Postpartal Psychologic Adaptations (p.

788-793)

VARQUEZ, KAREN D. VERGARA, CANDACE B. VICENTE CHARMAINE S. 2-10

Postpartal Period

Time of readjustment and adaptation for the entire

childbearing family, especially for the mother.

Postpartal Period
The woman experiences a variety of responses as she

adjust to the ff.:

A new family member Postpartal discomfort Changes in her body image The reality that she is no longer pregnant

Taking-In and Taking-Hold

Taking-In Period During the first day or two after birth

The woman tends to be

passive and somewhat dependent. Follows suggestions. Hesitates to make decisions Preoccupied with her needs

Taking-In and Taking-Hold

Taking-In Period Food and sleep are her major needs.

Nursing role:
Emotional support like talking to the mother about her perceptions of her labor and birth Sort out the reality from her fantasized experience Clarify anything that she did not understand

Taking-In and Taking-Hold

Taking-Hold Period Second or third day after birth

Ready to resume control over her life Concerned about:

controlling her bodily functions (eg. Elimination) If breastfeeding, she may worry about the quality of her milk Her ability to nurse her baby

Taking-In and Taking-Hold

Taking-Hold Period Might also feel that the nurse handles her baby more proficiently than she does

Nursing Role:
Provide assurance that she is doing well as a mother Emotional support

Maternal Role Attainment

A process by which a woman learns mothering

behaviors and becomes comfortable with her identity as a mother.

In most cases, maternal role attainment occurs

within 3 to 10 months after birth.

Maternal Role Attainment

Factors that influence the womans success in

attaining the maternal role:

Social support Womans age and personality traits Marital relationship Presence of underlying anxiety or depression Previous childcare skills Temperament of her infant The familys socioeconomic status

Maternal Role Attainment

Four Stages:
1. Anticipatory Stage During pregnancy The woman looks to role models, especially her own mother.

2. Formal Stage When the child is born Still influenced by the guidance of others Tries to act as she believes others expect her to act.

Maternal Role Attainment

3. Informal Stage When the mother begins to make her own choices about mothering Begins to develop he own style of mothering Find ways of functioning that work well for her. 4. Personal Stage Final stage of maternal role attainment The woman is comfortable with the notion of herself as mother

Maternal Role Attainment

Challenges of a woman as she adjust to her new role: Finding time for themselves Feelings of incompetence Fatigue from sleep deprivation The feeling of responsibility For women with older children, finding time for them is a challenge Infants behavior

Maternal Role Attainment

Nursing Role: Needs to be aware of the long-term adjustments and the stresses that the childbearing family faces. Providing anticipatory guidance about the reality of being a parent Giving postpartal family parenting literature for reference at home Provide ongoing parenting groups.

Postpartum Blues

Transient period of depression. Occurs during first few days of the puerperium

in 70% of all postpartal women.

Postpartum Blues

Frequently occurs while the woman is

hospitalized, but it may occur at home as well.

Usually resolve naturally within 10 to 14

days.

Postpartum Blues
Factors: Changing hormone levels Psychologic adjustments Unsupportive environments Insecurity Fatigue, discomfort and overstimulation

Postpartum Blues
Manifestations:
Tearfulness Anorexia Difficulty

in sleeping Feeling of letdown

Importance of Social Support

Family relationships
Source of stress Contact with parents of small children; decrease

with coworkers Great concern: No family or friends to form a social network - isolation at a time where the woman needs support can cause tremendous stress - postpartum depression, child neglect, abuse - New mother support groups

Development of Family Attachment

Mothers first interaction with her infant is influenced by

many factors(i.e. family of origin, degree of nurturing she received as a child,etc) Personal Characteristics: - Level of Trust - Level of self-esteem - Capacity for enjoying herself - Adequacy of knowledge about childbearing and childrearing - Her prevailing mood or usual feeling tone - Reactions to the present pregnancy Based on these factors the mother has developed some kind of emotional orientation

Initial Maternal Attachment Behavior

New mother demonstrates a regular pattern of

maternal behaviors at first contact with a normal newborn From fingertip exploration-extremities, to palmar contact with larger body areas, and finally enfolding infant with whole hand and arms - minutes to days

