First-time parents: acquisition of parenting skills

Abstract

Objective

Discover the parents’ nursing care needs after the birth of their first healthy child during the first 48 hours after normal delivery.

Methods

Qualitative and exploratory study in which 26 parents participated (13 fathers and 13 mothers). As a data collection strategy, semistructured interviews were used. Content analysis was applied to the answers, following Bardin’s premises.

Results

The parental figures identified care needs related to breastfeeding, the infant’s bath, the umbilical stump and cramps.

Conclusion

Mothers and fathers expect interventions from the nurses that allow them to feel capable of taking care of their infants safe and self-confidently.

Postpartum period; Nursing care; Breastfeeding; Infant, newborn

Resumo

Objetivo

Conhecer as necessidades dos pais, relativas aos cuidados de enfermagem, após o nascimento do primeiro filho saudável, nas primeiras 48 horas pós-parto eutócico.

Métodos

Estudo qualitativo exploratório, no qual participaram 26 progenitores (treze pais e treze mães). Como estratégia de colheita de dados recorreu-se à entrevista semiestruturada. As respostas foram alvo de análise de conteúdo, segundo os pressupostos de Bardin.

Resultados

As figuras parentais identificaram necessidades de cuidados relacionadas com a amamentação, o banho do recém-nascido, o coto umbilical e as cólicas.

Conclusão

Mães e pais esperam dos enfermeiros intervenções que lhes permitam sentir-se capazes de cuidar dos seus recém-nascidos com segurança e autoconfiança.

Período pós-parto; Cuidados de enfermagem; Aleitamento Materno; Recém-nascido

Resumen

Objetivo

Conocer las necesidades de los padres, en cuanto a los cuidados de enfermería después del nacimiento del primer hijo sano, en las primeras 48 horas después del parto eutócico.

Métodos

estudio exploratorio cualitativo, el cual involucró a 26 progenitores (13 padres y 13 madres). Como estrategia de recolección de datos se recurrió a la entrevista semiestructurada. Las respuestas fueron objeto de análisis de contenido, según los principios de Bardin.

Resultados

La figura de los padres identificó las necesidades de atención relacionados con la lactancia materna, el baño del bebé, el cordón umbilical y cólicos.

Conclusión

Las madres y los padres esperan de los enfermeros intervenciones que les permitan sentirse capaces de cuidar a sus recién nacidos con seguridad y confianza.

Periodo posparto; Atención de enfermería; Lactancia materna; Recién nacido

Introduction

The discovery of the care needs and the identification of the skills that couples intend to acquire in order to develop autonomy for newborn care when they return home are a priority in the context of the transition to parenthood.

The parents usually consider postpartum care as inferior in quality compared to the care received in the prenatal and intrapartum periods.⁽¹⁾ In addition, specialist nurses also classify the care they provide at a below-desired level. The reasons they appoint are: the reduction of hospitalization time, which results in a minimum amount of time to provide specialized care and the hospital environment, with countless tasks to perform. These professionals believe that changes are needed and that routine interventions do not translate into safe care. They also add that identifying and responding to individual needs are beneficial operational models that promote the quality of care and the parents’ rest.⁽¹⁾ It has also been found that lack of time, inappropriate space and lack of support mechanisms are the factors with the strongest negative impact on care provision during this transition period.⁽²⁾

To overcome the difficulties presented, some authors propose education and specific training, through which nurses specialized in maternal and obstetric health develop the skills to design and execute care programs that promote proper support and individualized care, focused on the needs of postpartum women.⁽³⁾

Another factor of discontent is the welcoming of the father figures, who expose their displeasure by feeling often neglected and treated as mere visitors, in hospital services with environments that do not promote the involvement and support they need to respond to the fathers’ needs. Nowadays, these fathers intend to participate in the care for their children and their partner.⁽⁴⁾ The evidence tells us that the father’s presence, night and day, throughout the hospitalization period, promotes the postpartum women’s feeling supported. In this sense, the father intends to be involved as much as possible in this new dynamic.⁽⁵⁾

In relation to the Portuguese context and specifically to the experience of these first hours postpartum, fathers and mothers express it in an unequal way. The maternal figures emphasize the physical fatigue and a psychological state that varies between joy and sadness. From the nurses, they expect attention, accompaniment and orientation. As for the father figures, they see their role as accessory, in a scenario in which mothers and newborns play the central roles and intend the nurses to be able to engage them more actively in this process.⁽⁴⁾

The literature shows that, although the fathers, mothers and nurses have a similar view of postnatal care, the changes seem to be difficult to implement in the reality of daily health care management, influencing the women’s daily lives and their relationships with family and friends, as well as their parenting skills.

