members or other mothers as an audience, whereas others are more comfortable talking with family and friends about the pregnancy and birth experience.
Because anxiety and preoccupation with her new role often narrow a mother's perceptions, information may have to be repeated. The new mother may require reminders to rest or, conversely, to ambulate enough to promote recovery.
Physical discomfort can interfere with the mother's need for rest and relaxation. The selective use of comfort measures and medication depends on the nurse. Many women hesitate to ask for medication, believing that any pain they experience is normal and to be expected; breastfeeding mothers may fear the effects of medication on the infant.
If the mother has received adequate nurturing in the first few hours or days, by the second or third day, her desire for independent action reasserts itself. In the dependent independent phase, the mother alternates between a need for extensive nurturing and acceptance by others and the desire to "take charge" once again. She responds enthusiastically to opportunities to learn and practice baby care or, if she is an accomplished mother, to carry out or direct this care (Mercer & Ferketich, 1995). Rubin (1961) described this phase as the taking-hold phase, noting that it lasts approximately 10 days. Evans and associates (1998) found that taking-hold behaviors began increasing between the evening of birth and the first morning despite high levels of sleep disturbance. Childbirth preparation classes, early contact with the newborn, rooming-in, and early discharge are some of the current obstetric practices that seem to enhance taking-hold behaviors (Martell, 1996; Wrasper, 1996).
Most mothers are discharged home during this dependent-independent phase. Once home, mothers must continue to cope with physical adaptations and psychologic adjustments.
Prenatally and postnatally, nurses can discuss common postpartal concerns that mothers experience and provide anticipatory guidance on coping strategies, such as resting when the infant sleeps and planning with an extended family member or friend to do the housework for the first week or two after the baby is born. Once a mother is home, periodic phone calls from a nurse who cared for her in the birth setting can provide the mother with an opportunity to vent her concerns and get support and advice from "her" nurse. First-time mothers inexperienced in child care, women whose careers had provided outside stimulation, women who lack friends or family members with whom to share delights and concerns, substanceabusing mothers, and adolescent mothers may need additional supportive counseling (see Research box).
Cocaine Addiction and Parenting Skills
The prevalence of cocaine exposure in pregnant women is estimated at 2% to 18%, with an annual cost for drug-exposed infants as high as $3 billion. Families are vulnerable to the physical, psychologic, social, and economic sequelae of the addictive behavior. Researchers have found that drug use interferes with normal mother-infant interactions and hardships are experienced by all members of the family.
This study used nonstructured interviews to examine parenting skills of 11 multiparous mothers recovering from cocaine addiction. Content analysis of the data identified four subthemes that emerged from psychologic/personal and environmental/contextual factors influencing parenting:
• Low self-esteem may have had its origin in family-of origin parenting style, sexual or physical abuse, neglect, and absence of emotional support.
• Maternal identity was difficult for addicts to develop, due to having limited caregiving experience, focusing on their own recovery needs, focusing on the physical but not the emotional needs of their children, and guilt about a cocaine-exposed child.
• Isolation occurred through separation from ongoing drug use in family members and friends, because family rejected the addict, or because of relocation.
• Chronic life stress included single parenting, relocation of children, and financial hardship.
IMPLICATIONS FOR PRACTICE
Nurses need to be educated about addiction and its treatment to provide care for these vulnerable women. Accepting addiction as a disease and supporting the mothers in their recovery also involves advocating for long-term, outpatient recovery programs tailored for women's lives. Counseling can provide insight into breaking the cycle of dysfunctional parenting. Nurses can provide information, encouragement, and modeling about discipline, child development, and cocaine exposure issues, as well as provide information about support groups and recovery resources.
Postpartum "blues." The "pink" period surrounding the first day or two after birth, characterized by heightened joy and feelings of well-being, is often followed by a "blue" period. Approximately 75% to 80% of women experience the postpartum blues or "baby blues" (Albright, 1993; Wood et al, 1997) that occur in women of all ethnic and racial groups (Campbell, 1992). During the blues, women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth day and subside by the tenth day. Other symptoms of postpartum blues include depression, a let-down feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and anger. Biochemical, psychologic, social, and cultural factors have been explored as possible causes of the postpartum depressive state; however, the etiology remains unknown. Whatever the cause, the early postpartum period appears to be one of emotional and physical vulnerability for new mothers, who may be psychologically overwhelmed by the reality of parental responsibilities. The mother may feel deprived of the supportive care she received from family members and friends during pregnancy. Some mothers regret the loss of the mother-unborn child relationship and mourn its passing. Still others experience a let-down feeling when labor and birth are complete. Fatigue after childbirth is compounded by the around-the-clock demands of the new baby and can accentuate the feelings of depression. Postpartum depressive symptoms can have a negative effect on maternal role attainment (Fowles, 1998). To help mothers cope with postpartum blues, nurses can suggest various strategies (see Self-Care box)
Patient Instructions for Self-Care
Coping with Postpartum Blues
• Remember that the "blues" are normal.
• Get plenty of rest; nap when the baby does if possible. Go to bed early, and let friends know when to visit.
• Use relaxation techniques learned in childbirth classes (or ask the nurse to teach you and your partner some techniques).
• Do something for yourself. Take advantage of the time your partner or family members care for the baby—soak in the tub or go for a walk.
• Plan a day out of the house—go to the mall with the baby, being sure to take a stroller or carriage, or go out to eat with friends without the baby. Many communities have churches or other agencies that provide child care programs such as Mothers' Morning Out.
• Talk to your partner about the way you feel—for example, about feeling tied down, how the birth met your expectations, and things that will help you.
• If you are breastfeeding, give yourself and your baby time to learn.
• Seek out and use community resources such as La Leche League or community mental health centers. One nationally recognized resource is as follows.
"Am I Blue?" (Johnson & Johnson, 1996), a self-administered questionnaire, can help mothers to assess their level of "blues" and to decide when to seek advice from their nurse, nurse-midwife, or physician (Fig. 8). Home visits and telephone follow-up calls by the nurse are important to assess the mother's pattern of "blue" feelings and behavior over time.
Fig. 8 "Am Blue?" (Courtesy Johnson & Johnson Consumer Products, Skillman, NJ.)
Although the postpartum blues are usually mild and short lived, approximately 10% to 15% of women experience a more severe syndrome termed postpartum depression (PPD) (Wood et al., 1997) (see Chapter 25). The symptoms can range from mild to severe, with women having "good days" and "bad days." PPD can go undetected because new mothers generally do not voluntarily admit to this kind of emotional distress out of embarrassment, guilt, or fear. Nurses need to teach women how to differentiate symptoms of the "blues" and PPD and to urge women to report depressive symptoms promptly if they occur.
In this phase, interdependent behavior reasserts itself, and the mother and her family move forward as a unit with interacting members. The relationship of the partners, although altered by the introduction of a baby, resumes many of its former characteristics. A primary need is to establish a lifestyle that includes but in some respects also excludes the baby. The couple needs to share interests and activities that are adult in scope.
The couple may begin to engage in sexual intercourse during the second to fourth week after the baby is born. Some couples begin earlier, as soon as it can be accomplished without discomfort, depending on factors such as timing, amount of vaginal dryness, and breastfeeding status. Sexual intimacy enhances the adult aspect of the family, and the adult pair shares a closeness denied to other family members. Many new fathers speak of the alienation experienced when they observe the intimate mother-infant relationship, and some are frank in expressing feelings of jealousy toward the infant. The resumption of sexual intimacy seems to bring the parents' relationship back into focus.
The interdependent phase, termed the letting-go phase, is often stressful for the parental pair. Interests and needs often diverge during this time. Women and their partners must resolve the effects on their relationship of their individual roles related to child rearing, homemaking, and careers. Mothers (and partners) may take a more traditional role in an effort to adapt to parenthood; however, traditional women have reported more family disorganization months into parenthood (Tomlinson & Irwin, 1993). A special continuing effort has to be undertaken to strengthen the adult-adult relationship as a basis for the family unit.
