OVERVIEW OF POST PARTAL CARE TO DISCHARGE

PLANNING:
 The postpartal period, or puerperium (from the Latin puer, for “child,” and parere, for “to
bring forth”), refers to the 6-week period after childbirth.
 It is a time of maternal changes that are both retrogressive (involution of the uterus and
vagina) and progressive (production of milk for lactation, restoration of the normal
menstrual cycle, and beginning of a parenting role).
 Protecting a woman’s health as these changes occur is important for preserving her future
childbearing function and for ensuring that she is physically well enough to incorporate her
new child into her family.
 The period is popularly termed the fourth trimester of pregnancy.
 The physical care a woman receives during the postpartal period can influence her health
for the rest of her life.
 The emotional support she receives can influence the emotional health of her child and
family so much that it can be felt into the next generation (McGarry et al., 2009).

PSYCOLOGICAL CHANGES OF THE POSTPARTAL PERIOD

A transition is a movement or passage from one position or concept to another or a pause
between what was and what is to be. It represents the internal process experienced by people when
change occurs. In a classic presentation of what transition entails, Bridges (1994) stated that
change is something that happens to people, and transition is how they respond to that change.
People move through several predictable stages during transition: first is the act of ending
old ways of thinking or believing (letting go); next, there is a neutral zone, during which the old
way is gone but the new way is not yet comfortable; and finally, there is a new beginning, during
which new ideas and concepts are put into action (Bridges, 1994). The postpartum period is a time
of transition, during which a couple gives up concepts such as “childless” or “parents of one” and
moves to the beginning of new parenthood.

Phases of the Puerperium

In her classic work on maternal behavior, Reva Rubin, a nurse, divided the puerperium into
three separate phases (Rubin, 1977). She viewed the first of these as a taking-in phase, or a time
when the new parents review their pregnancy and the labor and birth. The subsequent phases,
called the taking-hold phase and the letting-go phase, are times of renewed action and forward
movement. At the time these phases of the puerperium were identified, women were hospitalized
for 5 to 7 days after childbirth and moved in a paced manner from one step to the next. Today,
with hospitalization as short as a few hours, women appear to move through these phases much
more quickly and may even be experiencing two different phases at once.

Taking-In Phase
 The taking-in phase, the first phase experienced, is a time of reflection. During this 2- to 3-
day period, a woman is largely passive. She prefers having a nurse minister to her (such as bringing
her a bath towel or a clean nightgown) and make decisions for her, rather than do these things
herself. This dependence results partly from her physical discomfort because of afterpains or
hemorrhoids; partly from her uncertainty in caring for her newborn; and partly from the extreme
exhaustion that follows childbirth. As a part of thinking and pondering about her new role, the
woman usually wants to talk about her pregnancy, especially about her labor and birth. She holds
her new child with a sense of wonder and asks: Is birth really over? Could this child really have
been inside me? Could I be this lucky? During the taking-in phase, she rests to regain her physical
strength and to calm and contain her swirling thoughts. Encouraging her to talk about the birth
helps her integrate it into her life experiences.

Taking-Hold Phase
After a time of passive dependence, a woman begins to initiate action. She prefers to get
her own washcloth and to make her own decisions. Women who give birth without any anesthesia
may reach this second phase in a matter of hours after birth. During the taking-in period, a woman
may have expressed little interest in caring for her child. Now, she begins to take a strong interest.
As a rule, therefore, it is always best to give a woman brief demonstrations of baby care and then
allow her to care for her child herself—with watchful guidance. Although a woman’s actions
suggest strong independence during this time, she often still feels insecure about her ability to care
for her new child. She needs praise to give her confidence. This positive reinforcement begins in
the health care facility and continues after discharge, at home, and at postpartum and well-baby
visits. Do not rush a woman through the phase of taking-in or prevent her from taking hold when
she reaches this point. For many young mothers, learning to make decisions about their child’s
welfare is one of the most difficult phases of motherhood. It helps if a woman has practice in
making such decisions in a sheltered setting rather than taking responsibility alone.