Initial Maternal Attachment Behavior

En face- mother arranges

herself of the newborn so she has direct face-toface and eye-to-eye contact

Initial Maternal Attachment Behavior

Infants eyes open Greets the newborn and

talks in a high-pitched tone Sight, touch and hearing; smell may be involved Responds to verbal cues

Initial Maternal Attachment Behavior

Shock, disbelief, or denial

- I cant believe shes finally here - I feel like he is a stranger Feelings of connectedness between the newborn and family- expressed negatively or positively - Shes got your cute nose, Daddy Facial expressions, questions asked and its frequency- concerns about the infants general condition or normality

Initial Maternal Attachment Behavoir

Acquaintance phase Getting to know her baby Infant gives clear behavioral cues, infants responses to mothering will be predictable - Mother feel effective and competent -smile -grasping a finger

Initial Maternal Attachment Behavoir

Phase of mutual regulation Mother and infant seek to deal with the issue of the degree of control to be exerted by each partner in the relationship Balance between mothers needs and infants needs Each should obtain a good measure of enjoyment from the interaction. Negative feelings may surface or intensify - Nurse should be supportive when the mother vocalizes these feeling

Initial Maternal Attachment Behavoir

Reciprocity An interactional cycle that occurs simultaneously between mother and infant Mother and infant enjoy each others company Cuing behaviors, expectancy, rhythmicity, and synchrony Synchronous- interaction between mother and infant are gratifying, sought and initiated by both parents Find pleasure and delight in each others company and grow in mutual love.

Father-Infant Interactions
In Western cultures, commitment to family-centered

maternity care has fostered interest in understanding the feelings and experiences of the new father.
Father has a strong attraction to his newborn similar

to the mothers feelings of attachment.

Father-Infant Interactions
Engrossment

-the characteristic sense of absorption, preoccupation, and interest in the infant demonstrated by fathers during early contact. -strong feelings of attraction.

Siblings and Others

Infants are capable of maintaining strong

attachments within the family.

siblings, grandparents, aunts and uncles.

Siblings and Others

The social setting and personality of an individual

seem to be factors in developing attachments. Visiting hours and rooming in

Permits siblings in the attachment process

Cultural Influences in the postpartal period

New mothers cultural and personal values

influences her :

Postpartal care
Expectations about food and fluids Rest Hygiene Medications Relief measures Support and advice

Cultural Influences in the postpartal period

It is important that nurses should recognize that

sometimes they are approaching their clients care from their own perspective.
They need to offer and support individual choices.

Cultural Influences in the postpartal period

It is helpful for nurses to understand that there are

really differences in beliefs and practices of cultural groups.

European
Eat a full meal and large amounts of fluids Want to ambulate shortly after birth Shower, wash her hair and put on a fresh gown May or may not be interested in educational classes

Cultural Influences in the postpartal period

Some cultures emphasize postpartal routines or

rituals for mother and baby:

To restore harmony Hot-cold balance of the body

Cultural Influences in the postpartal period

Hispanic, African and Asian May avoid cold after birth (cold air, wind and water) Mexican Avoid eating hot foods such as pork Considered birth of a baby as a hot experience

Cultural Influences in the postpartal period

In many cultures, the extended family plays an

essential role during the puerperium.

The grandmother- the primary helper to mother and

newborn

Brings wisdom and experience, allowing the new mother to rest

Visiting hours may be expanded to allow family

members additional access.

Care of the Woman with a Postpartum Psychiatric Disorder

DID YOU KNOW THE RATE OF ADMISSION OF WOMEN INTO A PSYCHIATRIC HOSPITAL IS GREATER DURING THE YEAR AFTER CHILDBIRTH THAN ANY OTHER TIME IN A WOMANS LIFE

Types of Postpartum Psychiatric Disorders

Diagnostic and Statistical Manuarl of Mental Disorders (APA, 2000) One diagnosable syndrome with three subclasses: 1. Adjustment reaction with depressed mood 2. Postpartal Psychosis 3. Postpartum major mood disorder.

Adjustment Reaction with Depressed Mood

Aka Postpartum blues, maternal or baby blues

50%-80%
Mild depression interspersed with happier feelings Few days after birth, self limiting, few hours to

10days or longer Severe in primiparas; rapid alterations of estrogen, progesterone, and prolactin levels after birth

Adjustment Reaction with Depressed Mood

Overwhelmed
Unable to cope Fatigue

Anxious
Irritable Oversensitive

Key feature: Episodic tearfulness often without

identifiable reason

Adjustment Reaction with Depressed Mood

Validate existence Label as real but normal Provide reassurance Encourage partner to watch for and report signs that

mother is becoming more depressed.