In this sense, the practice of nursing care, in the context of the short period of postpartum hospitalization, should prioritize aspects such as a calm environment in the ward, which promotes rest, and also value individualized interventions specifically adapted to the parents’ needs, rather than the provision of standardized and universal care.

In view of the above, both parental figures and specialist nurses classify postpartum care as below-desired. Thus, this research is justified to find strategies that respond to the demands of both, in order to adapt and optimize the care provided, contributing to increase knowledge, promote improvements in the quality of care and, ultimately, achieve health gains.

The purpose of this study was to discover the parents’ nursing care needs after the birth of their first healthy child during the first 48 hours after normal delivery.

Methods

The paradigm underlying the research that underpins this study is classified, as regards the approach, as qualitative. The qualitative paradigm helps to understand individual perceptions of the world and can be defined as an open set of logically related assertions, concepts or propositions that guide thinking and inquiry.⁽⁶⁾

The study object is focused on the parents’ nursing care needs after the birth of their first healthy child, during the first 48 hours after normal delivery.

The semistructured interview was the technique selected for this research, because of its flexible nature, being neither fully open nor guided by a large number of precise questions.⁽⁷⁾

Participants’ ages range between twenty and forty. Regarding education, this varies between the 9th year and an undergraduate degree. Finally, as far as marital status is concerned, nine couples are married and the others live together but are single. They complied with the following inclusion criteria: postpartum women after normal delivery, a healthy newborn, parents living with the newborn and Portuguese. Exclusion criteria were: postpartum women with a newborn at risk and with an associated condition, who refused to participate in the study, whose newborn was preterm and/or was hospitalized in the intensive care unit.

Upon discharge, these fathers and mothers, who received nursing care during hospitalization after normal delivery at the obstetrical service in a central hospital in Porto, granted authorization for data collection at their homes until the first fifteen days of the newborn’s life.

Thirteen semistructured interviews were held, which took approximately two hours and addressed three fundamental questions: “Tell me about your experience during hospitalization after childbirth”, “What are your nursing care needs during postpartum hospitalization?”, “Given your nursing care needs, how do you envisage the nurse’s role during postpartum hospitalization?” The participants validated each of the interviews after viewing the transcript, about one week after they took place.

In total, there were 26 participants, that is, thirteen postpartum women and the respective fathers of the newborns. The number of interviews was delimited when the data became saturated, that is, when the answers to the fundamental questions became redundant.

The answers to the interviews were analyzed, considering the assumptions of Bardin, who organizes, synthesizes and transforms the data into manageable units, resulting from the search for patterns. During this coding process, the interview transcripts were numbered, using the following symbols - I, followed by the interview identification number: I1; I2, I3 ... The category that resulted from this analysis process was: acquisition of parenting skills, from which the following subcategories emerged: difficulties with regard to breastfeeding, hygiene care for the newborn, care for the umbilical stump and difficulties in dealing with the newborn’s cramps.

In this study, the ethical and legal principles were considered. The interviewees particularly received information about the objectives and purpose of the study, and also about the guaranteed anonymity, informed consent, confidentiality and data protection. Thus, in all phases of the study, all the assumptions required by the hospital’s teaching, training and research department were guaranteed, whose Ethics Committee evaluated and approved the project under reference 027/11 (015-DEFI/027- CES).

Results

The results of the interviews permitted identifying the dimension care needs, which comprises the following category: acquisition of parenting skills. The respondents recognized and described them as essential, during the study period, in the transition process to parenthood, being fundamentally associated with breastfeeding and newborn care. The following subcategories emerged from this category: difficulties with regard to breastfeeding, hygiene care for the newborn, care for the umbilical stump, and difficulties in dealing with colic of the newborn.

In the testimonies, this need for skills related to breastfeeding can be clearly identified, which the postpartum women translated as follows:

(...) the baby was unable to latch on and then became very irritated by this and only cried (... ) (I1); The main reason I needed help was with breastfeeding (...) (I3); The biggest difficulty and doubts I had were more based on breastfeeding. (I4); Usually, when I called for the nurses, it was because of him sucking (...) (I5); I needed support to put the baby at the breast and the breast in the baby, there, those practical adjustments (I6); The biggest difficulty I had was to help the baby latch on correctly (...) (I7); I needed help to breastfeed, which is quite complicated. (I8); The most common doubts were regarding breastfeeding (...) (I9); The trickiest part was figuring out how to breastfeed, because at first he would not take it and I did not know what to do (I10); My main difficulty was breastfeeding (...) we were very focused on the difficulties of breastfeeding (...) (I11); I had doubts about practical aspects of breastfeeding (I12); At first I had a lot of difficulties because of the breastfeeding. (I13).