Letting-Go Phase
In the third phase, called letting-go, a woman finally redefines her new role. She gives up
the fantasized image of her child and accepts the real one; she gives up her old role of being
childless or the mother of only one or two (or however many children she had before this birth).
This process requires some grief work and readjustment of relationships, similar to what occurred
during pregnancy. It is extended and continues during the child’s growing years. A woman who
has reached this phase is well into her new role.

Development of Parental Love and Positive Family Relationships

During pregnancy, almost every woman worries about her ability to be a “good” mother,
and this concern does not evaporate as soon as the baby is born. Some women seem able to
recognize a newborn’s needs immediately and to give care with confident understanding right from
the start. More often, however, a woman enters into a relationship with her newborn tentatively
and with qualms and conflicts that must be addressed before the relationship can be meaningful.
This is because parental love is only partly instinctive and a major portion develops gradually.
Factors such as a difficult labor or transport and separation from the newborn may lead to
symptoms of a traumatic stress disorder that slows the process or interferes with the ability to bond
warmly (Tam & Chung, 2007).
Many women may not experience maternal feelings for their infants until days or even
weeks after giving birth. Some fathers admit they have difficulty “claiming” or bonding with an
infant (feeling fatherly toward the new child) until as late as 3 months after the birth, when the
child begins to smile or coo and interact more directly with them. The ability of both parents to
reach out to their child can be strengthened by allowing them to touch and spend as much time as
possible with the new child during the first few hours of life.
Forming a strong bond with a child is not a problem only for first-time parents. Experienced
parents can have just as much difficulty because they worry that their hearts may not be big enough
to love that child, too. Because of these mixed feelings, parents may not show genuine warmth the
first time they hold their infant. Although a woman carried the child inside her for 9 months, she
now approaches her newborn as she would a stranger.
Gradually, as a woman holds her child more, she begins to express more warmth, touching
the child. This identification process is termed claiming or bonding. Looking directly at her
newborn’s face, with direct eye contact (termed an en face position), is a sign a woman is beginning
effective interaction. Many fathers can be observed staring at a newborn for long intervals in this
same way. Often termed engrossment, this action alerts caregivers to how actively the father, as
well as the mother, is beginning bonding. The length of time parents take to bond with a child
depends on the circumstances of the pregnancy and birth, the wellness and ability of the child to
meet the parent’s expectations, reciprocal actions by the newborn, and the opportunities the parents
have to interact with the child. Freedom from stringent health agency rules helps good parent–
child relationships to develop. To help parents sort out their feelings about being a mother or father
and about their new responsibility, provide a supportive presence and offer anticipatory guidance
as necessary.

Rooming-In
The more time a woman has to spend with her baby, the sooner she may feel competent in
child care, and the more likely she may be to form a sound mother–child relationship (Moore,
Anderson, & Bergman, 2009). If her infant stays in the birthing room with her (called rooming-in)
rather than in a central nursery, she can become better acquainted with her child and begin to feel
more confident in her ability to care for him or her after discharge (Fink, 2007). In many settings,
the father can stay overnight in the room, or room-in, as well. There are two types of rooming-in:
complete, in which the mother and child are together 24 hours a day, and partial, in which the
infant remains in the woman’s room for most of the time, perhaps from 8:00 AM to 9:00 PM, but
then the infant is taken to a small nursery near the woman’s room or returned to a central nursery
for the night. With both complete and partial rooming-in, the father and siblings can hold and feed
the infant when they visit.
Sibling Visitation
Separation from children is often as painful for a mother as it is for her children. Waiting
at home, separated from their mother and listening only to telephone reports of what a new brother
or sister looks like, can be very difficult for older children. They may picture the new baby as much
older than he or she actually is. “He is eating well” may produce an image of a child sitting at a
table using a fork and spoon. “He weighs 8 pounds” can be meaningless information. A chance to
visit the hospital and see the new baby and their mother reduces feelings that their mother cares
more about the new baby than about them. It can help to relieve some of the impact of separation.
It helps to make the baby a part of the family. Assess to be sure that siblings are free of contagious
diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit.
Then, have them wash their hands and, if they choose, hold or touch the newborn with parental
assistance. You may need to caution a woman that the opinions of a new brother or sister expressed
by her older children may not be complimentary. This baby with little hair is not their idea of a
“pretty baby.” If they thought the new baby would be big enough to play with, they may not believe
that he is a “big baby.” However, seeing the baby, even if the baby’s appearance is not what the
other children expected, is helpful in establishing strong relationships and should be encouraged.

