Learning Objectives
By the end of this section, you will be able to:
- Describe the psychologic adjustments that will occur during the postpartum period through the Maternal Role Attainment Theory and Rubin’s Puerperal Phases
- Describe psychologic warning signs during the postpartum period
- Explain the factors that influence parent-infant attachment in the nursing assessment of early attachment
The new family goes through many psychosocial changes and adaptations during the postpartum period. Attachment styles are different within families and among cultures. Psychologic concerns can negatively influence attachment, while social support can positively influence attachment. Theories like Mercer’s Maternal Role Attainment and Rubin’s “taking-in” and “taking-hold” phases can help the nurse understand how to help the parents and newborn develop successful attachment.
Attachment Behaviors and Family Adaptation
Assessing and supporting parental attachment is an important postpartum nursing responsibility. The postpartum person needs assistance in self-care and newborn care, including skin-to-skin contact, breast-feeding, and bonding. Family support allows the new parents to focus on adaptation to their new roles. Social support is critical for family adaptation. Lack of support can lead to postpartum depression and attachment disorders (Gałęziowska et al., 2021).
Maternal Role Attainment Theory
Maternal Role Attainment Theory was developed by Ramona Mercer, whose nursing career focused on studying the process of becoming a mother (Husmillo, 2013). Maternal Role Attainment Theory suggests that early skin-to-skin contact, breast-feeding, and minimizing time apart promotes bonding, decreases maternal anxiety, and allows for maternal role attainment. The nurse can positively influence this role attainment by reassuring the parent, educating the family on early contact and breast-feeding, and decreasing the time the dyad is apart. The first hour after birth has been referred to as the “Golden Hour” because of its importance to the bonding experience for both the newborn and postpartum person.
Rubin’s “Taking-in” and “Taking-hold” Phases
Rita Rubin (1967) described psychologic phases that occur as the postpartum person adapts to the maternal role (Table 20.5). Two of the phases are discussed here. During the taking-in phase, 1 to 3 days after birth, the postpartum person is concerned with physical recovery, adapting to body changes, and caring for the newborn. The person is dependent on the nurse or partner for help physically. The person is focused on their labor and birth experience. The nurse encourages the person to talk and process their feelings.
In the taking-hold phase, 4 to 10 days after delivery, the postpartum person begins to initiate actions without relying on the nurse or partner. Focus turns to the newborn. The nurse takes this opportunity to demonstrate newborn care. The person is more confident in caring for the baby and more comfortable in the role but continues to seek support from family, who can provide guidance and understanding. The nurse provides positive reinforcement and encourages the person’s independence when caring for the newborn. Because patients are routinely discharged between 24 and 48 hours after birth, nurses may need to teach newborn care prior to the patient being ready.
| Postpartum Days | Phase | Characteristics |
|---|---|---|
| First 3 days | Taking-in phase |
|
| Days 4–10 | Taking-hold phase |
|
Maternal-Newborn Attachment Behavior
Newborns develop secure attachments when warm, responsive, and emotionally present behaviors are consistently provided by the parent or caretaker (Curran et al., 2021). Newborns who develop secure attachment later exhibit social skills to express emotions and communicate, and they have higher self-esteem and emotional intelligence (Curran et al., 2021). Maternal-newborn contact has been shown to improve physiologic and psychologic attachment; this can be fostered by immediate skin-to-skin contact after birth (Norholt, 2020). Skin-to-skin contact, shown in Figure 20.12, regulates the infant’s temperature, increases breast-feeding success, and decreases the stress of the newborn (Gomes et al., 2023). The nurse can aid in skin-to-skin contact after birth and throughout the facility stay. The nurse is aware that positive attachment behaviors are exhibited by the newborn and parent interacting, and making and holding eye contact, and by the parent soothing the newborn.
Initial Parent-Newborn Attachment Behavior
Initial touch increases emotional bonds between parents and newborns. Attachment behaviors can be seen as affection shown to the newborn and include touch, eye contact, kissing, and holding the newborn’s hand (Barker et al., 2017). Other attachment behaviors are soothing the newborn and being attentive to their needs. If the newborn is stable, the nurse gives the parents time to hold and talk to the baby prior to performing assessments or administering medications.
The nurse can assess initial attachment behaviors to screen for risk factors for attachment disorders. Attachment assessment begins when the nurse admits the pregnant person to the labor unit. Pregnant persons who avoid talking about the baby or who seem unhappy about their pregnancy are at high risk for attachment disorder. Persons with a history of psychosocial difficulties are also at higher risk (Gerlach et al., 2022). The nurse observes initial attachment behaviors and becomes concerned about persons who avoid skin-to-skin contact, eye contact, soothing or talking to the newborn, or cuddling. Persons with a history of depression, homelessness, sexual abuse, or poverty can exhibit fewer attachment behaviors.