Little is known about postpartum maternal adjustment in the lesbian couple. Relationship satisfaction in first time lesbian parent couples appears related to egalitarianism, commitment, sexual compatibility, and communication skills, as well as the birth mother's decision for insemination by an anonymous sperm donor (Osterwell, 1991). Similar to heterosexual parent couples, most lesbian parent couples voice concern about less time and energy for their relationship after the arrival of the baby (Gartrell et al., 1996). Both partners consider themselves to be equal parents of the baby who share actively in child rearing (Brewaeys et al., 1995).
Research on paternal adjustment to parenthood indicates that fathers go through predictable phases during their transition to parenthood (Henderson & Brouse, 1991). During this period, fathers experience intense emotions (Box 2). Many fathers acknowledge that their expectations were of limited value once they were immersed in the reality of parenthood. Feelings that often accompany this reality are sadness, ambivalence, jealousy, frustration at not being able to participate in breastfeeding, and an overwhelming desire to be more involved, most of which are different from the feelings mothers report. On the other hand, some fathers are pleasantly surprised at the ease and fun of parenting. In their transition to mastery, fathers take control and become more actively involved in the infant's life
BOX 2 Paternal Adjustment to Fatherhood
Fathers as well as mothers are affected emotionally by the birth of an infant. For example, The News Tribune of Tacoma reported that Vin Baker, a professional basketball player, is receiving counseling for depression. Baker said that he is "fighting a lot of depression now and coping with a lot of different things." He has been removed from the starting lineup, which has been difficult. He also cites that becoming a father was stressful. "I was sitting at home, I was in tears, I was crying all day."
First-time fathers perceive the first 4 to 10 weeks of parenthood in much the same way that mothers do, that is, as a period characterized by uncertainty, increased responsibility, disruption of sleep, and inability to control time needed to care for the infant and reestablish the marital dyad. Fathers express concern about decreased attention from their partners relative to their personal relationship, the mother's lack of recognition of the father's desire to participate in decision making for the infant, and limited time available to establish a relationship with their infants. These concerns can precipitate feelings of jealousy of the infant. Discussing their needs with the partner and becoming more involved with their infants and partner can help alleviate such feelings of jealousy.
Fig. 9 Engrossment. Father is absorbed in looking at his newborn. (Courtesy Leslie Canerday, Phoenix, AZ.)
In American culture, neonates have a powerful impact on their fathers, who become intensely involved with their babies (Fig. 9). The term used for the father's absorption, preoccupation, and interest in the infant is engrossment. Characteristics of engrossment include some of the sensual responses relating to touch and eye-to-eye contact that have been discussed earlier and also the father's keen awareness of features both unique and similar to himself that validate his claim to the infant. An outstanding response is one of strong attraction to the newborn. Fathers spend considerable time "communicating" with the infant and taking delight in the infant's response to them. A sense of increased self-esteem and a sense of being proud, bigger, more mature, and older are all experienced by fathers after seeing their baby for the first time.
Fathers spend less time than mothers with infants, and fathers' interactions with infants tend to be characterized by stimulating social play rather than caretaking. The subtle and more open differences in stimulation from two sources, mother and father, provide a wider social experience for the infant.
Fathers can benefit from nursing interventions during the postpartum period just as mothers can. Nurses can arrange to teach infant care when the father is present and provide anticipatory guidance for fathers about the transition to parenthood. Separate prenatal and parenting classes and parenting support groups for fathers can provide them with an opportunity to discuss their concerns and have some of their needs met. Postpartum phone calls and home visits by the nurse should include time for assessment of the father's adjustment and needs.
FACTORS INFLUENCING PARENTAL RESPONSES
How parents respond to the birth of their child is influenced by various factors, including age, social networks, socioeconomic conditions, and personal aspirations of the future.
Maternal age has a definite effect on the outcome of pregnancy. The mother, fetus, and newborn are at highest risk when the mother is an adolescent or is more than 35 years old.
Although it is biologically possible for the adolescent female to become a parent, her egocentricity and concrete thinking interfere with her ability to parent effectively. The very young adolescent mother is inexperienced and unprepared to recognize the early signs of illness, potential danger, or household hazards. She may inadvertently neglect her child. The higher mortality rates among the infants of adolescent mothers are attributed to the inexperience, lack of knowledge, and immaturity of the mothers, causing them to be unable to recognize a problem and obtain the necessary resources to rectify the situation. Nevertheless, in most instances, with adequate support and developmentally appropriate teaching, adolescents can learn effective parenting skills.
The transition to parenthood may be difficult for adolescent parents. Coping with the developmental tasks of parenthood is often complicated by the unmet developmental needs and tasks of adolescence. Some young parents may experience difficulty accepting a changing self-image and adjusting to new roles related to the responsibilities of infant care. Other adolescent parents, however, may have higher self-concepts than their nonparenting peers (Alpers, 1998).
As adolescent parents move through the transition to parenthood, they may feel "different" from their peers, excluded from "fun" activities, and prematurely forced to enter an adult social role. The conflict between their own desires and the infant's demands, in addition to the low tolerance for frustration that is typical of adolescence, further contributes to the normal psychosocial stress of childbirth. Lower maternal education is associated with less favorable maternal responses to distress and infant behavior (Diehl, 1997).
Maintaining a relationship with the baby's father is beneficial for the teen mother and her infant. A close and satisfying relationship is positively correlated with maternal-fetal and maternal-infant attachment (Bloom, 1998). The involvement of the baby's father is related to appropriate maternal behaviors and positive mother-infant relationship (Diehl, 1997).
Adolescent mothers provide warm and attentive physical care; however, they use less verbal interaction than do older parents, and adolescents tend to be less responsive and to interact less positively with their infants than older mothers (Barratt & Roach, 1995; Thompson et al., 1995).
Interventions emphasizing verbal and nonverbal communication skills between mother and infant are important. Such intervention strategies must be concrete and specific because of the cognitive level of adolescents. Although some observers suggest that some adolescents may use more aggressive behaviors, a higher incidence of child abuse has not been documented. In comparison with adult mothers, teenage mothers have a limited knowledge of child development. They tend to expect too much of their children too soon and often characterize their infants as being fussy. This limited knowledge may cause teenagers to respond to their infants inappropriately.
The need for continued assessment of the new mother's parenting abilities during this postbirth period is essential. In addition, continued support should also be provided by involving the grandparents and other family members, as well as through home visits and group sessions for discussion of infant care and parenting problems. Outreach programs concerned with self-care, parent-child interactions, child injuries, and failure to thrive, in addition to programs that provide prompt and effective community intervention, prevent more serious problems from occurring. As the adolescent performs her mothering role within the framework of her family, she may need to address dependency versus independency issues. The adolescent's family members may also need help adapting to their new roles.
The adolescent father and mother face immediate developmental crises, which include completing the developmental tasks of adolescence, making a transition to parenthood, and sometimes adapting to marriage. These transitions can be stressful. The nurse may initiate interaction with the adolescent father by asking him to be present when postpartum home visits are made and to accompany the mother and the baby to well-baby checks at the clinic or pediatrician's office. With the adolescent mother's agreement, the nurse may contact the father directly. Adolescent fathers need support to discuss their emotional responses to the pregnancy. The father's feelings of guilt, powerlessness, or bravado should be recognized because of their negative consequences for both the parents and the child. Counseling of adolescent fathers must be reality oriented. Topics such as finances, child care, parenting skills, and the father's role in the birth experience must be discussed. Teenage fathers also need to know about reproductive physiology and birth control options, as well as safer sex practices.
The adolescent father may continue to be involved in an ongoing relationship with the young mother and his baby. In many instances he also plays an important role in the decisions about child care and raising the child. He may need help to develop realistic perceptions of his role as "father to a child." He is encouraged to use coping mechanisms that are not detrimental to his own, his partner's, or his child's well-being. The nurse enlists support systems, parents, and professional agencies on his behalf.
Maternal age greater than 35 years
Older mothers have unique needs related to increased biologic risk. Higher rates of gestational diabetes, pregnancy-induced hypertension, gestational bleeding, abruption placentae, and intrapartal fetal distress have been reported (Fretts et al., 1995; Gilbert, Nesbitt, & Danielson, 1999). Many of these mothers, because they are less physically resilient than younger women, may have a longer recovery period.
