Maternal Psychological Adaptation PDF

Chapter 15 Maternal Psychological Adaptation: Reva Rubin's Three Phases 1\. taking-in phase is the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. This phase is characterized by dependent behavior....

Chapter 15 Maternal Psychological Adaptation: Reva Rubin's Three Phases 1\. taking-in phase is the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. This phase is characterized by dependent behavior. (typically lasts 1 to 2 days) 2\. taking-hold phase, the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks. she will be taking hold and becoming preoccupied with the present and demonstrating increased autonomy. She will be particularly concerned about her health, the infant's condition, and her ability to care for them. 3\. letting-go phase, the third phase of maternal adaptation, the woman reestablishes relationships with other people. She adapts to parenthood in her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence. The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one Postpartum Period The puerperium period begins after the delivery of the placenta and lasts approximately 6 weeks. It is frequently called the "fourth trimester." During this period, the woman's body begins to return to its prepregnant state, and these changes generally resolve by the 6th week Reproductive System Adaptations Uterine involution occurs through these 3 stages: 1.Contraction of muscle fibers to reduce those previously stretched during pregnancy 2.Catabolism, which shrinks enlarged individual myometrial cells 3\. Regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge The uterus weighs approximately 1,000 g (2.2 lb) soon after birth. Approximately 1 week after birth, the uterus shrinks in size by 50% and weighs about 500 g (1 lb); at the end of 6 weeks, it weighs approximately 60 g (2 oz). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis. multiple gestation, hydramnios, or a large singleton fetus, a full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing (frequent and repeated distention decreases tone and causes muscular relaxationto )-interfere with involution. Lochia is the vaginal discharge that occurs after birth and continues for approximately 4 to 8 weeks. It results from involution. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection, such as endometritis. Afterpains are more acute in multiparous and breast-feeding women. Primiparous women typically experience mild afterpains. Afterpains usually respond to oral analgesics. The cervix typically returns to its prepregnant state by week 6. The cervix gradually closes but never regains its prepregnant appearance. Immediately after childbirth, the cervix is shapeless and edematous and is easily distensible for several days Vagina: Shortly after birth, the vaginal mucosa is edematous, relaxed, and thin with few rugae. the mucosa thickens and rugae return in approximately 3 weeks. It returns to its approximate prepregnant size by 6 to 8 weeks postpartum but will always remain a bit larger perineum is often edematous and bruised for the first day or two after birth. If the birth involved an episiotomy or laceration, complete healing may take as long as 4 to 6 months. Women should do Kegels. Failure to maintain and restore perineal muscular tone can lead to urinary incontinence later in life for many women Cardiovascular System Adaptations Cardiac output remains high for the first few days postpartum and then gradually declines to nonpregnant values within 3 months of birth. Blood volume returns to normal within 4 weeks postpartum. (an average of 500 mL with a vaginal birth and 1,000 mL with a cesarean birth). The cardiac output decreases to pre-labor values 24 to 72 hours postpartum, rapidly falls over the next 2 weeks and normalizes within 6 to 8 weeks postpartum. Blood plasma volume is further reduced through diuresis, which occurs between days 2 and 5. Hematocrit level remains relatively stable and may even increase. Thus, an acute decrease in hematocrit is not an expected finding and may indicate hemorrhage. (It is not uncommon for women to have a temperature elevation up to 100.4°F in the first 24 hours postpartum due to mild dehydration. There may also be a slight decrease in blood pressure. The nurse should be most concerned about a blood pressure elevation because preeclampsia may occur during the early postpartum period.) There is a decrease in cardiac output for up to 2 weeks postpartum. So you might see bradycardia (40-60 bpm). Takes 3 months to normalize. Tachycardia (heart rate above 100 bpm) in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Blood pressure falls mostly in the first 2 days, then increases 3 to 7 days after childbirth, and returns to prepregnancy levels by 6 weeks Coagulation returns to normal by week 3. Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. these coagulation factors remain elevated for 2 to 3 weeks postpartum hemoglobin and hematocrit levels to decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3. Urinary System Adaptations During pregnancy, the glomerular filtration rate and renal plasma flow increase significantly. Both usually return to normal by 6 weeks after birth. Anesthesia, hematomas, oxytocin, decreased bladder tone can make women retain urine. Risk for UTI. Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Normal function returns within a month after birth Causes of Postpartum Diuresis Postpartum diuresis occurs as a result of several mechanisms: the large amounts of iv fluids given during labor; a decreasing antidiuretic effect of oxytocin; the buildup and retention of extra fluids during pregnancy; and a decreasing production of aldosterone, the hormone that decreases sodium retention and increases urine production. All of these factors contribute to rapid filling of the bladder within 12 hours of birth Gastrointestinal (GI) System Adaptations most women experience decreased bowel tone and sluggish bowels for several days after birth. Subsequently, constipation is a common problem during the postpartum period. A stool softener can be prescribed for this reason. Musculoskeletal System Adaptations Women commonly experience fatigue and activity intolerance and have a distorted body image for weeks after birth secondary to declining relaxin and progesterone levels, which cause hip and joint pain that interferes with ambulation and exercise. Good body mechanics and correct positioning are important during this time to prevent low back pain and injury to the joints. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal. Separation of the rectus abdominis muscles, called diastasis recti, is more common in women who have poor abdominal muscle tone before pregnancy. Integumentary System Adaptations As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples gradually fades. The most common period for hair loss is within 3 months after birth, when estrogen returns to normal levels and more hairs are allowed to fall out. This hair loss is temporary, and regrowth happens in 4 to 6 months and sometimes 15 months, though hair may be less abundant than before pregnancy. Striae gravidarum (stretch marks) that developed during pregnancy on the breasts, abdomen, and hips gradually fade to silvery lines. However, these lines do not disappear completely. profuse diaphoresis (sweating) that is common during the early postpartum period and is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. Respiratory and Endocrine System Adaptations Tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values, typically within 1 to 3 weeks of birth. remain within the normal adult range of 16 to 24 breaths per minute. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. Estrogen is at its lowest level a week after birth. For the woman who is not breast-feeding, estrogen levels begin to increase by 2 weeks after birth. For the breast-feeding woman, estrogen levels remain low until breast-feeding frequency decreases. hCG levels are nonexistent at the end of the first postpartum week, and hPL is undetectable within 1 day after birth. Progesterone levels are undetectable by 3 days after childbirth, and production is reestablished with the first menses. Prolactin levels decline within 2 weeks for the woman who is not breast-feeding, but remain elevated for the lactating woman Lactation Breast milk typically appears within 4 to 5 days after childbirth. (AAP) recommends exclusive breast-feeding for 6 months followed by the introduction of appropriate complementary foods and continued breast-feeding to 1 year and beyond. Each breast gains nearly 1 lb in weight by term. colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the glandular cells to secrete milk instead of colostrum. This takes place within 4 to 5 days after giving birth. A newborn moves on their mother's abdomen up to her breast instinctively. Researchers term this movement the breast crawl that helps initiate breast-feeding immediately after childbirth. The woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breast-feeding. Breast milk production can be summarized as follows: Prolactin levels increase at term with a decrease in estrogen and progesterone levels. Estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production. Oxytocin is released from the posterior pituitary gland to promote milk let-down. Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release Engorgement occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours. can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Frequent emptying of the breasts helps minimize discomfort and resolve engorgement Treatments to reduce the pain of breast engorgement include heat or cold applications, cabbage leaf compresses, breast massage and milk expression, ultrasound, breast pumping, and anti-inflammatory agents. A nonprescription anti-inflammatory medication can also be taken for the breast discomfort and swelling resulting from engorgement. Postpartum Mood Disorders Perinatal mood disorders are one of the most common complications to occur during the postpartum period, impairing maternal caregiving skills. can be divided into three distinct entities in ascending order of severity: "maternal (baby) blues," postpartum depression, and psychosis baby blues" or "maternal blues," which are characterized by mild depressive symptoms, anxiety, irritability, mood swings, loss of appetite, trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue. These symptoms typically peak on postpartum days 4 and 5, may last hours to days, and usually resolve by day 10. they typically do not affect the mother's ability to function and care for her child Variables Affecting Maternal Role Attainment Confidence, age, relationship with father, socioeconomic status, birth experience, stress, support system, personality traits, self-concept, child- rearing attitudes, role strain, health status, preparation during pregnancy, relationship with own mother, depression, and anxiety Infant: Appearance, responsiveness, temperament, health status Engrossment: Partner Psychological Adaptation partners also go through a predictable three-stage process during the first 3 weeks as they too "try on" their roles as parents. STAGE 1: EXPECTATIONS New partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Stage 2 (reality) occurs when partners realize that their expectations in stage 1 are not in line with reality. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. STAGE 3: TRANSITION TO MASTERY In stage 3 (transition to mastery), the partner makes a conscious decision to take control and be at the center of the newborn's life regardless of preparedness. similar to that of the mother's letting-go phase when she incorporates the newest member into the family. Engrossment is characterized by seven behaviors: Visual awareness of the newborn---the partner perceives the newborn as beautiful. Tactile awareness of the newborn---the partner has a desire to touch or hold the newborn and considers this activity pleasurable. Perception of the newborn as perfect---the partner does not "see" any imperfections. Strong attraction to the newborn---the partner focuses all their attention on the newborn when in the room. Awareness of distinct features of the newborn---the partner can distinguish the newborn from others in the nursery. Extreme elation---the partner feels a "high" after the birth of the child. Increased sense of self-esteem---the partner feels proud, "bigger," more mature, and older after the birth of the child Chapter 16 Bonding versus Attachment Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. optimal bonding requires a period of close contact within the first few minutes/hours. Bonding is a continuation of the relationship that began during pregnancy. During this initial period, the infant is in a quiet, alert state, looking directly at the person holding them. It is affected by a multitude of factors, including the parents' socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. Attachment is the development of strong affection between an infant and a significant other (mother, father, sibling, and caregiver). This attachment is reciprocal; both the significant other and the newborn exhibit attachment behaviors. follows a progressive or developmental course that changes over time. individualized and multifactorial process that differs based on the health of the infant, the mother, environmental circumstances, and the quality of care the infant receives. attachment behaviors include seeking; physical caregiving behaviors; emotional attentiveness to the infant's needs; staying close to, touching, kissing, cuddling, and choosing the en face position (face-to-face) while holding or feeding the newborn; expressing pride in the newborn; and exchanging gratifying experiences with the infant. In a high-risk pregnancy, the attachment process may be complicated by premature birth (lack of time to develop a relationship with the unborn baby) and by parental stress due to fetal and/or maternal vulnerability. Typical Assessments in Postpartum Period includes vital signs and physical and psychosocial assessments. It also includes assessing the parents and other family members, such as siblings and grandparents, for attachment and bonding with the newborn Factors Increasing a Woman's Risk for Postpartum Complications Risk Factors for Postpartum Infection: Operative procedure (forceps, cesarean birth, vacuum extraction), History of diabetes, including gestational-onset diabetes ,Prolonged labor (more than 24 hours), Use of indwelling urinary catheter, Anemia (hemoglobin \24 hours), Manual extraction of placenta, Compromised immune system (HIV-positive) Risk Factors for Postpartum Hemorrhage: Precipitous labor (less than 3 hours),Uterine atony, Placenta previa or abruptio placenta, Labor induction or augmentation, Operative procedures (vacuum extraction, forceps, cesarean birth), Retained placental fragments, Prolonged third stage of labor (more than 30 minutes), Multiparity, more than three births closely spaced, Uterine overdistention (large infant, twins, hydramnios) Postpartum Danger Signs Fever \>100.4°F (38°C), Foul-smelling lochia or an unexpected change in color or amount Large blood clots or bleeding that saturates a peripad in an hour, Severe headaches or blurred vision, Visual changes, such as blurred vision or spots, or headaches, Calf pain with dorsiflexion of the foot Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites Dysuria, burning, or incomplete emptying of the bladder, Shortness of breath or difficulty breathing without exertion, Depression or extreme mood swings Vital Signs Assessment During the first hour: every 15 minutes During the second hour: every 30 minutes During the first 24 hours: every 4 hours After 24 hours: every 8 hours Temperature: Some women experience a slight fever, up to 100.4°F (38°C), during the first 24 hours. may be the result of dehydration because of fluid loss during labor. Temperature should be normal after 24 hours. A temperature above 100.4°F (38°C) may indicate infection and must be reported. Pulse rates of 60 to 80 beats per minute (bpm) at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia. Any pulse rate higher than 100 bpm warrants further investigation Respiratory rates in the postpartum woman should be within the normal range of 12 to 20 breaths per minute at rest. Any change in respiratory rate out of the normal range might indicate pulmonary edema, atelectasis (a side effect of epidural anesthesia), or pulmonary embolism and must be reported. Lungs should be clear on auscultation Pain: Nursing care should focus on measures to ease pain which