The hygiene care for the newborn was another aspect the interviewees considered to be important to gain skills in postpartum care, as shown in the following testimonies:

(...) but the bath that is given there is totally different than what is given here at home, here it’s is a towel with a jug of water (...) the baby is put there, he punches and shoots at the water, covers himself and that’s it (...) (I1); (...) the bath is not the same as what we give at home, it is a simpler bath, it is not with a bathtub, it is with compresses, it is a drier thing and at home it is not like that ... (I4); The bath is a little bit, I mean, that’s not even a bath, it is not! That’s like a rub! I think the first bath should be an actual bath and not a head rub (I7); I’m honest, at first I thought I was going to be a bath in a bathtub, I wish it had been. (I8); The part of the bath in the bathtub they did not explain and it is necessary (...) maybe, better teaching of this part is lacking... (I9); (...) the baby’s bath is not very explicit, it is dry and at home we have difficulties to adapt to the bathtub. (I11); But at home I did not choose the same way, there it’s with compresses and water and here I give an actual bath, but the way I start and the principles I do in the same way, but the rest is a bit different. (I12); I cannot bathe the baby so well, because here at home I give it in the bathtub and that, unfortunately, they did not teach. (I13).

Regarding care for the umbilical stump, three of the parents interviewed reported some degree of difficulty to perform this, as verified when they say that:

(...) I was afraid of doing harm because of the cord, that makes quite an impression and I needed them to reinforce what they had already taught (...) (I2); (...) what got me a lot more confused was the navel, because the cleaning was done very quickly and, although they explained, I felt some difficulty to handle it at home. (I8); They explained how to take care of the baby’s umbilical cord, how we had to disinfect, but they do it so quickly that, sometimes, you can’t see it well. (I10).

The other parents did not mention anything about care for the umbilical stump.

Another nursing care need the parents identified regarding skills acquisition was related to the crying associated with the presence of cramps in the newborn. Although addressed in several investigations, in practice, it remains a problem that is sometimes difficult to solve. The parents themselves stated that they felt the need to turn to the nurses to help and relieve the associated symptoms, as the following reports reveal:

(...) I had to ask for help because my daughter had cramps and cried a lot with pain and I did not know what to do (...) (I7); Sometimes I would call the nurse because of the cramps the baby had, to help me relieve her discomfort. (I9); Sometimes, I called the nurses because I was in doubts if the baby cried because of cramps and to help me massage for the baby to feel more comfortable (...) (I12); The baby wouldn’t stop crying (...) after they helped her to poo she felt more relieved and I noticed it was just cramps. (I13).

Discussion

The limitations of this study include the lack of knowledge about the level of preparation for parenting, planned/desired pregnancy, family contexts, parents’ expectations regarding parenting and the provision of nursing care. The different aspects these factors can assume can influence the way in which the parenting is experienced and entail consequences for the care needs the parents in this study reported.

Based on the results found, there are various conditioning factors in the postpartum transition experience to parenthood and nurses are an important resource in mobilizing and optimizing those factors. Nevertheless, the core role of these health team members should be based not only on technical competencies, but also on the development of strategies that clearly identify the parents’ needs, so that the interventions outlined promote the transition to parenting.

The postpartum as a stage loaded with transformations and adaptations to the new parental role demands, as we can perceive from the available reports, that the parents develop skills and acquire the behaviors necessary to cope with the new challenges.

Breastfeeding is one of those challenges, which lacks a set of theoretical and practical knowledge and, in the transition process to parenthood, it can be considered as a critical event that can be overcome through well-organized and planned interventions.⁽⁸⁾ To achieve this objective, it is essential that health professionals are knowledgeable on the determining factors of successful breastfeeding.⁽⁹⁾

Breastfeeding was traditionally the normal standard of behavior but, nowadays, different lifestyles are found, with artificial feeding models and habits. This lack of sociocultural memory about breastfeeding favors the insecurity of postpartum women as to their skills and the need for practical information about breastfeeding. Therefore, society itself should change its attitude, starting to consider breastfeeding as normal. This also means that family policy strategies should promote and support breastfeeding.⁽¹⁰⁾

The decision to breastfeed is a personal decision, but is subject to influences resulting from the socialization of each woman, from family and professional support.⁽⁹⁾ If a woman grew up in a breastfeeding environment, that is, if breastfeeding was practiced naturally, if she was breastfed, if she witnessed other women breastfeeding their babies and joins positive experiences related to breastfeeding, those experiences will probably influence her decision.

