NSG210 Durham Ch. 13: Transition to Parenthood

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 13, pp. 429-447 (textbooks/DURHAM_OB_CH13.pdf, also in textbooks/exam03/). Week 10 reading (OB Lectures 6-7, October 28); on Exam 3. The syllabus weekly outline also lists Ch. 13 under Week 12. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Maternal Adaptation and Role Attainment, Bonding and Attachment, Postpartum depression screenings). Postpartum mood disorders beyond the blues are in nsg210-durham-ch14-high-risk-postpartum.

Learning Outcomes

1. Describe the process of “becoming a mother.”
2. Identify factors that influence women and men in their transitions to mother and father.
3. Discuss bonding and attachment.
4. Identify factors that affect family dynamics.
5. Describe nursing actions that support couples during the transition to parenthood.

Nursing diagnoses: knowledge deficit about the parent role (first-time parent); risk for situational low self-esteem; risk for altered family processes; risk for altered parent-infant attachment related to anxiety.

Outcomes: parents verbalize role expectations, responsibilities and stressors; positive comments and actions toward family members; parents hold the infant close, attend to needs and interact.

I. The Transition to Parenthood

• A dynamic developmental process that starts with knowledge of the pregnancy and continues through the postpartum period; a major life event for every birth, first or tenth
• Common stressors: learning the role, childcare tasks, money, work-family conflict, chronic fatigue; lower couple satisfaction; less sexual and intimate activity
• Evidence-based practice (first-time parents): three challenges were loss of individuality and couplehood, inequality in childcare tasks, and managing social expectations. Barriers: fatigue and sleep loss, isolation, financial insecurity and workplace discrimination, balancing work

Factors that help or hinder the transition:

• Previous experience caring for infants and children
• How they were parented (positive memories help)
• Length and strength of the couple’s relationship
• Finances (concerns hinder)
• Education level (trouble reading care information hinders)
• Support systems
• Desire to be a parent
• Age (adolescents have a harder transition)

II. Parental Roles

• Each role has expectations (for example, others will recognize them as parents) and responsibilities (for example, to love and protect the child)
• Intentional learning: formal instruction. Incidental learning: observing other parents, recalling how they were parented, media. Most parents rely on incidental learning
• Role learning should start in pregnancy; couples who learn together have better outcomes

Expected findings: parents identify changing roles and accept lifestyle changes; discuss what the roles mean; incorporate the infant as a third person; support each other in caregiving.

Nursing actions:

• Protect uninterrupted rest (rest improves the ability to learn)
• Culturally sensitive care (role expectations vary by culture)
• Active listening; help parents state their expectations of each other (realistic, mutually agreed expectations reduce stress)
• Teach infant care with varied methods: handouts, videos, demonstration (burping, swaddling, soothing, stimulating)
• Positive feedback for infant care (new parents are insecure)
• Refer to community parenting classes and support groups

III. Motherhood

A. Becoming a mother (Mercer)

Mercer’s four stages:

1. Commitment, attachment and preparation during pregnancy
2. Acquaintance with the infant, increasing attachment, learning infant care and physical recovery in the early weeks
3. Moving toward a new normal over the first 4 months
4. Achieving maternal identity at about 4 months

• Mercer replaced “maternal role attainment” with “becoming a mother” because the process keeps evolving
• Influencing factors: how she was parented, life experiences, personal traits, culture, the pregnancy and birth experiences, support, willingness to be a mother, the infant’s appearance and temperament
• Expected findings: positive feelings about the pregnancy, healthy behaviors, nurturing and protective behavior, growing confidence, new family routines
• Nursing actions: review prenatal and labor records for risk factors; rooming-in or couplet care; private family time; comfort measures; listen to her concerns; teach infant care; praise her care

B. Rubin’s maternal phases (Table 13-1)

Rubin’s work dates from the 1960s, when sedation and 5-day stays with nursery care slowed the phases; women now move through them faster. A delay in moving through the phases may mean she is having trouble becoming a mother.