might include perineal care, a clean gown, mouth care, providing warm blankets, ensuring adequate fluid intake to facilitate healing, repositioning frequently, and encouraging rest between assessments. Many postpartum orders will have the nurse premedicate the woman routinely. if the woman has severe pain in the perineal region, check for a hematoma by inspecting and palpating the area. If one is found, notify the health care provider immediately Physical Assessment: Postpartum Period Breasts: Cracked, blistered, fissured, bruised, or bleeding nipples in the breast-feeding woman are generally indications that the baby is improperly positioned on the breast. For women who are not breast-feeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. not breast-feeding, the prolactin levels fall and return to normal levels within 2 to 3 weeks. Lactogenesis (the onset of milk secretion) is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone with the continued presence of prolactin Uterus: auscultate her bowel sounds prior to uterine palpation. If the client has had a cesarean birth and has a (PCA) pump, instruct her to self-medicate prior to fundal assessment. One to 2 hours after birth, the fundus is between the umbilicus and the symphysis pubis. 6 to 12 hours after birth, the fundus is at umbilicus. If the fundal height is higher (abnormal), investigate this immediately to prevent excessive bleeding. should be nonpalpable by 10 to 14 days postpartum Bladder; Considerable diuresis---as much as 3,000 mL/day---begins within 12 hours after childbirth and continues for several days. A single voiding may be 500 mL or more. By 21 days postpartum, the diuresis is usually complete. Postpartum urinary retention is defined as the inability to empty the bladder within 6 hours after a vaginal birth. continuous urinary catheterization is thought to delay fetal descent. After the woman voids, palpate and percuss the area again to determine adequate emptying of the bladder. Bowels; Spontaneous bowel movements may not occur for 1 to 3 days after giving birth. a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. Lochia; ask her how many perineal pads she has used in the past 1 to 2 hours and how much drainage was on each pad. A woman who saturates a perineal pad within 30 to 60 minutes is bleeding much more than one who saturates a pad in 2 hours. Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss Light or small: an approximately 4-in stain or a 10- to 25-mL loss Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is saturated within 1 hour after changing it Check under the woman by turning her to either side to make sure additional blood is not hidden and not absorbed on her perineal pad. This also a good time to assess for the presence and condition of hemorrhoids since the nurse is visually inspecting the perineum C-Section= less lochia Episiotomy; to assess the episiotomy and perineal area, position the woman on her side with her top leg flexed upward at the knee and drawn up toward her waist. If necessary, use a penlight to provide adequate lighting during the assessment. gently lift the upper buttock to expose the perineum and anus. Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas. Assess for hemorrhoids and their condition. normal episiotomy site should not have redness, discharge, or edema. The majority of healing takes place within the first 2 weeks, but it may take 4 to 6 months for the episiotomy to heal completely. Assess every 8 hours to detect hematomas or signs of infection. A white line running the length of the episiotomy is a sign of infection, as is swelling or discharge. Severe, intractable pain, perineal discoloration, and ecchymosis indicate a perineal hematoma, assessment of the epidural wound site is important as well as checking for any side effects of the medication injected such as itching, nausea and vomiting, or urinary retention. Extremities; determine the degree of sensory and motor function return (recovery from anesthesia) by asking the woman if she feels sensation at various areas the nurse touches and also by observing her ambulation stability. Emotional Status Assessment: Postpartum Period Assess the woman's emotional status by observing how she interacts with her family, her level of independence, energy levels, eye contact with her infant (within a cultural context), posture and comfort level while holding the newborn, and sleep and rest patterns. Be alert for mood swings, irritability, or crying episodes. Stages in the Transition to Parenthood Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions: Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior. Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and the parental role. Individualization: Parents are aware of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in a way, one of detachment Teaching Topics for Postpartum Period The breast-feeding mother's nutritional needs are higher than they were during pregnancy. instruct mothers to keep the door to the room closed when their infant is in the room with them. They should check the identification of anyone who enters their room or who wants to take the infant out of the room. This will prevent infant abduction. Adjust fluid intake to produce a 24-hourly urine output of 1,000 to 2,000 mL Use a sitz bath after every bowel movement to cleanse the rectal area and relieve enlarged hemorrhoids. Avoid tub baths for 4 to 6 weeks until joints and balance are restored to prevent falls. Wash your hands before changing perineal pads, after disposing of