Adjustment of older mothers to changes involved in becoming a parent and seeing themselves as competent is aided by support from their partners. Support from other family members and friends are also important for positive self-evaluation of parenting, a sense of well-being and satisfaction, and help in dealing with stress.
Changes in the sexual aspect of a relationship can be a stressor for new midlife parents. Mothers report that finding time and energy for a romantic rendezvous is more difficult. They attribute much of this to the reality of caring for an infant, but the decreasing libido that normally accompanies getting older also contributes.
Work/career issues are sources of conflict for older mothers (Reese & Harkless, 1996). Conflicts emerge over being disinterested, worrying about giving enough attention to work with the distractions of a new baby, and anticipating what it will be like to return to work. Child care is a major factor causing stress about work.
Another major issue for older mothers with careers is the perception of loss of control (Reese & Harkless, 1996). Mothers older than 35, when compared with younger mothers, are at a different stage in their careers, having attained high levels of education, career, and income. The loss of control experienced when going from the consistency of a work role to the inconsistency of the parent role comes as a surprise to many. Helping the older mother have realistic expectations of herself and of parenthood is essential.
New mothers who are also perimenopausal may find it hard to distinguish fatigue, loss of sleep, decreased libido, or other physiologic symptoms as the cause of the changes in their sex lives. Although many women view menopause as a natural stage of life, for midlife mothers this cessation of menstruation coincides with the state of parenthood. The changes of midlife and menopause can add more emotional and physical stress to older mothers' lives because of the time- and energy-consuming aspects of raising a young child. Resources that older parents may find helpful are listed under Resources at the end of this chapter.
Paternal age older than 35 years
Older fathers describe their experience of midlife parenting as wonderful but not without drawbacks. What they see as positive aspects of parenthood in older years include increased love and commitment between the spouses, a reinforcement of why one married in the first place, a feeling of being complete, experiencing of "the child" again in oneself, more financial stability than in younger years, and more freedom to focus on parenting rather than on career. A common theme expressed is sharing: sharing joy, sharing in raising the child, sharing as a family. The main drawback of midlife parenting is the change that it makes in the relationships with their partners.
Cultural beliefs and practices are important determinants of parenting behaviors. Culture defines what is socially acceptable in terms of eye contact, touch, and space (Lipson, Dibble, & Minarik, 1996). Culture influences the interactions with the baby, as well as the parent's or family's caregiving style. For example, the provision for a period of rest and recuperation for the mother after birth is prominent in several cultures. Asian mothers must remain at home with the baby at least 30 days after birth and are not supposed to engage in household chores, including care of the baby. Many times the grandmother takes over the baby's care immediately, even before discharge from the hospital (Geissler, 1999). Likewise, Jordanian mothers have a 40-day lying-in after birth during which their mothers or sisters care for the baby (Geissler, 1999). In Mexico, Hispanics practice an intergenerational family ritual, la cuarentena. For 40 days after birth, the mother is expected to recuperate and get acquainted with her infant. Traditionally, this involves many restrictions concerning food (e.g., spicy or cold foods, fish, pork, and citrus are avoided; tortillas and chicken soup are encouraged); exercise; and activities, including sexual intercourse. Abdominal binding is a traditional practice, and many women avoid tub bathing and washing their hair. Traditional Hispanic husbands do not expect to see their wives or infants until both have been cleaned and dressed after birth. La cuarentena incorporates individuals into the family, instills parental responsibility, and integrates the family during a critical life event (Geissler, 1999; Niska, Snyder, & Lia-Hoagberg, 1998).
Desire for and valuing of children is salient in all cultures. In Asian families, children are valued as a source of family strength and stability, are perceived as wealth, and are objects of parental love and affection. Infants almost always are given an affectionate "cradle" name that is used during the first years of life; for example, a Filipino girl might be called "Ling-Ling" and a boy "Bong-Bong." See Table 2-2 for examples of some traditional cultural beliefs that may be important to parents from African-American, Asian, and Hispanic cultures.
Knowledge of cultural beliefs can help the nurse make more accurate assessments and diagnoses of observed parenting behaviors. For example, nurses may become concerned when they observe cultural practices that appear to reflect poor maternal-infant bonding. Algerian mothers may not unwrap and explore their infants as part of the acquaintance process because in Algeria, babies are wrapped tightly in swaddling clothes to protect them physically and psychologically (Geissler, 1999). The nurse may observe a Vietnamese woman who gives minimal care to her infant but refuses to cuddle or further interact with her baby. This apparent lack of interest in the newborn is this cultural group's attempt to ward off "evil spirits" and actually reflects an intense love and concern for the infant (Galanti, 1991). An Asian mother might be criticized for almost immediately relinquishing the care of the infant to the grandmother and not even attempting to hold her baby when it is brought to her room. However, in Asian extended families, members show their support for a new mother's rest and recuperation by assisting with the care of the baby. Contrary to the guidance given to mothers in the United States about "nipple confusion," a mix of breastfeeding and bottle-feeding is standard practice for Japanese mothers. This is out of concern for the mother's rest during the first 2 to 3 months and does not lead to any problems with lactation; breastfeeding is widespread and successful among Japanese women (Sharts-Hopko, 1995).
Socioeconomic conditions often determine access to available resources. Parents whose economic condition is made worse with the birth of each child and who are unable to use an effective method of fertility management may find childbirth complicated by concern for their own health and a sense of helplessness. Mothers who are single, separated, or divorced from their husbands or without a partner, family, and friends for whatever reason may view the birth of a child with dread. Serious financial problems may override any desire for mothering the infant.
PARENTAL SENSORY IMPAIRMENT
In the early dialogue between the parent and child, all senses—sight, hearing, touch, taste, and smell—are used by each to initiate and sustain the attachment process. A parent who has an impairment of one of the senses needs to maximize use of the remaining senses.
VISUALLY IMPAIRED PARENT
Although parents who are visually impaired need the presence and the support of another responsible person, they can become adept in many child care activities. A strength that visually impaired people have is a heightened sensitivity to other sensory outputs. A blind mother can tell when her infant is facing her because she can feel the baby's breath on her face.
One of the major difficulties that visually impaired parents experience is the skepticism, open or hidden, of health care professionals. Blind people sense a reluctance on the part of others to acknowledge that they have a right to be parents. All too often, nurses and doctors lack the experience to deal with the childbearing and child-rearing needs of visually impaired mothers, as well as mothers with other disabilities (such as the hearing impaired, physically impaired, and mentally challenged). The best approach by the nurse is to assess the mother's capabilities. From that basis, the nurse can make plans to assist the woman, often in much the same way as for a mother without impairments. Visually impaired mothers have made suggestions for providing care for women such as themselves during childbearing (Box 3). Such approaches by the nurse can help avoid a sense of increased vulnerability on the mother's part.
BOX 3 Nursing Approaches for Working with Visually Impaired Parents
1. Parents who are blind need verbal teaching by health care providers because maternity information is not accessible to blind people.
2. A visually impaired parent needs an orientation to the hospital room that allows the parent to move about the room independently. For example, "Go to the left of the bed and trail the wall until you feel the first door. That is the bathroom."
3. Parents who are blind need explanations of routines.
4. Parents who are blind need to feel devices (e.g., monitors, pelvic models) and to hear descriptions of the devices.
5. Visually impaired parents need "a chance to ask questions."
6. Visually impaired parents need the opportunity to hold and touch the baby after birth.
7. Nurses need to demonstrate baby care by touch and to follow with, "Now let me see you do it."
8. Nurses need to give instructions such as, "I'm going to give you the baby. The head is to your left side."
Eye-to-eye contact is considered important in American culture. With a parent who is visually impaired, this critical factor in the parent-child attachment process is obviously missing. However, the blind parent, who may never have experienced this method of strengthening relationships, does not miss it. The infant will need other sensory input from that parent. An infant looking into the eyes of a mother who is blind may not be aware that the eyes are unseeing. Other people in the newborn's environment can also participate in active eye-to-eye contact to supply this need. A problem may arise, however, if the visually impaired parent has an impassive facial expression. Her infant, making repeated unsuccessful attempts to engage in face play with the mother, will abandon the behavior with her and intensify it with the father or other people in the household. Nurses can provide anticipatory guidance regarding this situation and help the mother learn to nod and smile while talking and cooing to the infant.