Postpartum Psychosis
Symptoms - Agitation 1 to 2 per 1000 First 3months postpartum

- Hyperactivity
- Insomnia - Mood lability - Confusion - Irrationality - Difficulty remembering or

Improvement- 95% women

in 2 to 3 months Increase risk in next pregnancy

concentrating - Poor judgment - Delusions - Hallucinations

Postpartum Major Mood Disorder

Postpartum depression 7%-30% postpartum Risk factors 1. Primiparity 2. Ambivalence 3. History of postpartum 4. 5. 6.

woman in North American Anytime during first postpartum year - Four weeks (before onset of menses and upon weaning) NOT associated with depression during pregnancy

7.

depression or bipolar illness Lack of social support Lack of stable and supportive relationship Lack of supportive relationship Dissatisfaction with herself.

Postpartum Major Mood Disorder

Clinical Therapy
Women with history of postpartum psychosis or

depression or other high risks:

Should be referred to a mental health professional for counseling Biweekly visits between the second and sixth week postpartum for evaluation

Common treatment measures Medication Individual or group psychotherapy Practical assistance with child care

Clinical Therapy
Treatment for postpartum psychosis: Lithium Antipsychotics or electroconvulsive therapy with psychotherapy Removal of the infant Social support Treatment for postpartum depression: Psychotherapy Antidepression medications(serotonin reuptake inhibitors)

Clinical Therapy
If social support is not available, the woman and her

family may encouraged to contact Depression after Delivery (DAD).

DAD is a national support network that provides literature and volunteers.

Many of the drugs in treating postpartum psychiatric

conditions are contraindicated in breastfeeding women.

Nursing Assessment and Diagnosis

Ideally a depression assessment should be completed

each trimester to update a pregnant womans risk status.

The Eidenburgh Postnatal Depression Scale

Score above 12- suffers from postpartum depression

Becks revised Postpartum Depression Predictors Inventory (PDPI-Revised)

Nursing Assessment and Diagnosis

Objective signs of depression Anxiety Irritability Poor concentration Forgetfulness Sleep difficulties Appetite change Fatigue Tearfulness

Nursing Assessment and Diagnosis

Ineffective Individual Coping related to postpartum

depression
Risk for Altered related to postpartal mental illness

Nursing Plan and Implementation

Teaching for Self-Care Offer realistic information and anticipatory guidance Debunking myths about the perfect mother or perfect newborn Social support The nurse should also alert the mother, spouse and other family members to the possibility of postpartum blues in early days of birth. Symptoms of postpartum depression should be described and encouraged her to call her health provider if symptoms become severe.

Nursing Plan and Implementation

Community-Based Nursing Care Home visits. Telephone follow-up at 3 weeks postpartum. If a woman presents symptoms of depression, refer to a mental health professional immediately. Providing information and emotional support. Assistance in providing care for the infant. Postpartum follow-up, as well as visits from a psychiatric home health nurse.

Primary Prevention Strategies for Postpartum Depression

1.

2.

3.

4. 5. 6.

7.

Celebrate childbirth but appreciate that it is a life-changing transition that can be stressful. Consider keeping a journal where you write down your feelings. Appreciate that you do not have to know everything to be a good parent. Connect to others who are parents. Set a daily schedule and follow it even if you dont like it. Prioritize daily tasks. Remember that you do not have to entertain or care for everyone who drops by.

Primary Prevention Strategies for Postpartum Depression (contd)

8.

9. 10.

11. 12. 13. 14.

15.

If someone volunteers to help you with tasks or baby care, take them up on it. Maintain outside interests. Eat a healthful diet. Limit alcohol. Quit smoking. Get some exercise. Get as much sleep as possible. Limit major changes the first year insofar as possible. Spent time with others. If things get overwhelming, and you feel yourself slipping into depression, reach out someone for help. Attend a postpartum support group if someone is available.

Evaluation

The womans signs of depression are identified and

she receives therapy quickly.

The newborn is cared for effectively by the father or

another support person until the mother is able to participate more fully.

Thank you!

END.