Section II. PSYCHOLOGICAL NEEDS OF THE POSTPARTAL PATIENT

6-7. GENERAL

A major psychological task for the parents is the process of bonding and attachment with their newborn. This takes place the first three to four days of postpartum. The practical nurse is in a unique position to observe and offer psychological support and reassurance to the postpartal patient. This supportiveness can help in correcting negative bonding and reinforce the positive maternal infant adaptations that are the basis for a strong and healthy family relationship. This lesson will focus on the processes by which the psychological needs of the postpartal patient are actually filled.

6-8. PHASES OF THE RESTORATIVE PERIOD OF MATERNAL BEHAVIOR FOLLOWING DELIVERY

The restorative period is the postpartal period/time of delivery to the four to six week stabilization point. The phases are referred to as the taking-in phase, taking-hold phase, and letting-go phase.

a. Taking-In Phase. During this phase the mother is oriented primarily to her own needs. She primary focuses on sleeping and eating. She may be quite passive and dependent. The mother is reacting to the intense, physical effort expended during delivery and the intense, emotional effort required of her during labor. The mother does not usually initiate contact with the infant. This is not out of disinterest. It may result from her own immediate dependency. Nevertheless, she is taking-in information that helps her to identify the infant. She may use her finger-tip to touch her infant. This serves as one of the first steps in the identification process. She holds the baby facing her so they can explore each other's face (in the face position). The mother relives the delivery experience which allows her to integrate it fully with reality, fully realized her baby is born, and to identify her infant as being outside and separate from her. This phase, taking-in phase, may last for a day or two. The nurse should plan activities so that the patient can rest as much as possible because failure to allow the patient to receive the necessary and earned rest may yield a "sleep hunger" which may be manifested by irritability, fatigue, and general interference with the normal restorative process. The father's role is primarily being supportive of his wife and his family.

b. Taking-Hold Phase. During this phase the mother strives for independence and autonomy, she becomes the "initiator." She is concerned about her ability to control her bodily functions (that is, bowels, bladder, and if breast-feeding, concerned about adequate amount and quality of milk). She takes an active part in trying to control these functions. She is concerned about her ability to take care of her newborn. This phase is associated with a great deal of anxiety (especially by a new mother). She may have several mood swings. The mother might be involved in a lot of activity trying to accomplish tasks. Fatigue and exhaustion may occur if the mother is not helped to set realist expectations and limits for herself. The nurse is responsible to allow the mother to actually perform infant care tasks, reinforce all positive actions (do not impose yourself), and provide guidance, instruction, and demonstration, as necessary. Reassurance and explanation about infant care are especially needed in this phase. This phase lasts for about ten days (most of this phase is accomplished at home).

c. Letting-Go Phase. Generally, this phase occurs when the mother returns home. The mother must accomplish two separations during this phase. The separations are to realize and accept the physical separation from the baby and to relinquish her former role of a childless person. The mother must adjust her life to the relative dependency and helplessness of her child. If she quits work, she must adapt (even if only temporarily) to less freedom, less autonomy, and less social stimulation. If she continues to work, she must handle the additional strain of finding sitters and meeting additional workload. The mother may experience a let-down feeling, which is called postpartal, or baby, "blues." This is a form of depression that is usually temporary and may occur in the hospital.

6-9. POSTPARTUM "BLUES"

a. Possible causes of postpartum "blues" are: hormonal changes that occur during the postpartal period; the emotional stresses associated with increased responsibilities of an infant and restrictions imposed by caring for an infant; ego adjustment that accompanies role transition from wife and childless person to mother; and the discomfort, fatigue, and exhaustion that may contribute or cause the condition.

b. Common manifestations experienced by the mother are let-down feeling (for no apparent reason, so the mother thinks), irritability, tears, loss of appetite, and difficulty sleeping.

c. Associated feelings experienced by the mother, secondary to her depression are:

(1) Guilt about her unaccustomed emotional displays (does not know why she is crying and identifies, "the tears just come").

(2) Loss of control over herself and over lack of the ability to care for herself.

(3) Feelings of failure as a mother, wife, or any other role of her involvement.

d. Nursing care responsibilities for postpartal "blues" patients.

(1) Recognize and interpret the mother's behavior on an individual basis. Not all women act the same way during childbirth and not all women will react to childbirth in the same way. There may be underlying things influencing the mother's behavior that may not be apparent.

(2) Allow the mother to cry as she wishes. Provide privacy for her. Let her know there is nothing wrong with her behavior. Crying may even be therapeutic.

(3) Convey to the mother that change takes time. This is the single most important concept to convey to the mother. She may not be able to do everything she wants as soon as she and her baby go home. It may take weeks or even months before she is able to make the transition to caring for her baby, her family, her home, and herself. It is okay not to accomplish everything immediately.

(4) Be understanding. Understanding and anticipatory guidance help the parents realize these feelings are a normal accompaniment to this role transition.

6-10. MATERNAL ADAPTATION FOLLOWING DELIVERY

a. Positive (Successful) Bonding and Taking-Hold. This reveals a warm mother-infant relationship beginning. It is identified by maternal-infant behavior to include mother fondling and caressing the infant, establishing eye contact with her infant, talking and cooing to her baby, and attempting to evoke a smile or vocal response from her baby.

b. Negative Bonding. Occasionally, a mother may have difficulty adapting to her maternal role and bonding with her infant. This may be caused by immaturity, lack of knowledge about infant care and behavior, and/or deep-rooted psychological problems. The mother may express inappropriate responses. These responses may include reluctance to hold, fondle, or interact with her infant, may find the infant unattractive or ugly, may find her infant has a serious hidden disease or defect, and/or may appear disgusted by the infant's drooling, sucking sounds, urine, or feces.

c. Evaluation of Maternal Adaptation. The nursing staff will make frequent observation of maternal-infant behavior during the hospital stay. All maternal-infant behavior (positive and negative) should be documented in the mother's chart as well as the infant's chart. Maternal-infant behavior that appears maladaptive should be viewed on an individual basis and reported to the professional nursing staff for evaluation by the health care team.

6-11. SPECIAL NURSING CARE NEEDS OF THE SINGLE MOTHER

a. Pregnancy is usually not planned by the single mother. Many times, the nursing staff does not know the true cause of the pregnancy. Pregnancy may result from teenage pregnancy, incest, rape, failure of a birth control method, or pregnancy conceived prior to a divorce. Lack of planning may impact on the mother's ability to care for the infant and the other's readiness to want to care for an infant.

b. Considerable time should be spent with the patient. Do not be judgmental. Offer kindness and understanding, attend to her postpartum needs, and evaluate maternal-infant adaptation responses.

(1) If the single mother is keeping the infant, the nurse should teach basic infant care skills, encourage positive maternal-infant adaptation responses, and provide resources for assistance in the community.

(2) If placing the infant for adoption, the nurse should provide emotional support, use individual assessment of each mother in determining if mother and infant should be separated, and allow the mother and family to do caretaking activities. An emotionally healthy mother with the support of family and staff may work through this crisis better if allowed to do caretaking activities for her baby.

c. The social worker or community health nurse can help solve problems with income, employment, childcare, transportation, emotional support, and assistance in the home.

d. Considerations for discharge planning. Make discharge plans based on the patient's age, maturity level, knowledge level, and maternal-infant adaptation process during hospital stay. A significant concern should be availability and support of family, relatives, friends, knowledge level, and maternal-infant adaptations process during the hospital stay.