The parent who has a hearing impairment faces another set of problems, particularly if the deafness dates from birth or early childhood. The mother and her partner are likely to have established an independent household. A number of devices that transform sound into light flashes are now marketed and can be fitted into the infant's room to permit immediate detection of crying. Even if the parent is not speech trained, vocalizing can serve as both a stimulus and a response to the infant's early vocalizing. Deaf parents can provide additional vocal training by use of recordings and television so that from birth the child is aware of the full range of the human voice. Sign language is acquired readily by young children, and the first sign used is as varied as the first word.
Section 504 of the Rehabilitation Act of 1973 requires that hospitals and other institutions receiving funds from the U.S. Department of Health and Human Services use various communication techniques and resources with the deaf, including having staff members or certified interpreters who are proficient in sign language. For example, provision of written materials with demonstrations and having nurses stand where the parent can read their lips (if the parent practices lip reading) are two techniques that can be used. A creative approach is for the nursing unit to develop videotapes in which information on postpartum care, infant care, and parenting issues is signed by an interpreter and spoken by a nurse. A videotape in which a nurse signs while speaking would be ideal.
Because the family is an interactive, open unit, the addition of a new family member affects everyone in the family. Siblings have to assume new positions within the family hierarchy. The older child's goal is to maintain the lead position. Parents are faced with the task of caring for a new child while not neglecting the others. Parents need to distribute their attention in an equitable manner.
Reactions of siblings may result from temporary separation from the mother, changes in the mother's or father's behavior, or the siblings' response to the infant's coming home (Bartlett & McGrath, 1999). Positive behavioral changes of siblings include interest in and concern for the baby and increased independence. Regression in toileting and sleep habits, aggression toward the baby, and increased seeking of attention and whining are examples of negative behaviors.
Fig. 10 Parents introducing "big" brother to infant daughter. (Courtesy Kim Molloy, Knoxville, IA.)
Parents, especially mothers, spend much time and energy promoting sibling acceptance of a new baby. Participating in sibling preparation classes makes a difference in the ability of mothers to cope with sibling behavior. Older children are actively involved in preparing for the infant, and this involvement intensifies after the birth of the child. Parents have to manage the feeling of guilt that the older children are being deprived of parental time and attention. Parents have to monitor the behavior of older children toward the more vulnerable infant and divert aggressive behavior. Strategies that parents have used to facilitate acceptance of a new baby by siblings are presented in Box 4.
BOX 4 Strategies for Facilitating Sibling Acceptance of a New Baby
1. Take your firstborn child on a tour of your hospital room and point out similarities to his or her birth. "This is like the room I was in with you, and the baby is in the same kind of bassinet that you were in."
2. Have a small gift from the baby to give to your older child each day.
3. Give the older child a T-shirt that says "I'm a big brother" (or "sister").
4. Arrange for your children to be in the first group (grandparents, sister) to see the newborn. Let them hold the baby in the hospital. One mother and father arranged for their firstborn son to be present at the births of his three brothers and to be the first one to hold them.
5. Plan time for both children. "When I get home, I'll arrange my day so that I can have the baby's care done in the morning while Sam (first child) is at school. Maybe the baby will sleep part of the afternoon and I can spend some time with Sam."
6. Fathers can spend time with the older sibling while mothers are taking care of the baby and vice versa. Siblings like to have time and attention from both parents.
7. Give preschool and early school-age siblings a newborn doll as "their baby" to care for. Give sibling a photograph of the new baby to take to school to show off "his" or "her" baby. Older siblings may enjoy the responsibility of helping care for the newborn, such as learning how to give the baby a bottle or change a diaper. One mother let her preschooler help burp the new baby by patting on the baby's back. She figured her son could pat the baby fairly firmly without harming him and at the same time get out some pent-up aggressive feelings.
Siblings demonstrate acquaintance behaviors with the newborn. The acquaintance process depends on the information given to the child before the baby is born and on the child's cognitive development level. The initial behaviors of siblings with the newborn include looking at the infant and touching the head (Fig. 11). The initial adjustment of older children to a newborn takes time, and children should be allowed to interact at their own pace rather than being forced to do so. To expect a young child to accept and love a rival for the parents' affection assumes an unrealistic level of maturity. Sibling love grows as does other love, that is, by being with another person and sharing experiences (Fig. 12). The relationship that develops between siblings has been conceptualized as sibling attachment. This bond between siblings involves a secure base in which one child provides support for the other, is missed when absent, and is looked to for comfort and security.
Fig. 11 First meeting. A, Boy with mother during first meeting with new sibling. B, First tentative touch. C, Testing with fingertip. D, Relationship more secure: it is now okay to hold with whole hand. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Fig. 12 Sister kisses her new brother. Family contacts are important for newborn and siblings. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Grandparents experience a transition to grandparenthood. Intergenerational relationships shift, and grandparents must deal with changes in practices and attitudes toward childbirth, child rearing, and men's and women's roles at home and in the workplace. The degree to which grandparents understand and accept current practices can influence how supportive they are perceived to be by their adult children.
At the same time that they are adjusting to grandparenthood, the majority of grandparents are experiencing normative middle- and old-age life transition issues, such as retirement and a move to smaller housing, and need support from their adult children. Some may feel regret about their limited involvement because of poor health or geographic distance. Maternal grandmothers, more so than the other three grandparents, may have high expectations of themselves that cause them to be very self-critical.
The extent of involvement of grandparents in the care of the newborn depends on many factors, for example, the willingness of the grandparents to become involved, the proximity of the grandparents, and ethnic and cultural expectations of the grandparents' role. If the new parents live in the United States, Asian grandparents typically are asked to come to the United States to care for the baby and the mother after birth and to care for the children once the parents return to work. In the United States, paternal grandparents, in contrast to those in other cultures, frequently consider themselves secondary to the maternal grandparents. Less seems expected of them and they are initially less involved. Nevertheless, these grandparents are eager to help and express great pleasure in their son's fatherhood and his involvement with the baby (Fig. 13).
Fig. 13 Father, grandfather, and new grandson get acquainted. Note fingertip touch by grandfather. (Courtesy Sharon Johnson, Petaluma, CA.)
For first-time parents, pregnancy and parenthood can reawaken old issues related to dependence versus independence. Couples often do not plan on their parents' help immediately after the baby arrives. They want time "to be a family," inferring a couple-baby unit, not the intergenerational family network. Contrary to their expectations, however, new parents do call on their parents for help. The majority of maternal grandmothers are present soon after the birth, being called in on short notice by the parents after several nights with a crying baby.
A simple technique to help people span the generation gap is through a printed "letter to new parents" (written from the grandparents' perspective), which can be included in prenatal kits distributed in childbirth preparation classes and made available to all family members on the postpartum unit. Grandparents' classes can be used to bridge the generation gap and help the grandparents understand their adult children's parenting concepts. The classes include information on up-to-date childbearing practices, family-centered care, infant care, feeding, and safety (car seats), as well as exploration of roles that grandparents play in the family unit.
CARE MANAGEMENT—PRACTICAL SUGGESTIONS FOR THE FIRST WEEKS AT HOME
Numerous changes occur during the first weeks of parenthood. Care management should be directed toward helping parents cope with infant care, role changes, altered lifestyle, and change in family structure resulting from the addition of a new baby. Parents may have inadequate or incorrect understanding of what to expect in the early postpartum weeks. Developing skill and confidence in caring for an infant can be especially anxiety provoking.
Nurses, especially those making postpartum visits to parents' homes, are in a prime position to help new families. The nurse's role becomes primarily one of teacher supporter, focusing on enabling new parents to become capable of self-care and infant care and of meeting the needs of the family unit.
Assessment and Nursing Diagnoses
Assessment should include a psychosocial assessment focusing on parent-infant attachment, adjustment to the parental role, sibling adjustment, social support, and education needs, as well as mother's and baby's physical adaptation. Early home visits are an excellent opportunity for the nurse to assess beginnings of successful or harmful parenting behaviors and provide positive reinforcement for loving and nurturing behaviors with the infant. Parents who interact in inappropriate or abusive ways with their infant should be followed more closely, and an appropriate mental health practitioner or professional social worker should be notified (Johnson & Johnson, 1996).
