Which characteristic feature would the nurse observe in the patient who may be experiencing baby blues?

One of the most important areas of assessment is careful observation of specific 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 relies more on skillful observation and interviewing. Rooming-in of mother and infant and liberal visiting privileges for father or partner, siblings, and grandparents provide nurses with excellent opportunities to observe interactions and identify behavior that demonstrate positive or negative attachment. Attachment behaviors can be easily observed during infant feeding sessions. Box 20-1 presents guidelines for assessment of attachment behaviors.

Box 20-1   Assessing Attachment Behaviors

• 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 resembles, and what appears special about their infant over other infants?

• When parents are holding the infant, what kind of body contact is seen—do parents feel at ease in changing the infant’s position, are fingertips or whole hands used, and does the infant have 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, and 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, 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 and 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, problems with breastfeeding (Tharner, Luijk, Raat, et al., 2012), premature birth, and being separated from the infant at birth (Flacking, Lehtonen, Thomson, et al., 2012; Hoffenkamp, Tooten, Hall, et al., 2012) can delay the development of initial positive feelings toward the newborn. Referral to groups such as La Leche League International (www.llli.org) or Postpartum Support International (www.postpartum.net) can be useful.

Rooming-in is common in family-centered care. With this practice, the infant stays in the room with the mother. In some facilities, the newborn never leaves the mother’s presence; nurses perform the initial and ongoing assessments and care in the room with the parents. In other hospitals, the infant is transferred to the postpartum or mother-baby unit from the transitional nursery (if the facility uses one) after showing satisfactory extrauterine adjustment. Nurses encourage the father or partner to participate in caring for the infant in as active a role as desired. They can also encourage siblings and grandparents 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, their partners, and family members are equal and integral parts of the developing family.

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. Postpartum nurses need to consider and encourage activities that optimize family-centered care (Welch, Hofer, Brunelli, et al., 2012). Baby Friendly status for a hospital is one means to promote family-centered care (Jaafar, Lee, and Ho, 2012; Perrine, Scanlon, Li, et al., 2012; Smith, Moore, and Peters, 2012; Vasquez and Berg, 2012).

Touch, or the tactile sense, is used extensively by parents 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. Mothers lift their infants to their breasts, enfold them in their arms, and cradle them. Once the infant is close, the mother begins the exploration process with her fingertips, one of the most touch-sensitive areas of the body. Within a short time, she uses her 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. Parents seem to have an innate desire to touch, pick up, and hold the infant (Fig. 20-4). They comment on the softness of the baby’s skin and note details of the baby’s appearance. As parents become increasingly sensitive to the infant’s like or dislike of different types of touch, they draw closer to the baby.

Touching behaviors of mothers vary in different cultural groups. 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 (Waugh, 2011).

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. If the parent continues to stimulate the infant, the baby may again become fussy.

Synchrony refers to the “fit” between the infant’s cues and the parent’s response. When parent and infant have a synchronous interaction, it is mutually rewarding (Fig. 20-6). Parents need time to learn to interpret the infant’s cues correctly. For example, the infant develops a specific cry in response to different situations such as boredom, loneliness, hunger, and discomfort. The parent may need assistance in interpreting these cries, along with trial-and-error interventions, before synchrony develops.

Historically, the transition to parenthood was viewed as a crisis. The current perspective is that parenthood is a developmental transition rather than a major life crisis. The transition to parenthood is described as a time of disorder and disequilibrium, as well as satisfaction, for mothers and their partners. Usual methods of coping often seem ineffective during this time. Some parents are so distressed that they cannot support each other. Because men typically identify their spouses as their primary or only source of support, the transition can be harder for the fathers. They often feel deprived when the mothers, who are also experiencing stress, cannot provide their usual level of support. Many parents are unprepared for the strong emotions such as the helplessness, inadequacy, and anger that arise when dealing with a crying infant. However, parenthood allows adults to develop and display a selfless, warm, and caring side that may not be expressed in other adult roles.

For the majority of mothers and their partners, the transition to parenthood is an opportunity rather than a time of danger. Parents try new coping strategies as they work to master their new roles and reach new developmental levels. As they work through the transition, they often find personal strength and resourcefulness.

Parents need to reconcile the actual child with the fantasy and dream child. This process 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 never accept the child.

Many parents know the sex of the infant before birth because 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 can 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.”

The normal appearance of the neonate—size, color, molding of the head, or bowed appearance of the legs—is startling for some parents. Nurses can encourage parents to examine their babies and to ask questions about newborn characteristics.

Parents need to become adept in the care of the infant, including caregiving activities, noting the communication cues the infant gives to indicate needs and responding appropriately to those needs. Self-esteem grows with competence. Breastfeeding helps mothers feel they are contributing in a unique way to the welfare of the infant. The parent may interpret the infant’s response to his or her parental care and attention as a comment on the quality of that care. Infant behaviors that parents interpret 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 parents view as negative can result in alienation of parent and infant.

Some people view assistance, including advice by husbands, partners, wives, mothers, mothers-in-law, and health care professionals, as supportive. Others view advice as criticism or an indication of how inept these others judge 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 be 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.