Factors that slow the phases:

• CNS-depressing drugs (magnesium sulfate, analgesics) causing drowsiness and slow responses
• Complications of pregnancy, birth or postpartum, including cesarean birth (pain shifts her focus to self)
• Preterm or ill infant
• Mood disorders such as depression (focus on self)
• Lack of partner or social support (exhaustion)
• Adolescent mothers (focus inward and on peers)
• Lack of money (focus on basic needs)
• Cultural norms (some cultures expect the mother to rest rather than give care for the first months)

C. Rubin’s maternal touch

Progresses over a few hours with early continuous contact, or over several days if the infant is in the NICU:

1. Initial: tentative touch with the fingertips
2. Second: strokes the infant’s head or body with her hand
3. Final: holds the infant in her arms close to her body

• En face: mother and infant face to face with eye contact; reached in the final stage and promotes bonding
• Breastfeeding mothers may feel awkward holding the infant close in the early stages; reassure that this resolves with contact

IV. Fatherhood

• Men usually do not fantasize about or role-play fatherhood; they evaluate how they were fathered, and fatherhood may not feel real until the birth. Expectant fathers tend to picture parenting older children rather than infants
• The meaning of “father” depends on how he was fathered, culture (some cultures exclude men from birth and infant care), friends, family and his partner
• The partner strongly influences his level of involvement; she must want and support it
• Evidence-based practice (expectant fathers): themes were being there, fathering older children, preparing the child for society, the heaviness of the role, and relying on women for support. Father involvement starting in pregnancy is linked to better maternal and infant outcomes
• Factors in the transition: developmental and emotional age, culture, relationship with partner, knowledge of fatherhood, prior fathering, how he was fathered, money, support

Engrossment (Greenberg and Morris, 1974): a father’s absorption, preoccupation and interest in his newborn; he may gaze at the baby for long periods. Seven characteristics:

1. Visual awareness (sees the infant as attractive)
2. Tactile awareness (wants to touch the infant)
3. Awareness of the infant’s distinct features
4. Perceives the infant as perfect
5. Strong attraction to the infant
6. Strong elation
7. Increased self-esteem

Nursing actions for fathers: teach and demonstrate diapering, feeding and holding; praise his interactions; let him talk about what fathering means; help the couple agree on his role. Early contact (involvement in labor and birth) builds comfort and a more active role.

Expected paternal findings (vary by culture): prolonged gazing, helps with care, holds the infant close, delights in the infant’s features, expresses love for infant and partner.

Maladaptive paternal findings (may be cultural): little interest, negative comments, ignores cues, sadness or anger toward partner or infant, absent or emotionally unavailable, mood swings, family conflict over the infant.

V. Adolescent Parents

• Taking on parent responsibilities while still working through adolescent developmental tasks; few life experiences to draw on; often financial and educational challenges
• Many adolescent mothers report that parenting helped them mature and become more responsible (EBP: themes included becoming more responsible, mature and motivated; challenges included isolation from friends, feeling burdened, sleep loss, money and protecting the child)
• Adolescent fathers need recognition and inclusion; those involved prenatally are more involved after the birth

Nursing actions:

• Assess knowledge; teach at an age-appropriate level (young teens and older teens learn differently)
• Include the adolescent father in teaching and in prenatal care, as the mother is comfortable
• Include the maternal grandmother in infant care teaching (teen mothers often live with or rely on her)
• Help the couple discuss expectations of each other

VI. Same-Sex Parents

• 5.1% of US women and 3.9% of men identify as LGBT; 8.1% of millennials. Acceptance is rising
• Lesbian couples must decide which partner will carry and how (most use artificial insemination with a known or unknown donor); insemination timing and failed cycles are stressful
• Couples usually see themselves as coparents and share care equally; they report less parenting stress, less feeling of incompetence and less isolation than heterosexual couples
• Non-birthing mother: may feel invisible and unsupported; parental rights vary by state even when married, so recommend legal advice
• Both mothers may breastfeed. Induction of lactation for the non-birthing mother: hormone therapy, pumping, an at-breast supplementer, or a combination; start preparing several months before birth (La Leche League has resources)
• Children of same-sex parents have the same emotional, social and cognitive development as other children
• EBP (lesbian women and motherhood): women feared disclosing their identity; all experienced some homophobia (exclusion, heterosexual assumptions, inappropriate questions, refusal of service). Use gender-neutral intake forms and attend LGBTQ health training

Nursing actions: self-assess attitudes and beliefs; assess knowledge; include both mothers in teaching; ask whether both plan to breastfeed and support each; encourage both to hold and care for the infant.