Nursing diagnoses pertinent to transition to parenthood include the following:
• Readiness for enhanced family coping related to
-positive attitude and realistic expectations for newborn and adapting to parenthood
-nurturing behaviors with newborn
-verbalizing positive factors in lifestyle change
• Risk for impaired parenting related to
-lack of knowledge of infant care
-feelings of incompetence or lack of confidence
-unrealistic expectations of newborn/infant
-fatigue from interrupted sleep
• Parental role conflict related to
-role transition and role attainment
-lack of resources to support parenting (e.g., no paid leave)
• Risk for impaired parent-infant attachment related to
-difficult labor and birth
Expected Outcomes of Care
A plan of care is formulated in collaboration with the family, incorporating their priorities and preferences, to meet their specific needs. Expected outcomes for effective transition to parenthood include that the parents will do the following:
• Demonstrate behaviors that reflect appreciation of sensory and behavioral capacities of the infant
• Verbalize increasing confidence and competence in feeding, diapering, dressing, and sensory stimulation of the infant
• Identify deviations from normal in the infant that should be brought to the immediate attention of the primary health care provider
• Relate effectively to the newborn's siblings and grandparents
Plan of Care and Interventions
Instructions for the first days at home
Parents, especially first-time parents, must be helped to anticipate what the transition from hospital to home will be like. Anticipatory guidance can help prevent a shock of reality that might negate the parents' joy or cause them undue stress. Even the simplest strategies can provide enormous support. Written information reinforcing education topics is helpful to provide to parents, as is a list of available community resources, both local and national. Classes in the prenatal period or during the postpartum stay are helpful. Instructions for the first days at home should minimally include activities of daily living, dealing with visitors, and activity and rest.
Activities of daily living. Given the demands of a newborn, the mother's discomfort or fatigue associated with giving birth, and a busy homecoming day, even small details of daily life can become stressful. Such things as using disposable diapers, preparing frozen or microwave dinners during pregnancy, or getting takeout meals can decrease stress by eliminating at least one or two parental responsibilities during the first few days at home.
Planning for discharge soon after an infant feeding ensures that the couple will have adequate time to get home and relatively settled before the next feeding. Offering a sample carton of premixed bottles for the formulafed infant prevents need for rushed preparation of formula.
Visitors. New parents are often inadequately prepared for the reality of bringing a new infant home because they romanticize the homecoming. One mother stated, "By the time we drove an hour through traffic, my stitches were hurting and all I wanted was a warm sitz bath and some private time with Bill and the baby, in that order. Instead a carload of visitors pulled into the driveway as we were unbuckling the baby from his car seat. I thought I would surely cry."
The nurse can help parents to explore ways, in advance, to assert their need to limit visitors. When family and friends ask what they can do to help, new parents can suggest they prepare and bring them a meal or pick up items at the store. Parents can work out a signal for alerting the partner that the mother is getting tired or uncomfortable and needs the partner to invite the visitors to another room or to leave. Some mothers find that wearing a robe and not appearing ready for company leads visitors to stay a shorter time. A sign on the front door saying "Mother and baby resting-Please do not disturb" may be useful.
Activity and rest. Because mothers have reported fatigue to be a major problem during the first few weeks after giving birth, mothers need to be encouraged to limit their activities and be realistic about their level of fatigue. Activities should not be sustained for long periods of time. Family, friends, and neighbors can be solicited for support and help with meals, housecleaning, picking up other children, and so on. Rest periods throughout the day are important. Mothers can nap when the baby sleeps. Adequate nutrition is also important for postpartum recovery and in dealing with fatigue.
Providing practical suggestions for infant care can help parents adjust to parenthood. Mothers and fathers want to feel capable and confident in the physical care of their infant. The nurse should assess each parent's need for instruction on care such as bathing, clothing, and safety
Infant bathing. The infant bath time provides a wonderful opportunity for parent-infant social interaction. Some fathers consider this their own special time with their babies. While bathing their baby, parents can talk to the infant, caress and cuddle the infant, and engage in arousal and imitation of facial expressions and smiling (Fig. 14).
Fig. 14 A, Baths can be special times for babies and parents. B, After the bath, the baby is gently dried to minimize heat loss. (Courtesy Leslie Canerday, Phoenix, AZ.)
Sponge baths are used until the infant's umbilical cord falls off and the umbilicus is healed (see Chapter 19, Teaching Guidelines box on sponge baths). At around 10 to 14 days, tub baths can be started (Box 5). Newborns do not need a bath every day. The diaper area and creases under the arms and neck need more attention. Parents can pick a time for the bath that is easy for them and when the baby is awake, usually before a feeding.
See guidelines for sponge bathing (see Chapter 19).
Place liner on bottom of tub to prevent infant from slipping.
Add 3 inches of comfortably warm water (36.6° to 37.2° C —pleasantly warm to your inner wrist).
Wash face and shampoo hair as for sponge bath. Undress baby. Lower infant slowly into water.
Hold baby safely with fingers under the baby's armpit, with your thumb around the shoulder.The other hand supports the baby's bottom and legs.
Wash the front of the baby.
Go from front to back between the legs. Rinse with a wet washcloth.
Wash the baby's back with your free hand lathered with soap.
Rinse well with the wet washcloth.
Remove infant from the water and gently pat dry.
An important consideration in skin cleansing is preservation of the skin's acid mantle. The acid mantle is formed from the uppermost horny layer of the epidermis, sweat, superficial fat, metabolic products, and external substances such as amniotic fluid, microorganisms, and cosmetics. By 4 days of age, the newborn skin surface becomes more acidic, falling to within the bacteriostatic range (pH 5). Thus only plain, warm water should be used. Alkaline soaps (such as Ivory), oils, powders, and many lotions alter the acid mantle and provide a medium for bacterial growth (Lund et al., 2001). Powders are not recommended, because the infant can inhale powder.
Infant clothing. A simple rule of thumb for dressing infants is to dress them as the parents would dress themselves, adding or subtracting clothes and wraps for the infant as necessary. A shirt and diaper may be sufficient clothing for the young infant. A bonnet is needed to protect the scalp and to minimize heat loss if it is cool or to protect against sunburn and to shade the infant's eyes if it is sunny and hot. Sunglasses for infants are available. Wrapping the infant snugly in a blanket maintains body temperature and promotes a feeling of security. Overdressing in warm temperatures can cause discomfort and prickly heat rash. Underdressing in cold weather also can cause discomfort; cheeks, fingers, and toes can easily become frostbitten.
Infants have sensitive skin; therefore new clothes should be washed before putting them on the infant. Baby clothes should be washed with a mild detergent and hot water. A double rinse usually removes traces of the potentially irritating cleansing agent or acid residue from urine or stool. If possible, the clothing and bed linens are dried in the sun to neutralize residue. Parents who use coin operated machines in laundromats to wash and dry clothes may find it expensive or impossible to wash and rinse the baby's clothes well.
Bedding requires frequent changing. The top of a plasticcoated mattress should be washed frequently, and the crib or bassinet should be dusted with a damp cloth. The infant's toilet articles may be kept convenient for use in a box, basket, or plastic carrier.
Infant safety. Providing for the safety of an infant is not a matter of common sense. There are many things new parents may not be aware of that are potential dangers to their infant (e.g., window blind cords near the crib or a parent throwing an infant in the air during play). Nurses should provide parents with concrete instructions on infant safety (Box 6).
BOX 6 Tips for Keeping Your Baby Safe
Never leave your baby alone on a bed, couch, or table.
Even newborns can move enough to eventually reach the edge and fall off.
Never put your baby on a cushion, pillow, beanbag, or waterbed to sleep. Your baby may suffocate. Also, do not keep pillows, large floppy toys, or loose plastic
sheeting in the crib.
Do not place your infant on his or her stomach to sleep during the first few months of life. The American Academy of Pediatrics advises against this prone position because it has been associated with an increased incidence of sudden infant death syndrome (SIDS). The side-lying or back-lying position is preferable.