The analysis of the interviews revealed that all the couples interviewed wanted their children to be breastfed. It became clear though that breastfeeding was one of the most valued nursing care needs and that most often aroused doubts, mainly concerning the practical part of the technique.

The strategies the health professionals need to develop should mainly promote self-confidence in the women/couples’ capacity to breastfeed and to overcome difficulties, through information based on practical aspects related to the technique. These interventions are supported by studies that demonstrate that information on the benefits of breastfeeding and support are useful, especially in first-time mothers. In addition, their effectiveness increases if the breastfeeding technique is addressed together with the promotion of women’s confidence in their ability to breastfeed and their individual needs.⁽¹¹⁾

These breastfeeding promotion practices entail economic repercussions, with the potential to reduce the rate of admissions and rehospitalization in health facilities⁽⁹⁾ and should be ensured beyond the postpartum hospitalization period, aiming to reduce the early weaning rate.⁽¹²⁾

It is essential to remember that breastfeeding is a major public health issue because of its irreplaceable contribution to health promotion and disease prevention. It is universally established that nurses play a fundamental and unique role in the adherence to and maintenance of breastfeeding.

The institution where this study was conducted is certified as a Baby Friendly Hospital. That is, it supports, protects and promotes breastfeeding, as advocated by the World Health Organization, in association with the United Nations Children’s Fund (UNICEF), training professionals with specific skills in this area and who comply with the ten measures, ensuring that mothers and infants can receive proper support and up-to-date information for the sake of successful breastfeeding.

Regarding the hygiene care for the newborn, it is evidence-based knowledge that the importance of the maintenance and the integrity of the infant’s skin lies beyond doubt. This works as the first protective barrier and the optimization of its functions depends on the care it receives, which includes the bath.⁽¹³⁾

The parents prefer the immersion bath and the researchers support this modality as the first option, as it causes fewer hemodynamic variations, adding that the use of products should be minimized whenever possible due to the risk of percutaneous absorption.⁽¹⁴⁾

It is important to consider that the transition of the infant’s skin from intrauterine to extrauterine life is gradual, it does not happen immediately or drastically, as is the case for example with the respiratory system. The role of the vernix seems to be quite significant, exerting a protective function of the outer layer of the skin, minimizing the risk of infection, aiding in thermoregulation and maintaining pH and hydration, so its removal is discouraged.⁽¹⁵⁾

For the study participants, the absence of an immersion bath caused some displeasure. In this institution, due to the inexistence of bathtubs, this procedure is carried out partially, that is, hygiene care is provided to the infant on a rigid surface, where the newborn is undressed as the skin is cleansed with compresses moistened with water.

This approach does not seem to agree with expectations and parental needs, as parents express their dismay because they did not get the opportunity to observe the bath in the bathtub, which results in difficulties to adapt to the reality existing in the home context.

Therefore, it is recommended that this procedure corresponds to the recommendations of the most recent scientific evidence, to the expectations and needs of the target population of the care and to the home contexts after the discharge.

Regarding umbilical stump care, the institutional procedure once again does not follow the scientific evidence, as the protocol recommends the use of 70% alcohol.

It is known that merely washing and drying the umbilical stump, a process often referred to as dry care, is associated with the early fall of the umbilical stump and that the routine application of topical products in this area is discouraged due to the risk of absorption.⁽¹⁶⁾

Recently, a new study was published in France, which supported the above mentioned data, concluding that the cleaning of the umbilical stump with soap and water, followed by drying, does not have inferior results in the prevention of omphalitis in term newborns in developed countries when compared to the use of antiseptic agents.⁽¹⁷⁾ Other authors add that the application of antimicrobial agents may lead to bacterial colonization by more virulent strains.⁽¹⁸⁾

Although international recommendations are clear about the most appropriate care, many practitioners implement and recommend unequal practices, making any attempt to standardize nursing care with an impact on the health of newborns inconsistent.⁽¹⁹⁾

Thus, care for the umbilical stump remains relevant in the current context, being closely related to the infections acquired during the postpartum period. Although omphalitis is closely related to neonatal morbidity and mortality, this occurrence is currently rare in developed countries but should be prevented with all possible resources.