Maternal Concerns and Feelings in the Postpartal Period

Traditionally, it is assumed that the bulk of a woman’s concerns in the postpartal period
center on the care of her new infant. Based on this, classes in the postpartal period have
traditionally focused on teaching how to breastfeed and bathe infants. Although these acts are
concerns for many mothers, they are not necessarily every new mother’s chief concern. A woman
has come through a tremendous psychological experience during pregnancy and the birth of a
child. She is in the middle of a complete role change. It can be expected, therefore, that some of
her attention and interest during this time will be directed inward as she tries to view herself in this
new role. Typical issues identified by postpartal women include breast soreness; regaining their
figure; regulating the demands of housework, their partner, and their children; coping with
emotional tension and sibling jealousy; and fatigue.

Abandonment
Many mothers, if given the opportunity, admit to feeling abandoned and less important
after giving birth than they did during pregnancy or labor. Only hours before, they were the center
of attention, with everyone asking about their health and well-being. Now, suddenly, the baby
seems to be everyone’s chief interest. Relatives ask about the baby; the gifts are all for the baby.
Even a woman’s obstetrician, who has made her feel so important for the last 9 months, may ask
during a visit, “How’s that healthy 8-pound boy?” It can make a woman feel confused by a
sensation very close to jealousy. And how can a good mother be jealous of her own baby? You
can help a woman move past these feelings by verbalizing the problem: “How things have
changed! Everyone’s asking about the baby today and not about you, aren’t they? How does that
make you feel?” These are welcome words for a woman to hear. It is reassuring to know that the
sensation she is experiencing, although uncomfortable, is normal. When a newborn comes home,
a father may express much the same feelings. He may become resentful of the time the mother
spends with the infant. Perhaps the two used to sit at the table after dinner and discuss their day or
the future, and now she hurries away to feed the baby.

Disappointment
Another common feeling parents may experience is disappointment in the baby. All during
pregnancy, they pictured a chubby-cheeked, curly-haired, smiling girl or boy. They have instead a
skinny baby, without any hair, who seems to cry constantly. It can be difficult for parents to feel
positive immediately about a child who does not meet their expectations in this way. It can cause
parents to remember their adolescence, when they felt gangly and unattractive, or to experience
feelings of inadequacy all over again. You can never change the sex, size, or look of a child, but
in the short time you care for a postpartal family, you can help to change the feelings of a mother
or father about their infant. Handle the child warmly, to show that you find the infant satisfactory
or even special. Comment on the child’s good points, such as long fingers, lovely eyes, and good
appetite. During periods of crisis such as childbearing, it is possible for a key person such as a
nurse to offer support to tip a scale toward acceptance or at least help a person involved to take a
clearer look at his or her situation and begin to cope with the new circumstances.

Postpartal Blues
During the postpartal period, as many as 50% of women experience some feelings of
overwhelming sadness (Buultjens & Liamputtong, 2007). They may burst into tears easily or feel
let down or irritable. This temporary feeling after birth has long been known as the “baby blues.”
This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and
progesterone that occurs with delivery of the placenta. For some women, it may be a response to
dependence and low self-esteem caused by exhaustion, being away from home, physical
discomfort, and the tension engendered by assuming a new role, especially if a woman is not
receiving support from her partner. The syndrome is evidenced by tearfulness, feelings of
inadequacy, mood lability, anorexia, and sleep disturbance. Anticipatory guidance and
individualized support from health care personnel are important to help the parents understand that
this response is normal. You can assure a woman that sudden crying episodes may occur;
otherwise, she may have difficulty understanding what is happening to her.