When using an infant carrier, stay within arm's reach when the carrier is on a high place, such as a table, sofa, or store counter. If at all possible, place the carrier on the floor near you.
Infant carriers do not keep your baby safe in a car. Always place your baby in an approved car safety seat when traveling in a motor vehicle (car, truck, bus, or van). Car safety seats are recommended for travel on trains and airplanes as well. Use the car seat for every ride. Your baby should be in a rear-facing infant car seat from birth to 20 pounds, and the car seat should be in the back seat of the car (see Fig. 24). This is especially important in vehicles with front passenger air bags, because when air bags inflate they can be fatal for infants and toddlers (see Fig. 25).
When bathing your baby, never leave him or her alone.
Newborns and infants can drown in 1 to 2 inches of water.
Be sure that your hot water heater is set at 49° C or less.
Always check bathwater temperature with your elbow before putting your baby in the bath.
Do not tie anything around your baby's neck. Pacifiers, for example, tied around the neck with a ribbon or string may strangle your baby.
Check your baby's crib for safety. Slats should be no more than 2V2 inches apart. The space between the mattress and sides should be less than 2 finger widths.
There should be no decorative knobs on the bedposts.
Keep crib or playpen away from window blind and drapery cords; your baby could strangle on them.
Keep crib and playpen well away from radiators, heat vents, and portable heaters. Linens in crib or playpen could catch fire if in contact with these heat sources.
Install smoke detectors on every floor of your home.
Check them once a month to be sure they work. Change batteries once a year.
Avoid exposing your baby to cigarette or cigar smoke in your home or other places. Passive exposure to tobacco smoke greatly increases the likelihood that your infant will have respiratory symptoms and illnesses.
Be gentle with your baby. Do not pick your baby up or swing your baby by the arms or throw him or her up in the air.
Anticipatory guidance regarding the newborn
Anticipatory guidance helps prepare new parents for what to expect as their newborn grows and develops. Parents with realistic expectations of infant needs and behavior are prepared better to adjust to the demands of a new baby and to parenthood itself.
New parents can be overwhelmed by a large volume of information and become anxious. Anticipatory guidance should include the following: newborn sleep-wake cycles, interpretation of crying and quieting techniques, infant developmental milestones, sensory enrichment/infant stimulation, recognizing signs of illness, and well-baby follow-up and immunizations. Printed materials and audio tapes or videotapes for parents to take home are helpful.
Development of day-night routines. Nurses can help prepare new parents for the fact that most newborns cannot tell the difference between night and day and must learn the rhythm of day-night routines. Nurses should provide basic suggestions for settling a newborn and for helping him or her develop a predictable routine. Examples of such suggestions include the following:
• In the late afternoon, bring the baby out to the center of family activity. Keep the baby there for the rest of the evening. If the baby falls asleep, let the baby do so in the infant seat or in someone's arms. Save the crib or bassinet for nighttime sleep.
• Give the baby a bath right before bedtime. This soothes the baby and helps him or her expend energy.
• Feed the baby for the last evening time around 11 PM and put him or her to bed in the crib or bassinet.
• For nighttime feedings and diaper changes, keep a small night-light on to avoid turning on bright lights. Talk in soft whispers (if at all) and handle the baby gently and only as absolutely necessary to feed and diaper. Nighttime feedings should be all business and no play! Babies usually go back to sleep if the room is quiet and dark.
A predictable, stable routine gradually develops for most babies; however, some babies never develop one. New parents will find it easier if they are willing to be flexible and to give up some control during those early weeks.
Interpretation of crying and quieting techniques. Crying is an infant's first social communication. Some babies cry more than others, but all babies cry. They cry to communicate that they are hungry, uncomfortable, wet, ill, or bored, and sometimes for no apparent reason at all. The longer parents are around their infants, the easier it becomes to interpret what a cry means. Many infants have a fussy period during the day, often in the late afternoon or early evening when everyone is naturally tired. Environmental tension adds to the length and intensity of crying spells. Babies also have periods of vigorous crying when no comforting can help. These periods of crying may last for long stretches until the infants seem to cry themselves to sleep. Possibly the infants are trying to discharge enough energy so that they can settle themselves down. The nurse needs to reinforce for new parents that time and infant maturation will take care of these types of cries.
Crying because of colic is a common concern of new parents. Babies with colic cry inconsolably for several hours, pull their legs up to their stomach, and pass large amounts of gas. No one really knows what colic is or why babies get it. Parents can be encouraged to contact their nurse-practitioner or pediatrician if they are concerned that their baby has colic.
Certain types of sensory stimulation can calm and quiet infants and help them get to sleep. Important characteristics of this sensory stimulation—whether tactile, vestibular, auditory, or visual—appear to be that the stimulation is mild, slow, and rhythmic, and consistently and regularly presented. Tactile stimulation can include warmth, patting, back rubbing, and covering the skin with textured cloth. Swaddling to keep arms and legs close to the body (as in utero) provides widespread and constant tactile stimulation and a sense of security. Vestibular stimulation is especially effective and can be accomplished by mild rhythmic movement such as rocking or by holding the infant upright, as on the parent's shoulder.
The nurse can teach parents a number of strategies that help quiet a fussy baby, prevent crying, and induce quiet attention or sleep (Boxes 7 and 8).
BOX 7 How to Swaddle an Infant
1. Fold down the top corner of the blanket. Position the infant on the blanket with the infant's neck near the fold.
2. Bring the blanket around the infant's right side and across the infant, tucking the corner under the left side.
3. Bring the bottom of the blanket up to the infant's chest.
4. Bring the remaining corner of the blanket across the infant, tucking the corner under the infant's right side. The infant should be wrapped securely but not tightly; some room should be left for the infant to move.
BOX 8 Infant Quieting Techniques
Many newborns feel insecure in the center of a large crib. They prefer a small, warm, soft space that reminds them of intrauterine life. Try a smaller bed, such as a bassinet, portable crib, buggy, or cradle, or use a rolled-up blanket to turn a corner of the big crib into a smaller place.
Carry your baby in a frontpack or backpack.
Swaddle your newborn snugly in a receiving blanket.
Swaddling keeps your newborn's arms and legs close to his or her body, similar to the intrauterine position.
It makes the newborn feel more secure.
Prewarm the crib sheets with a hot water bottle or heating pad that you remove before putting your baby to bed. Some babies startle when placed on a cold sheet.
Some newborns need extra sucking to soothe themselves to sleep. Breastfeeding mothers may prefer to let their infant suckle at the breast as a soothing technique.
Other mothers choose to use a pacifier. Stroke the pacifier against the roof of the baby's mouth to encourage him or her to suck it during the first 2 weeks. Around 3 months of age, infants become able to consistently find and suck their thumbs as a way of self-consoling.
A rhythmic, monotonous noise simulating the intrauterine sounds of your heartbeat and blood flow may help your infant settle down. Some parents have found that putting the baby in a portable crib beside the dishwasher or washing machine helps settle a fussy baby.
Movement often helps quiet a baby. Take your baby for a ride in the car, or take your baby for an outing in a stroller or carriage. Rock your baby in a rocking chair or cradle.
Place your baby on his or her stomach across your lap; pat and rub his or her back while gently bouncing your legs or swaying them from left to right.
Babies enjoy close skin-to-skin contact. A combination of this and warm water often helps soothe a fussy baby. Fill your tub with warm water. Get in and let the baby lie on your chest so that the baby is immersed in the water up to his or her neck. Cuddle the baby close.
Let your baby see your face. Talk to your baby in a soothing voice.
Your baby may simply be bored. Bring him or her into the room where you and the rest of the family are.
Change your baby's position; many babies like to be upright, such as being held up on your shoulder
Developmental milestones. Knowledge of infant growth and development helps parents have realistic expectations of what an infant can do. When parents under stand and appreciate the limitations and developing abilities of their infant, adjustment to parenthood can go more smoothly. Emphasizing the individuality of the infant enhances the capacity of the family to offer their infant an optimally nurturing environment (Brazelton, 1995).