soiled pads, and after voiding. always patting gently from front to back and washing her hands thoroughly before and after perineal care. For hemorrhoids, have the client apply witch hazel-soaked pads, ice packs to relieve swelling, or hemorrhoidal cream or ointment if ordered. Nursing Management in Postpartum Period: Nursing Interventions If the woman had a vaginal delivery, she may be discharged within 24 to 48 hours or sooner. If she had a cesarean birth, she may remain hospitalized for up to 72 hours. Nurses need to focus on pain and discomfort, immunizations, nutrition, activity and exercise, infant care, lactation instruction, discharge teaching, sexuality and contraception, and follow-up with the limited time they have with their clients. Providing culturally diverse care within our global community is challenging for all nurses, because they must remember that one's culture cannot be easily summarized in a reference book but rather must be viewed through one's own life experiences Teaching about Breast Care wear a supportive, snug bra 24 hours a day throughout lactation period to support enlarged breasts and promote comfort. A woman who is not nursing should wear it until engorgement ceases and then should wear a less restrictive one. All new mothers should use plain water to clean their breasts, especially the nipple area; soap is drying and should be avoided. Daily assessment includes the milk supply (breasts will feel full as they are filling), the condition of the nipples (red, bruised, fissured, or bleeding), and the success of breast-feeding. palpating both breasts will help identify whether the breasts are soft, filling, or engorged. Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts. Breast engorgement usually occurs during the first week postpartum. usually resolves within 72 hours. encourage frequent feedings at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. allow the newborn to feed on the first breast until it softens before switching to the other side (SUPRESSING LACTATION): Wear a supportive, snugly fitting bra 24 hours daily, but not one that binds the breasts too tightly or interferes with breathing. Suppression may take 5 to 7 days to accomplish. Take mild analgesics to reduce breast discomfort. Let shower water flow over your back rather than your breasts. Avoid any breast stimulation in the form of sucking or massage. Drink to quench your thirst. Restricting your fluid intake will not dry up your milk. Reduce your salt intake to decrease fluid retention. Use ice packs or cool compresses inside the bra to decrease local pain and swelling; change them every 30 minutes. Promoting Parental Roles Provide as many opportunities as possible for parents to interact with their newborn. Encourage parents to explore, hold, and provide care for their newborn. Praise them for their efforts. Model behaviors by holding the newborn close, calling the newborn's name, and speaking positively. Speak directly to the newborn in a calm voice while pointing out the newborn's positive features to the parents. Evaluate the family's strengths, weaknesses, and readiness for parenting. Assess for risk factors such as lack of social support and the presence of stressors. Observe the effect of culture on the family interaction to determine healthy family dynamics. Monitor parental attachment behaviors to determine whether alterations require referral. Positive behaviors include holding the newborn closely or in an en face position, talking to or admiring the newborn, or demonstrating closeness. Negative behaviors include avoiding contact with the newborn, calling them names, or showing a lack of interest in caring for them. Monitor the parents' coping behaviors to determine alterations that need intervention For the siblings of the baby; Expect and tolerate some regression (thumb sucking, bedwetting). Explain childbirth in an appropriate way for the child's age. Encourage discussion about the new infant during relaxed family times. Encourage the sibling(s) to participate in decisions, such as the baby's name and toys to buy. Take the sibling on a tour of the maternity suite. Buy a T-shirt that says "I'm the big (brother or sister)." Spend "special time" with the child. Move the sibling from their crib to a youth bed months in advance of the birth of the newborn. Show the older sibling photos of the baby growing. Let them pat the baby beneath the bulge, talk to the baby, and feel the baby kick. Make the older sibling feel important by giving them the title, "mommy's helper." Encourage grandparents to pay attention to the older child when visiting. Tell the older sibling that their friends come and go, but siblings are forever. Encourage "Do unto others as you would have them do unto you" ( Challenges Facing Families after Discharge Lack of role models for breast-feeding and infant care. Lack of support from the new mother's own mother if she did not breast-feed. Increased mobility of society, which means that extended family may live far away and cannot help care for the newborn and support the new family. Nonsupportive, overwhelmed, and fatigued partner. Feelings of isolation and limited community ties for women who work full-time. Shortened hospital stays; parents may be overwhelmed by all the information they are given in the brief hospital stay. Prenatal classes usually focus on the birth itself rather than on skills needed to care for themselves and the newborn during the postpartum period. Limited access to education and support systems for families from diverse cultures.