Partner-Newborn Attachment
Support persons who are more involved during the prenatal, birth, and postpartum periods feel more attached to their newborn and report higher levels of self-esteem and self-worth (Lagarto & Duaso, 2022). The nurse can nurture the support person’s interactions by encouraging skin-to-skin contact, listening to and addressing their concerns, and providing gentle guidance on soothing and caring for the newborn, as shown in Figure 20.13. Research has shown that education on attachment skills during the prenatal period—at prenatal visits or childbirth education classes—can increase partner-newborn attachment (Dagla et al., 2023). Having family support to demonstrate newborn care is also helpful. Persons with positive parental role models are more inclined to demonstrate positive interactions with the newborn. The nurse compliments the support person on changing diapers or soothing the baby and assesses their comfort with handling the newborn and providing care. It is important for the support person to participate in the physical care of the newborn so that they feel they are contributing, are valued, or have some form of control of the situation (Lagarto & Duaso, 2022).
Lagarto & Duaso (2022) noted the partner’s mental health and relationship with the postpartum person had the largest impact on attachment with the newborn. This study also found that partners who were separated or divorced from the birthing parent had fewer interactions with the newborn, lacked understanding of their partner’s experience, and were more emotionally distant. The nurse encourages the parents to discuss how to share responsibilities and time with the newborn.
Attachment by Siblings, Extended Family, and Others
Extended families can provide emotional, physical, and social support to new parents, decreasing the incidence of postpartum depression. Family support allows the parents to rest, decreasing fatigue and stress. The nurse assesses if the parents have the family support they need. Siblings must also adapt to having a new family member. This adaptation is reliant upon the age of the sibling, preparation and education of the sibling regarding the new baby, and feelings of attachment and security of the sibling to the parents (American Academy of Pediatrics [AAP], 2021) (Figure 20.14.) The nurse helps the new parents brainstorm ways to help siblings adapt to the new baby. Some birthing facilities provide sibling classes to aid in attachment. The nurse will also explain how siblings and children will be able to meet the newborn within the facility.
Research suggests that the positive or negative role the family plays in the postpartum and newborn phase can prevent or trigger postpartum disorders (Rosa & Astuti, 2021). Persons with lack of family support have increased postpartum disorders. Positive support of the family—exhibited by providing love and support, bringing nutritious food, allowing adequate rest, and helping care for the baby—helps prevent postpartum disorders. The nurse is aware that persons living away from extended family or who do not have good relationships with family are at increased risk for postpartum depression.
Postpartum Psychosocial Concerns and Complications Affecting Parent-Newborn Attachment
Many psychosocial factors can influence the health of the postpartum patient. Postpartum depression, substance use, lack of support, poverty, and trauma are examples. The nurse assesses each postpartum person for potential psychosocial risk factors, including noting existing social supports and identifying persons at risk for complications. The nurse discusses financial problems, homelessness, safety in the home, and history of domestic violence (Gerlach et al., 2022). The nurse also asks about substance use in the home. A social work consultation can be requested to offer help and support to families struggling with any of these issues.
Legal and Ethical Issues
Homelessness and Postpartum
Homelessness is linked to higher rates of morbidity and mortality as well as poor mental health (Kelly et al., 2023). In turn, poor mental health is a contributing factor to homelessness. Stressors such as homelessness, food insecurity, and financial hardships are associated with an increased incidence of postpartum depression (Kelly et al., 2023). For persons who are socioeconomically challenged, many barriers exist for mental health services. Because these parents are focused on survival instead of bonding, the newborn will be affected by possible maladapted bonding. This can begin a cycle of stress and mental illness. How can our society address these issues and stop this cycle?
Psychosocial concerns affecting parent-infant attachment can be related to poverty, homelessness, discrimination, or substance use. Families without financial means or a place to live struggle with attachment due to the increased stress of their situation. The nurse understands that if the parent is focused on where to live and how to feed the family, newborn attachment is not the first priority. Postpartum persons who are survivors of domestic violence are at increased risk for attachment disorder. If persons are afraid of their partners, they will sometimes seek shelter and be in hiding and, therefore, lack family and social support (Gerlach et al., 2022). The nurse can assist the parent in finding shelter and assistance.
Other Patients and Partners at Risk for Disordered Attachment
Parents of a newborn in the NICU are also at risk for attachment problems. Parents are limited in the amount of care they can provide to a sick newborn, which leads to fear, stress, and feelings of insecurity. The equipment used in the NICU and attached to the baby can make parents feel overwhelmed and afraid to touch their newborn. Nurses in the NICU can foster bonding and attachment by recognizing the need for parental involvement, acknowledging their feelings, and encouraging parents to participate in appropriate newborn care.
Persons with substance use disorders (SUD) are at risk for impaired maternal-newborn attachment. Some persons with SUD had childhood experiences of violence and parental substance use. Their view of childhood caregivers is often contradictory and characterized by trauma (Punamäki et al., 2021). Many times, postpartum persons with SUD also have a history of social, legal, and economic struggles. Parents with a history of trauma or childhood abuse can have difficulty with infant attachment.