Transition to Parenthood



Transition to Parenthood


Shannon E. Perry



Learning Objectives


On completion of this chapter, the reader will be able to:


• Identify parental and infant behaviors that facilitate and those that inhibit parental attachment.


• Describe sensual responses that strengthen attachment.


• Compare maternal adjustment and paternal adjustment to parenthood.


• Describe ways in which the nurse can facilitate parent-infant adjustment.


• Examine the effects of the following on parenting responses and behavior: parental age (i.e., adolescence and older than 35 years), same-sex parenting, social support, culture, socioeconomic conditions, personal aspirations, and sensory impairment.


• Describe sibling adjustment.


• Describe grandparent adaptation.


Becoming a parent creates a period of change and instability for men and women who decide to have children. This period 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 is a process of role attainment and role transition. The transition is an ongoing process as the parents and infant develop and change.



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 known as attachment. Using the terms attachment and bonding, Klaus and Kennell (1976) originally proposed that there is a sensitive period during the first few minutes or hours after birth when mothers and fathers must have close contact with their infant to optimize the child’s later development. 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 more than minutes or hours were needed 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. 20-1).


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FIG 20-1 Hands. (Courtesy Cheryl Briggs, RNC, Annapolis, MD.)

The concept of attachment includes mutuality; that is, the infant’s behaviors and characteristics elicit 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. Most caregivers are 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, the parent’s disappointment can delay the attachment process. Table 20-1 presents a comprehensive list of classic infant behaviors affecting parental attachment. Table 20-2 presents a corresponding list of parental behaviors that affect infant attachment.




TABLE 20-2


Parental Behaviors Affecting Infant Attachment








































FACILITATING BEHAVIORS INHIBITING BEHAVIORS
Looks; gazes; takes in physical characteristics of infant; assumes en face position; eye contact Turns away from infant; ignores infant’s presence
Hovers; maintains proximity; directs attention to, points to infant Avoids infant; does not seek proximity; refuses to hold infant when given opportunity
Identifies infant as unique individual Identifies infant with someone parent dislikes; fails to recognize any of infant’s unique features
Claims infant as family member; names infant Fails to place infant in family context or identify infant with family member; has difficulty naming
Touches; progresses from fingertip to fingers to palms to encompassing contact Fails to move from fingertip touch to palmar contact and holding
Smiles at infant Maintains bland countenance or frowns at infant
Talks to, coos, or sings to infant Wakes infant when infant is sleeping; handles roughly; hurries feeding by moving nipple continuously
Expresses pride in infant Expresses disappointment, displeasure in infant
Relates infant’s behavior to familiar events Does not incorporate infant into life
Assigns meaning to infant’s actions and sensitively interprets infant’s needs Makes no effort to interpret infant’s actions or needs
Views infant’s behaviors and appearance in positive light Views infant’s behavior as exploiting, deliberately uncooperative; views appearance as distasteful, ugly

Data from Mercer R: Parent-infant attachment. In Sonstegard L, Kowalski K, Jennings B, editors: Women’s health (vol 2), New York, 1983, Grune & Stratton.


An important part of attachment is acquaintance. Parents use eye contact (Fig. 20-2), 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. 20-3). 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. Mother and father examine 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 “Daniel 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.”


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FIG 20-2 Eye-to-eye contact. (Courtesy Cheryl Briggs, RNC, Annapolis, MD.)

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FIG 20-3 Early acquaintance between parents and infant. (Courtesy Kathryn Alden, Chapel Hill, NC.)

Conversely, 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 to facilitate parental attachment are numerous and varied (Table 20-3). 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 can 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 Competence box).



TABLE 20-3


Examples of Parent-Infant Attachment Interventions



















































































INTERVENTION LABEL AND DEFINITION ACTIVITIES
Attachment Promotion
Facilitating the development of an affective, enduring relationship between infant and parent Discuss with patient culture-based expressions of attachment prior to and after birth.
Place newborn skin-to-skin with parent immediately after birth.
Provide opportunity for parent or parents to see, hold, and examine newborn immediately after birth (i.e., delay unnecessary procedures and provide privacy).
Discuss infant behavioral characteristic with parent.
Assist parent of multiples in recognizing individuality of each infant.
Instruct parent on attachment development, emphasizing its complexity, ongoing nature, and opportunities.
Family Integrity Promotion: Childbearing Family
Facilitation of the growth of individuals or families who are adding an infant to family unit Respect and support family’s cultural value system.
Assist family in developing adaptive coping mechanisms to deal with the transition to parenthood.
Prepare parent(s) for expected role changes involved in becoming a parent.
Prepare parent(s) for responsibilities of parenthood.
Reinforce positive parenting behaviors.
Identify effect of newborn on family dynamics and equilibrium.
Lactation Counseling
Assisting in the establishment and maintenance of successful breastfeeding Correct misconceptions, misinformation, and inaccuracies about breastfeeding.
Provide mother the opportunity to breastfeed after birth, when possible.
Instruct on infant’s feeding cues (e.g., rooting, sucking, and quiet alertness).
Determine frequency of normal feeding patterns, including cluster feedings and growth spurts.
Discuss strategies aimed at optimizing milk supply (e.g., breast massage, frequent milk expression, complete emptying of breasts, kangaroo care, and medications).
Instruct on signs and symptoms warranting reporting to a health care practitioner or lactation consultant.
Parent Education: Infant
Instruction on nurturing and physical care needed during the first year of life Determine parent(s)’ knowledge and readiness and ability to learn about infant care.
Provide anticipatory guidance about developmental changes during first year of life.
Teach parent(s) skills to care for newborn.
Demonstrate ways in which parent(s) can stimulate infant’s development.
Discuss infant’s capabilities for interaction.
Demonstrate quieting techniques.
Risk Identification: Childbearing Family
Identification of individual or family likely to experience difficulties in parenting, and prioritization of strategies to prevent parenting problems Ascertain understanding of English or other language used in community.
Determine developmental stage of parent or parents.
Review prenatal history for factors that predispose patient to complications.
Monitor parent-infant interactions, noting behaviors thought to indicate attachment.
Plan for risk-reduction activities, in collaboration with the individual or family.
Refer to the appropriate community agency for follow-up if risk for parent problems or a lag in attachment has been identified.


