Promoting close relationship (as between a mother and

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        PromotingMaternal-newborn bonding during the postpartum period RegisCollegeMalikaAmmor     IntroductionThe purpose of thisconcept analysis is to promote maternal-newborn bonding.  The process ofattachment with a new-born is natural for some mothers and complex for others.This crucial process starts with parents before and during the conception, andbecomes stronger the moment when the new mother hears her new-born cry for thefirst time. What occurs during the early postpartum period can carry lifelongimplications for both mother and newborn. Therefore, it is important to implementinterventions to enhance the bonding process and overcome barriers that mayhinder it from occurring (Husmillo,2013).

The primary focus is topromote awareness and the importance of maternal-newborn bonding among nursesto better detect and help prevent any potential physiological and psychologicalconsequences. Nurses play a vital role in the detection of an impairedconnection between mother and child and is responsible for determining theappropriate care path to improve the bond.Review of LiteratureDefinitionsThe word bonding has manyuses in the English language. It can be used as either a noun or a verb, and indifferent situations, for example, when describing the relationship betweenmother and child, individuals and objects. The term bonding is the process of developing aclose relationship, especially through frequent or constant association.(Webster’s new world compact dictionary, 2003). Confusion exists in theliterature regarding the definition of bonding.

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This is mainly because of theattachment process. Thus, the definition can vary depending on the perspectivetaken. Limited literature was found regarding maternal–infant bonding. Accordingto bonding theory (Klaus & Kennell, 1976), there is a crucial sensitiveperiod in the first few hours and days after birth. At this time, a positivebond can be formed between the mother and her infant.

Furthermore, if bondingis unsuccessful, the consequences may be negative and long lasting (Klaus , 1976). In this concept, thebonding is applied to the onsetof the attachment before and after to the conception and after birth. Itcements this bond and gives it reality to the formation of a close relationship(as between a mother and child or between a person and an animal). On the otherhand, Dictionary.com defined bonding as psychology, animal behavior: arelationship that begins at the time of birth between a parent and offspringand that establishes the basis for an ongoing mutual and intense attachment.

A postpartum (or postnatal) period beginsimmediately after the fourth stage of birth and can be extended to sixweeks. As the mother’s body, including hormone levelsand uterus size, returns to a non-pregnant state. The WorldHealth Organization (WHO) describes the postnatal period as the mostcritical period that the mother encounters in the whole process from conceptionto delivery.

While these basicdefinitions appear to be accepted, the concept of maternal-newborn bondingduring the postpartum couldn’t be found and it is known to be a complex conceptwith many differing aspects. Maternal-infant bonding means a development of thecore relationship between mother and child after birth. These definitions were broad andencompassed many different disciplines including chemistry, biology andpsychology.Review of literature in Nursing and other disciplinesBonding experience is thebeginning of the process of attachment between the mother her newborn.Attachments begins as a bonding interaction; this bond is the most crucial tothe development of the infant. Childbirth is a natural event that incorporatesthe same basics for all women. The differences are derived from the type ofapproach utilized, preparations, education and the birth experience itself.

(Sauchuk, 1984).In psychology, thematernal-newborn bonding starts after the cutting of the umbilical cord. Atthat moment, the physical bond ends while the emotional and psychological bondbegins. Many psychologists believe thematernal-newborn bond give the psychological foundation and maybe even thesocial and physical buffer we need to thrive in the world (Conde, Azar,Rossello, 2003). Psychological research shows that the quality of care infantsreceive affects how they later get along with friends, how well they do inschool and how they react to new and possibly stressful situations (Winston, 2016).The psychological aspect of bonding was developed in the late 1950s. Itdescribes how babies become attached to their mothers. Securely attached babiesconsider the mother a safe base from which to explore their environment.

Theygain assurance from her presence and use her as a source of comfort when theyare distressed or upset. In chemistry, maternal-newbornbonding is defined as a hormonal control system and permanent organization ofbrain synapses. Oxytocin is the most abundant neuropeptide in the brain thatprovides the foundation for the capacity to form relationships with others(Feldman, Gordon, & Zagoory-Sharon, 2011). Oxytocin is released from theposterior pituitary during the postpartum bonding process and helps reduce anynegative symptoms that may be experienced by new mothers, such as anxiety orstress. Oxytocin can be released during breastfeeding which can enhance thebonding process.This surge in oxytocinlevels results in the mother becoming more familiar with and attracted to theunique odor of her newborn. The response from the mother puts the foundationfor many future developments of bonding.From a nursingperspective, this concept of maternal-newborn bonding is frequently used in thematernal, newborn, and pediatric fields and is referred to the strongconnection between the mother and her child.