VII. Bonding and Attachment

• Bonding: emotion that begins in pregnancy or soon after birth; UNIDIRECTIONAL, parent to infant (Klaus and Kennell)
• Attachment: emotional connection that forms between infant and parent; BIDIRECTIONAL (Bowlby); lifelong impact and the foundation for future relationships
• Affected by time, proximity, whether the pregnancy was planned or wanted, and the parents’ ability to work through developmental tasks; also knowledge, past experience with children, maturity and education, extended support, expectations of the pregnancy and infant, culture

Table 13-2:

Risk factors for delayed bonding and attachment:

• Maternal illness in pregnancy or postpartum
• Neonatal illness or prematurity requiring separation
• Prolonged or complicated labor that exhausts the couple
• Postpartum fatigue and discomfort
• Adolescent or developmentally challenged mother
• Outside stressors: money, poor support, early return to work

Expected findings: hold the infant close; call the infant by name or correct sex; respond to needs; speak positively; interested in learning; ask appropriate questions; comfortable giving care.

Maladaptive findings: calling the infant “it”; avoiding eye contact (may be cultural); not responding to cries; emotionally unavailable; letting others give all care without interest (may be cultural); poor feeding technique (propping bottles, not burping, irritated when nursing).

Nursing actions:

• Review records and assess for risk factors and cultural beliefs
• Teach why bonding and attachment matter and to respond to infant cues (crying, cooing, movement)
• Promote: early and prolonged skin-to-skin contact, rooming-in or couplet care, positive comments, breastfeeding, talking about the birth experience
• When mother and infant are separated (maternal illness or NICU): photos of the infant for her room; take parents to the NICU to see and touch; let them give care; teach pumping and bring milk to the NICU; tell them they can call the NICU any time
• Delay unnecessary procedures; provide rest and comfort; role model en face position and calling the infant by name; explain that discomfort holding the infant close fades with contact
• Reciprocity: a rhythm between parent and infant that strengthens with each interaction

VIII. Communication Between Parent and Infant

• Infants communicate by crying, cooing, facial expressions, eye movements, smelling, cuddling, and arm and leg movements
• Entrainment: the infant moves arms and legs in rhythm with adult speech
• Synchrony: reciprocal, mutually rewarding interactions (en face gazing and cooing; infant grasping the father’s finger while they gaze)
• A newborn placed on the mother’s abdomen will crawl to the breast
• Cue-sensitive parents know the best times to interact, how to comfort, how to help the infant self-comfort, and when the infant is overstimulated

Table 13-3, infant states:

Nursing actions: assess parent-infant interaction (gentle touch, holding close, talking or singing, en face when culturally acceptable, responding to cues, infant responds to touch and voice); role model; praise; teach infant communication, eye contact, synchrony, cues, entrainment and states.

IX. Family Dynamics

• Family dynamics: the unique ways members interact; adaptation determines cohesion
• Compositions: married or unmarried couples (opposite or same sex), adoptive couples, adolescent mothers with or without support, single women, blended families
• Coparenting: how parents relate to each other as parents; shared responsibility, support and coordination; does NOT mean equal roles or authority. Shaped by beliefs and values, culture, and the infant’s temperament

A. Multiparas (Mercer, 1979)

• More experience but usually more exhaustion and less help than with the first child
• Concerns: will the other children feel abandoned; can she love this child as much; can she care for more than one; will she get rest; will family help again
• Strategies: quality time with the older child while the baby sleeps, a sling to free her hands, prepared meals, partner takes on more housework and care of the older child

B. Sibling rivalry

• Younger children lose being “the baby”; older children may feel burdened with responsibility
• Critical Component, sibling adjustment: talk about the baby during pregnancy; let siblings feel the baby move and hear the heartbeat; visit mother and baby in the hospital and hold the baby with supervision; lie in bed with mother; give a present “from the baby”; quality one-on-one time (reading, games, listening); a special outing while the baby stays with a sitter; explain why babies cry

C. Nursing actions for family dynamics

Review records; assess prior infant experience; watch for maladaptive behavior and refer to social services or the community health nurse; respect culture; anticipatory guidance about adjustments; help parents plan for siblings; praise family interactions; give the family and the couple chances to talk.