Based on the discourse analyzed, umbilical stump care should be approached more consistently and parents should get the the opportunity to train the cleaning technique and develop the skills necessary to monitor the mummification process, as the prevention and rapid diagnosis of infections depend on these skills. Moreover, in the international literature, there are authors who suggest the creation of institutional protocols, in order to standardize procedures.⁽¹⁹⁾

Regarding cramps, their etiology remains unknown and, consequently, there is no consensus about the treatment methods.^(9,20,21) This limitation of knowledge makes it impossible to develop guidelines and therefore, researchers do not advocate universal diagnoses or treatments, but rather the creation of decision algorithms capable of assisting in the identification of the diagnosis and, consequently, the choice of the most effective treatment through stepwise decision making.⁽²²⁾

It is known that “the prevalence of childhood cramps varies from 8% to 40% of live births, the highest percentage being due to the introduction of artificial milk and foods”.⁽²³⁾

The main sign of cramps is crying, and a measuring tool - Infant Colic Scale was developed, through which parents fill out a daily form, to measure the irritability and amount of crying.⁽²³⁾ By merely focusing on crying, however, we are at risk of making a hardly differential diagnosis. Crying can be related to different needs of the infants, such as hunger or pain, and can also be physiological.

In view of the ambiguity in the definition of symptoms in relation to the diagnosis of abnormal crying, it is essential to consider the general health of the newborn, the pre- and postnatal history, family history of allergies, the postpartum woman’s diet (in case of breastfeeding) and the parents’ response to the baby’s crying, in order to avoid other precipitating factors of crying.⁽²⁰⁾

For some of the couples who participated in this study, the complexity inherent in the identification of signs and symptoms and the consequent acquisition of skills to cope with the presence of cramps was also evident.

There is research suggesting that breastfeeding mothers should avoid ingesting cow’s milk for at least two weeks and should maintain this restriction if the child’s response is favorable. In addition, if formula milk is used, preference should be given to options that contain extensively hydrolyzed proteins, lactose-free and containing prebiotics.⁽²²⁾

More recently, data emerged supporting probiotic supplementation^(20,24) as, in the first weeks of life, children exhibiting cramps were those with lower diversity and intestinal microbiotic stability.⁽²¹⁾ Specifically when Lactobacillus reuteri was administered, the symptoms of colic improved when compared to placebo, but the authors considered that further studies were necessary to validate this evidence and support the recommendations.⁽²⁵⁾

Likewise, a number of alternatives have been tested, including the use of soy hydrolyzed formulas, lactose-reduced or fiber-enriched, sucrose, herbal teas, music therapy, vibration, massage and spinal manipulation. None of them has proved to be effective though.⁽²⁵⁾

On the other hand, less conventional approaches have become increasingly important.⁽²⁰⁾ Thus, nurses’ action in this aspect of symptom relief can contribute to reduce the indiscriminate use of drugs, which is often observed under these circumstances, and promote the use of non-pharmacological strategies to relieve pain caused by colic and gas in newborns.⁽²³⁾

Despite extensive research in the area, the etiology of colic is still not clearly defined in order to support and sustain the different perspectives stated. It is easy to see that, without an identified etiology, there is no effective method of treatment.

Thus, with regard to colic, it is important to enable parental figures to acquire skills that help them cope with this problem, in order to more easily identify the cause of crying, providing practical information that may be useful in relieving the discomfort the infant feels and remember the self-limited nature of this condition.

Conclusion

The development of this study allowed us to understand how some parents experienced the transition to parenthood during postpartum hospitalization after normal delivery. The parental figures clearly present and identify needs for care. They note that the support of the nursing team is fundamental for the development of skills and safety in performing procedures they identify as essential to respond to newborn care. Fathers and mothers want to be integrated and participate actively in nursing decisions and interventions that promote the autonomous practice of parenting. To this end, as the hospitalization takes place, they need to increasingly take control over care. Based on the results obtained, it is concluded that the demonstration of flexibility and receptivity to clarify doubts, execute procedures and supervise the parental competences, as well as the existence of a common line guiding the practices among the nursing team members, promote a more proper experience of the transition to parenthood.

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Publication Dates

• Publication in this collection
  Jul-Aug 2018

History

• Received
  10 Apr 2018
• Accepted
  10 Aug 2018