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Data from Bulechek G, Butcher H, Dochterman J, et al: Nursing interventions classification (NIC), ed 6, St Louis, 2013, Mosby.



image Cultural Competence


Fostering Bonding in 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 patient follows. Incorrect judgments may be made about mother-infant bonding if nurses do not practice culturally sensitive care.


Adapted from D’Avanzo C: Mosby’s pocket guide to cultural assessment, ed 4, St Louis, 2008, Mosby.



Assessment of Attachment Behaviors


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.



Parent-Infant Contact


Early Contact


Early close contact may facilitate the attachment process between parent and child. Although a delay in contact does not necessarily mean that attachment will be inhibited, additional psychologic energy may be necessary 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.


Early skin-to-skin contact between the mother and newborn immediately after birth and during the first hour facilitates maternal affectionate and attachment behaviors (Flacking, Lehtonen, Thomson, et al., 2012; Hung and Berg, 2011; Moore, Anderson, Bergman, et al., 2012). The newborn is placed in the prone position on the mother’s bare chest; the baby and mother’s chest are covered with a warm, dry blanket. This practice promotes early and effective breastfeeding and increases breastfeeding duration. It is also associated with less infant crying, improved thermoregulation (especially in low-birth-weight infants), and improved cardiorespiratory stability in late preterm infants (Moore, Anderson, Bergman, et al., 2012; Thukral, Sankar, Agarwal, et al., 2012).


Parents who cannot 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 affectionate ties with their parents. Nurses need to stress that the parent-infant relationship is a process that develops over time.



Extended Contact


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).



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 cultural variations are often seen in these interactive behaviors.



The Senses


Touch


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.


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FIG 20-4 Breastfeeding in first hour after birth. (Courtesy Julie and Darren Nelson, Loveland, CO.)

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).



Eye Contact


Parents repeatedly demonstrate interest in having eye contact with the baby. 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 North American culture, eye contact appears to reinforce the development of a trusting relationship and is an important factor in human relationships at all ages. In other cultures, eye contact is perceived differently (see Cultural Competence box). 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 mal de ojo (evil eye), resulting from excessive admiration. Women and children are thought to be more susceptible to the mal de ojo (D’Avanzo, 2008).


As newborns become functionally able to sustain eye contact with their parents, they spend time in mutual gazing, often in the en face position. In this position, the parent’s face and the infant’s face are approximately 8 inches apart and on the same plane (see Fig. 20-2). Nurses and nurse-midwives/physicians can facilitate eye contact immediately after birth by positioning the infant on the mother’s abdomen or breasts with the mother’s and the infant’s faces on the same plane. Dimming the lights encourages the infant’s eyes to open. To promote eye contact, instillation of prophylactic antibiotic ointment into the infant’s eyes can be delayed until the infant and parents have had some time together in the first hour after birth.







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. 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.


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FIG 20-6 Sharing a smile; an example of synchrony. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)


Parental Role After Birth


Adaptation involves a stabilizing of tasks and a coming to terms with commitments. Parents demonstrate growing competence in child care activities and become increasingly 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 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.



Parental Tasks and Responsibilities


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.



Becoming a Mother


Rubin (1961) identified three phases of maternal role attainment in which the mother adjusts to her parental role. These phases extend over the first several weeks and are characterized by dependent behavior, dependent-independent behavior, and interdependent behavior (Table 20-4). Rubin’s research was conducted when the length of stay in the hospital was for a longer period (3 to 5 or more days). With today’s early discharge, women seem to move through the phases faster.



Mercer (2004) suggested that the concept of maternal role attainment be replaced with becoming a mother to signify the transformation and growth of the mother’s identity. Becoming a mother implies more than attaining a role. It includes learning new skills and increasing her confidence in herself as she meets new challenges in caring for her child or children.


Mercer (2004) identified four stages in the process of becoming a mother (Mercer and Walker, 2006, pp. 568-569):


Related posts:

  1. High Risk Perinatal Care: Gestational Conditions
  2. 21st Century Pediatric Nursing
  3. Labor and Birth Processes
  4. Newborn Nutrition and Feeding

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Sep 16, 2016 | Posted by in NURSING | Comments Off on Transition to Parenthood

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