X. Postpartum Blues

• Also called baby blues; occur in the first few postpartum weeks, last a few days, affect the MAJORITY of women
• She feels sad and cries easily but can still care for herself and the infant
• Causes: hormonal changes, fatigue, stress of the new role
• Signs: anger, anxiety, mood swings, sadness, weeping, difficulty sleeping and eating
• Nursing actions: explain that it is common; stress rest; teach the partner to give emotional and physical support; seek care if symptoms last beyond 4 weeks or worry her or the family (possible postpartum depression, Ch. 14)

XI. Parents With Sensory Impairment

Critical Component: treat them as people, not disabilities; they have the same capacity to love and nurture and the same need for teaching. Most already have strategies; assess their plans and adapt care. Explore tools to support bonding, infant care teaching, safety and family dynamics.

Visually impaired parents:

• Use her name in report (never “the blind woman in room 211”)
• Introduce yourself and others on entering; announce when you leave
• Speak directly and clearly in a normal voice
• Keep doors, cabinets and closets closed
• Sighted guide: she holds your elbow; never push, pull or grab; never pull the cane
• Do not touch or play with a guide dog in harness; ask first
• Orient the room in logical order from a fixed point; describe food by clock position
• Offer to read printed material; make room for Braille equipment
• Teach hands-on (she diapers while you explain); discharge teaching in Braille or audio

Hearing-impaired parents:

• Face them; articulate without exaggerating; normal volume; 6 to 8 feet away with window light behind them
• Do not cover your mouth or turn away; one speaker at a time; reduce background noise
• If misunderstood, use different words rather than repeating louder
• Written teaching, graphics and visuals; time to study illustrations
• Use a registered interpreter for medical information: speak to the patient, not the interpreter; avoid “tell them”; allow time; check understanding. A nod may mean “continue,” not “I understand”
• Get attention by flicking the lights, not shouting, waving or touching
• Hearing aids amplify sound 6 to 10 times, so loud noise is uncomfortable
• Closed captions, writing pad
• Ask how the home is adapted (cry-activated flashing light, closed-circuit TV)

XII. Clinical Pathway: Transition to Parenthood

Discharge criteria: positive bonding and attachment; parents understand infant cues and care; extended family is supportive.

Care plan example (delayed bonding after an unplanned cesarean in a first-time mother): treat pain first (side-lying with the infant beside her, no pressure on the abdomen); short teaching sessions after pain medication; cluster care for rest; clarify the reasons for the cesarean; bring the infant to her and praise her care.

High-Yield Numbers

• Taking-in: first 24 to 48 hours
• Taking-hold: 24 to 48 hours through the first few weeks
• Maternal identity (Mercer): about 4 months
• Baby blues: majority of women, first few weeks, lasts a few days; refer if beyond 4 weeks
• Engrossment: 7 characteristics
• Maternal touch: 3 stages (fingertips, hand, arms close to body)
• Hearing-impaired: speak from 6 to 8 feet; hearing aids amplify 6 to 10 times

Priority Nursing Actions and Red Flags

• Taking-in: be directive, meet her physical needs, keep teaching short; save major teaching for taking-hold
• Fingertip touching on day 1 is normal (initial stage of maternal touch), not a red flag
• Red flags for attachment: calling the baby “it,” ignoring cries, no interest in care, negative comments, propped bottles. Consider culture before labeling behavior maladaptive; refer to social services when truly maladaptive
• Separated mother and infant (NICU): photos, NICU visits, hands-on care, pumping, 24-hour phone access
• Crying and sadness but still able to care for self and infant in the first weeks: baby blues (reassure, rest, support). Persisting beyond 4 weeks or unable to function: evaluate for postpartum depression
• Bonding is one-way; attachment is two-way
• Quiet alert is the best state for interaction; do not wake an infant from deep sleep to feed or play
• Interpreter: speak to the patient

Medications

No chapter-specific medications. Magnesium sulfate and opioid analgesics are noted only because CNS depression can slow progression through the maternal phases.

Related

• nsg210-durham-ch12-postpartum-care
• nsg210-durham-ch14-high-risk-postpartum
• nsg210-durham-ch05-psychosocial-cultural-pregnancy
• INDEX