Nurses engagement and support duringpostpartum is crucial to ensure mothers experience adequate bonding with theirbabies and promote mothers’ successful transition into motherhood. Nurses playsa vital role in detecting the initial relationship that the mother and newbornhave whether positive or negative. The inside view of this relationship enablesnurses in implementing the appropriate strategies that support maternal–newbornbonding while providing specialized care. Different methods are being used bynurses and midwives to facilitate maternal–newborn bonding and can becategorized around two major themes: Mother–nurse/midwife interaction involvespsycho-social support and effective communication, whereas maternal–newborninteraction involves maternal involvement in newborn care and breastfeeding.Defining AttributesThe critical defining attributes are the list ofcharacteristics of the concept that are cited often (Walker & Avant, 2005).The defining attributes for promoting maternal-newborn bonding during thepostpartum period include affection, relationship and attachment.Affection is a mentalor emotional state or tendency; disposition or feeling.

It is afeeling of caring for someone or something. It is a subjective response to aperson, thing or situation.in the medical definition the affection is amoderate feeling or emotion (Merriam-Webster Online Dictionary’s, 2017).Relationship, the way in which two or more concepts, objects, or people areconnected, or the state of being connected.

it is a relation that connect andbind participants. In the medical definition, a relationship is an emotionalattachment between individuals. Finally, the attachment, the most importantcomponent of the attributes, is defined as a feeling that binds one to aperson, thing, ideal, devotion or regard (Merriam-Webster Online Dictionary’s, 2017). Attachment is a specific and confined aspectof the relationship between an infant and his mother that is involved withmaking the infant safe, secure and protected. The goal of the attachment is toset limits, teach new skills (Benoit, 2004).

Attachment influences the infant’sphysical, cognitive and psychological development.Definition of the conceptThe definition ofthe concept is to promote maternal-newborn bonding during the postpartumperiod, as it relates to advanced practice nursing. It includes theaccumulation of all the related definitions and can further describe theconnection that occurs between a mother and newborn during the first-timemeeting and in the future. This concept analysis has specific implications fornurses working in maternity units, where part of their role is the facilitationof the special, close relationship between the mother and her child during thesensitive period. Model caseA model case is anexample of the use of the concept that demonstrates all the defining attributesto the concept (Walker & Avant, 1995).Mrs.

M is a30-year-old pregnant woman, married to her soulmate five years ago. The couplewere very happy and excited to finally expect their first baby after multipleattempts. Mrs. M was admitted at the hospital with an active labor. The couplebegan to talk about how they can’t wait to see the baby and were teasing eachother who he will resemble. Mrs.

M labor advanced quickly and delivered ahealthy first baby boy. The nurse placed the baby on Mrs. M for skin-to-skincontact shortly after the labor and assisted Mrs. M with breastfeeding as well.Mrs. M looked very happy and kissed her baby on the cheek when positioning thebaby on her chest. During the hospital journey, Mrs. M was very attentive toher baby needs and was breastfeeding him on demand.

As the nurses changed, theywould always find Mrs. M having some interaction with her newborn. This model caseexhibits all the attributes of the maternal-newborn bonding as described in theliterature. The act of smiling, kissing and touching her child, represented aunique experience that enabled the mother to develop a strong tie to her newchild. Borderline caseA borderline casecan be referred to as one in which some, but not all, of the criticalattributes of the concept studied are present. The inconsistent nature of theborderline case underscores the perfection of the model case and lends clarityto the qualities of the defining attributes (Walker & Avant, 2005).

Mrs. B, 29-year-oldpregnant woman with her second child. She had a work-related stress for thelast two months, which contributed to some dizziness and occasional headaches.

Mrs. B went to her obstetrical/gynecologist for her 34 weeks routineappointment. At the doctor’s office, her blood pressure showed high values,even with three different readings.

She informed the doctor of her symptoms andfor how long she had them. The doctor sent Mrs. B immediately to the hospitalfor admission to labor and delivery for further testing and monitoring. Uponadmission, all readings showed Mrs. B had a preeclampsia condition and nursesput her on magnesium sulfate. Mrs. B delivered a baby girl shortly after.

Shebriefly saw and held her infant before she was transferred to the neonatalintensive care unit. While Mrs. B remained in labor and delivery on magnesiumsulfate, she was getting regular updates on her baby condition from the nurses. This case shows some attributes but not all.

For example, Mrs. B didnot have a chance to experience extensive skin-to-skin time with her baby atthe time of birth. RelatedcaseMrs. R, 37 years oldpregnant with her third baby was scheduled for a C-section. After her pre-opadmission, everything seemed normal and Mrs. R was so excited to finally meether new baby. Shortly after Mrs.

R delivered a baby boy, herobstetrical/gynecologist showed her the new baby for a brief moment so she canmeet him for first time. The nurse started her care on the baby and Mrs. R wasso happy that the baby is doing fine. Mrs. R and her baby were transferred tothe PACU to be monitored for the next two hours.  Mrs. R was so ready for the skin-to-skincontact with her baby but quickly the nurse noticed that Mrs.