Brazelton (1995) suggests the concept of "touch-points" for intervention, that is, points at which a change in the system (baby, parent, and family) is brought about by the baby's spurts in development (cognitive, motor, or emotional).
Immediately before each spurt in development, there is a predictable short period of disorganization in the baby. Parents are likely to feel disorganized and stressed as well. Because these periods of disorganization are predictable, nurses can offer parents anticipatory guidance to help them understand what happens with infant development and to prepare them for the subsequent spurts in development.
Two touch-points occur during the early postpartum newborn period: one soon after birth and another at 2 to 3 weeks (Brazelton, 1995). In the hospital or at a home visit during the first week, the nurse can use Brazelton's Neonatal Behavioral Assessment Scale (Brazelton & Nugent, 1996) to demonstrate to parents their baby's amazing repertoire of abilities. In this way, parents begin to appreciate their baby's individuality and become more sensitive to their baby's behavioral cues. At 2 to 3 weeks, the home care nurse or pediatric office nurse should assess for the regular end-of-the-day fussy period that most infants have between 3 and 12 weeks of age. Helpful topics to include in the anticipatory guidance are the normalcy and positive value of the fussy period, how to settle a fussy baby, and ways to help a baby develop a predictable schedule.
It is also helpful for nurses to provide parents with information on month-by-month infant growth and development. Written information that parents can refer to later is especially helpful. See Table 4 for a summary of infant growth and development during the first 2 to 3 months.
Table 4 Growth and Development During Infancy
Weight gain of 150 to 210 g weekly for first 6 mo
Height gain of 2.5 cm monthly for
first 6 mo
Head circumference increases by 1.5 cm monthly for first 6 mo
Primitive reflexes present and strong
Doll's eye reflex and dance reflex fading
Preferential nose breathing (most infants)
Posterior fontanel closed
Crawling reflex disappears
Primitive reflexes fading
• Assumes flexed position with pelvis high but knees not under abdomen when prone (at birth, knees flexed under abdomen)
• Can turn head from side to side when prone, lifts head momentarily from bed Has marked head lag, especially when pulled from lying to sitting position Holds head momentarily parallel and in midline when suspended in prone position
Assumes asymmetric tonic neck reflex position when supine
When held in standing position, body limp at knees and hips
In sitting position back is uniformly rounded, absence of head control
• Assumes less flexed position when prone —hips flat, legs extended, arms flexed, head to side
Less head lag when pulled to sitting position
Can maintain head in same plane as rest of body when held in ventral suspension
When prone, can lift head almost 45 degrees off table
When held in sitting position, head is held up but bobs forward
Assumes asymmetric tonic neck reflex position intermittently
Able to hold head more erect when sitting, but still bobs forward
Has only slight head lag when pulled to sitting position
Assumes symmetric body positioning
Able to raise head and shoulders from prone position to a 45- to 90 degree angle from table; bears weight on forearms
When held in standing position, able to bear slight fraction of weight on legs
Regards own hand
Hands predominantly closed
Grasp reflex strong
Hand clenches on contact with rattle
Hands often open
Grasp reflex fading
• Actively holds rattle but will not reach for it
Grasp reflex absent
Hands kept loosely open
Clutches own hand; pulls at blanket and clothes
• Able to fixate on moving object in range of 45 degrees when held at a distance of 20-25 cm
Visual acuity approaches 20/100*
Follows light to midline
Quiets when hears a voice
Binocular fixation and convergence to near objects beginning
When supine, follows dangling toy from side to point beyond midline
Visually searches to locate sounds
Turns head to side when sound is made at level of ear
• Follows object to periphery (180 degrees)
• Locates sound by turning head to side and looking in same direction
Begins to have ability to coordinate stimuli from various sense organs
Cries to express displeasure
Makes small throaty sounds
Makes comfort sounds during feeding
• Vocalizes, distinct from crying
Crying becomes differentiated
Vocalizes to familiar voice
• Squeals aloud to show pleasure
Coos, babbles, chuckles
Vocalizes when smiling
"Talks" a great deal when spoken to
Less crying during periods of wakefulness
Is in sensorimotor phase—stage I, use of reflexes (birth-1 mo), and stage II, primary circular reactions (1-4 mo)
Watches parent's face intently as she or he talks to infant
• Demonstrates social smile in response to various stimuli
Displays considerable interest in surroundings
Ceases crying when parent enters room
Can recognize familiar faces and objects, such as feeding bottle
Shows awareness of strange situations
Infant stimulation. Interacting with their parents is an important way in which infants learn about themselves and their environment. Nurses can teach parents a variety of ways to stimulate their infant's development and to enrich the infant's learning environment. Home health nurses are in a prime position to evaluate the home environment and to make suggestions to parents for promotion of their baby's physical, cognitive, and emotional development.
Suggestions for teaching infants during the first few months are presented in Boxes 9 and 10. Table 5 presents suggestions for visual, auditory, tactile, and kinetic stimulation.
BOX 9 Teaching Your Newborn
• Newborns learn things every day. You can teach your newborn by playing with him or her and giving your newborn toys that help him or her to learn.
• Talk to your baby a lot. Tell your baby what is going on in the room ("Listen to the dog barking."). Label objects that you see or use ("Here's the washcloth.") and describe things you are doing ("Let's put the shirt over Kerry's head!").
• Look at your baby's face and make eye contact. Play face-making games: smile, stick out your tongue, open your eyes wide. As your baby gets older, he or she will try to imitate these facial expressions.
• Babies like music and rhythmic movement. Rock or swing your baby as you sing to him or her in a gentle voice.
• Acknowledge your baby's attempts to "answer" your talking and singing. He or she will respond to you by looking in your direction, making eye contact, moving his or her arms and legs, and/or making sounds.
• Babies like bright colors and vivid contrasts. Show your baby pictures and objects that are black and white, bright primary colors (red, blue, yellow, green), and/or large patterns. Keep colorful mobiles and toys where your baby can see them.
• Babies like to be held upright. Holding your newborn on your shoulder lets your baby look around his or her world and provides vestibular stimulation. Let your baby lift his or her head for a few seconds. Keep your hand ready to support your baby's head.
BOX 10 Teaching Your 1- to 2-Month-Old Infant
At 1 to 2 months of age, your infant is gaining more control of his or her movements: more head control, even holding an object briefly in his or her hand. Your baby also is becoming more social. He or she demonstrates behaviors to engage you in interaction: smiling, cooing, making longer eye contact, and following you with his or her eyes.
During these months you can help your baby learn if you:
• Put your baby on his or her stomach on a blanket on the floor. Lie on your stomach facing your baby. Talk to your baby to get him or her to raise his or her head to see you.
• Roll your baby onto his or her back and play with your baby's legs. Move the legs in a bicycle-riding motion. Try to get your baby to kick his or her legs.
• Play hand games, such as pat-a-cake, with your baby; kiss your baby's fingers; place your baby's hands on your face. Bring your baby's hands in front of his or her eyes as you play; get your baby to look at his or her hands.
• Encourage your baby to watch and follow things with his or her eyes. Use a noise-making toy, such as a rattle or a chime, or a brightly colored object about 12 inches from his or her eyes; move it slowly to one side and then the other. Objects hanging from a play frame are good for your baby to watch while he or she is on his or her back or sitting in an infant seat.
• Continue to talk and sing a lot to your baby. Continue to tell your baby what you are doing with him or her and what is going on in the immediate environment.
• Keep your baby near you during times when the family usually is together, such as at mealtimes. Infant seats, especially ones that bounce or rock, and infant swings
are good to use at these times.
Play During Infancy: From Birth Through 3 Months
Look at infant at close range
Hang bright, shiny object within 20-25 cm of infant's face and in midline
Hang mobiles with black-and-white contrast designs
Talk to infant, sing in soft voice
Play music box, radio, television
Have ticking clock or metronome nearby
Hold, caress, cuddle
Keep infant warm
May like to be swaddled
Rock infant, place in cradle
Use carriage for walks
Provide bright objects
Make room bright with pictures or mirrors on walls
Take infant to various rooms while doing chores
Place infant in infant seat for vertical view of environment
Talk to infant
Include in family gatherings
Expose to various environmental noises other than those of home
Use rattles, wind chimes
Caress infant while bathing, at diaper change
Comb hair with a soft brush
Use infant swing
Take in car for rides
Exercise body by moving extremities in swimming motion
Use cradle gym
Another method of sensory enrichment that parents can learn to use is infant massage. This type of nurturing touch can help create a loving bond between the infant and parent and has been shown to contribute to the physical and emotional well-being of the massage giver and receiver (Schneider, 1996, 1997). Infant massage is a gentle, warm communication done with the infant, not to the infant. The focus is on reciprocal interaction between infant and parent; the parent talks to the infant, asks permission to start the massage, questions the infant, and facilitates dialogue.
One of the most important benefits of infant massage for the parents is the improved ability to read their infant's cues (Schneider, 1997) (Box 11). Positive cues include eye contact, smiling, looking at the parent's face, babbling or cooing, and smooth movements of arms and legs. Negative cues from the infant include pulling away, frowning, grimacing, turning the head away, arching the back, crying, squirming, and flailing the arms and legs. Increased ability to read their infant's cues can increase parental confidence and self-esteem, thereby assisting adaptation to parenthood.
BOX 11 Benefits of Infant Massage
IN THE PSYCHOSOCIAL DOMAIN
Benefits to the Infant of Receiving Massage
• Promotes bonding and attachment
• Promotes body/mind/spirit connection
• Increases self-esteem
• Increases sense of love, acceptance, respect, and trust
• Enhances communication
Benefits to the Parent of Giving Massage
• Improves ability to read infant cues
• Improves synchrony between caregiver and infant
• Promotes bonding
• Increases confidence in parenting
• Increases communication—verbal and nonverbal
• Improves relaxation
• Provides time to share and quality time
• Promotes parenting skills
IN THE PHYSIOLOGIC/PHYSICAL GROWTH DOMAIN
Benefits to the Infant of Receiving Massage
• Improves relaxation and release of accumulated stress
• Stimulates circulation
• Strengthens digestive, circulatory, and gastrointestinal systems, which can lead to weight gain
• Reduces discomfort from teething, congestion, gas, colic, and emotional stress
• Improves muscle tone/coordination
• Increases elimination, circulation, and respiration
• Improves sleep patterns
• Increases hormonal function
Benefits to the Parent of Giving Massage
• Improves sense of well-being
• Reduces blood pressure
• Reduces stress
• Improves overall health
Well-baby follow-up and immunizations. Parents should be advised to plan for their infant's health follow-up care at the following ages: 2 to 4 weeks, then every 2 months until 6 to 7 months, then every 3 months until 18 months, at 2 years, at 3 years, at preschool, and every 2 years thereafter. These well-baby follow-up visits with a nurse-practitioner or pediatrician are important for the parents, as well as the infant. They provide a time for parents to have questions answered, to get reassurance about their adaptation to parenthood, and to receive anticipatory guidance for the ensuing weeks before the next well-baby visit.
The schedule for immunizations should be reviewed with parents (Table 6). An infant's ability to protect himself or herself against antigens by the formation of antibodies develops sequentially; therefore the infant must be developmentally capable of responding to these antibodies. This is the reason for planning sequential immunizations for infants.
Table 6 Immunizations
AGE OF ORIGINAL IMMUNIZATION
DTP (diphtheria, tetanus, pertussis)
HIB (Haemophilus influenzae b conjugate vaccine)
TOPV (trivalent oral poliovirus vaccine)
MMR (measles, mumps, rubella)
HBIG (if mother is HBsAg positive)
HBV (hepatitis B)*
Tuberculin skin test (not an immunization)
2, 4, 6 mo
2, 4, 6 mo (HIBTITER vaccine); 2, 4 mo (PedvaxHIB vaccine)
2, 4 mo
15 mo (12 mo if community outbreak)
Within 12 hr of birth
Before hospital discharge, 1-2 mo, 6-18 mo, or 1-2 mo, 4 mo, 6-18 mo
A form of passive immunity is already present in colostrum and breast milk. These antibodies are specific for microbes present in the mother's gastrointestinal tract and protect against overgrowth as fresh colonization occurs in the newborn.
The active ingredients in immunizations for diphtheria pertussis-tetanus, hepatitis B, rubella, measles, and mumps, as well as the oral poliovirus vaccine, do not appear to be altered by breast milk and should be given according to the regular recommended schedule (Lawrence, 1999).
Recognizing signs of illness. As well as explaining the need for well-baby follow-up visits, the nurse should discuss with parents the signs of illness in newborns (Box 12). Parents should be advised to call their nurse-practitioner or pediatrician immediately if they notice such signs and to ask about over-the-counter medications, such as Tylenol for infants, to keep at home (see Plan of Care).
PLAN OF CARE Home Care Follow-up: Transition to Parenthood
NURSING DIAGNOSIS Deficient knowledge of infant care related to lack of experience/lack of support
Expected Outcomes Infant care routines are adequate, and infant appears healthy.
• Observe infant care routines (bathing, diapering, feeding, play) to evaluate parental ease with care and adequacy of techniques.
• Observe infant appearance (height-weight ratio, head circumference, fontanels, skin tone and turgor); assess infant's vital signs, overall tone, reflexes, and age-appropriate developmental skills to evaluate for signs indicative of inadequate care.
• Explore available support systems for infant care to determine adequacy of existing system.
• Demonstrate troublesome care routines and have involved family members return demonstration to facilitate improvements in care.
• Provide ongoing follow-up as needed to ensure amelioration of identified potential and actual care deficits.
NURSING DIAGNOSIS Disturbed sleep pattern related to infant demands and environmental interruptions
Expected Outcomes Woman sleeps for uninterrupted periods and feels rested on waking.
Nursing Interventions/ Rationales
• Discuss woman's routine and specify things that interfere with sleep to determine scope of problem and direct interventions.
• Explore ways woman and significant others can make environment more conducive to sleep (e.g., privacy, darkness, quiet, back rubs, soothing music, warm milk); teach use of guided imagery and relaxation techniques to promote optimal conditions for sleep.
• Eliminate things or routines (e.g., caffeine, foods that induce heartburn, strenuous mental/physical activity) that may interfere with sleep.
• Advise family to limit visitors and activities to avoid further taxation and fatigue.
• Have family plan specific times to care for the newborn to allow mother time to sleep; have mother learn to use infant nap time as a time for her to nap as well to replenish energy and decrease fatigue.
NURSING DIAGNOSIS Risk for impaired home maintenance related to addition of new family member/inadequate resources/inadequate support systems
Expected Outcome Home exhibits signs of safe and functional environment.
Nursing Interventions/ Rationales
• Observe the home environment (e.g., available living space and sleeping arrangements; adequacy of facilities for food preparation and storage, hygiene and toileting; overall state of repair; cleanliness; presence of safety hazards) to determine adequacy and effective use of resources.
• Observe arrangements for the newborn, such as sleeping space, care equipment and supplies (bathing, changing, feeding, transportation) to determine adequacy of resources.
• Explore who is responsible for cooking, cleaning, child care, and newborn care and determine whether the mother seems adequately rested to determine adequacy of support systems.
• Identify and arrange referrals to needed social agencies (e.g., Aid to Families with Dependent Children [AFDC], Women, Infants, and Children [WIC] program, food pantries) to ameliorate resource deficits (finances, supplies, equipment).
NURSING DIAGNOSIS Risk for interrupted family processes related to inclusion of new family member
Expected Outcome Infant is successfully assimilated into family structure.
Nursing Interventions/ Rationales
• Explore with family the ways that the birth and neonate have changed family structure and function to evaluate functional and role adjustment.
• Observe family interaction with the newborn and note degree of bonding, evidence of sibling rivalry, and involvement in newborn care to evaluate acceptance of newest family member.
• Clarify identified misinformation and misperceptions to promote clear communication.
• Assist family to explore options for solutions to identified problems to promote effective problem resolution.
• Support family efforts as they move toward adjusting and incorporating the new member to reinforce new functions and roles.
• If needed, make referrals to appropriate social services or community agencies to ensure ongoing support and care
Evaluation is based on the expected outcomes of care. The plan is revised as needed based on the evaluation findings.