R washemorrhaging and called for help to manage the situation. The baby wastransferred to the neonatal unit while the team care was taking care of Mrs. R.The situation was under control and Mrs. R condition was stable, but she was sotired and in so much pain after the C-section that did not have time to spendwith her newborn. This case shows thatsome of the attributes were present but some were missing such as therelationship and attachment because the patient did not have the chance to meether newborn even though she was prepared and ready to have this bonding.ContrarycaseA contrary case isan example that does not represent the concept and contains any of the demeaning attributes (Walker & Avant, 2005).Mrs.

C is a20-year-old female was admitted to the emergency room due to severe back pain.Upon admission, she denied being pregnant, but was unable to recall her lastmenstrual cycle. Hcg test confirmed her pregnancy. Mrs. C was taken toradiology for an ultrasound to determine the weeks of the fetus.

The ultrasoundrevealed that she is 37 weeks pregnant. She was transferred to labor anddelivery for further monitoring. She delivered a baby boy after 24 hours. Mrs.C did not want the infant on her chest, refused to hold her baby or have him inthe same room next to her. The nurse transferred the baby to neonatal intensivecare unit for boarding. The nurse tried to have a discussion with the motherabout her feelings but was not successful.

The mother asked to place her newinfant for adoption. Per hospital regulations and protocols, the nurse notifiedthe Child Protective Services to take appropriate actions and put in place anadoptive plan for the mother and newborn.In this contrarycase, it is clear that none of the defining attributes are presents.

Contrarycases, however, can be very useful in the analysis of the concept.Concept analysis isgreatly assisted by these two steps in so far as they are helpful in addingimprovement to the critical attributes, but they are often overlooked (Walkerand Avant, 2005). AntecedentsThe antecedents are helpful tothe theorist in identifying the underlying assumptions regarding the conceptunder study (Walker and Avant, 2005).

Antecedents can be defined as events thathappened prior to the occurrence of the concept.In this concept, firstantecedent is the pregnancy, which is the starting point for thematernal-newborn bonding. Research shows that the maternal bonding with thebaby to be during pregnancy can influence the infant development during thefirst few months after delivery (Sullivan, 2011).The touch is another importantantecedent that plays a crucial role in the maternal newborn bonding. The touchincludes the skin-to-skin after birth. It is known as kangaroo care (L Furman,Kennell, 2000).

The research shows a change in the mothers’ perception of herchild, attributable to the skin-to-skin contact in the kangaroo-carryingposition. This effect is related to a subjective “bonding effect” that may beexplained readily by the inspiring nature of the Kangaroo mother careintervention (Furman, Kennell, 2000). ConsequencesThe consequences are thoseevents or incidents that occur as a result of the occurrence of the concept(Walker and Avant, 2005). The main consequences associated to bonding are loveand trust. The love that the mother has for her newborn before birth andcontinue unconditionally after birth.

When the newborn has bonded with themother, he/she develops a sense of protection and security. A trustingrelationship has formed between the mother and her newborn.  From that point, the newborn now reliescompletely on the mother to fulfill all of his basic needs. Empiricalreferences            Theexistence of empirical referents, which are classes or categories of a realphenomenon, demonstrates the existence of the concept itself (Walker and Avant,2005).  The empirical references were identified, as very usefulinstruments in the development that are demonstrably connected to thetheoretical base of the concept and, as such, contribute to the content as wellas the construct validity of any new instrument (Walker and Avant, 2005). There are several tools and scales that are used to assessthe maternal-newborn bonding used by the practitioners. These includes the Birmingham Post-Natal Bondingquestionnaire (BPNB) that was develop by Brockington and George in 1998,Postpartum Bonding Questionnaire (PBQ) was advanced by Brockington et al (2001)for a timely diagnosis of mother–child bonding disorders, Postpartum ParentingBehavior Scale (PPBS) was formulated to measure clearly defined observed,maternal behaviors toward the infant shortly after in the Pre/Post-natalbonding scale (PPBS) (Cuijlits, 2016). Finally, the Mother-to-Infant Bonding(MIB) scale is to measure the emotions of a mother to her new baby by Taylorand Al in 2005 (Zeitlin et al, 1999).

The most popular tool among practitionersis the PPBS scale, instrument with good psychometric properties; goodfactor structure, internal consistency, and construct validity.          Theresearch shows the validity and use of the PPBS in clinical practice. The PPBScan be used in the pre- and postnatally for detecting risk groups of women withpoor bonding. Also bonding scores can be related to infant attachment and childdevelopment (Cuijlits, 2016).The implementation of the PPBS scale help the practitionersto assess and implement intervention to enhance bonding, in order to empower amother-newborn relationship.Summary andconclusionThe maternal-newborn bonding concept illustrates the effecta strong bond has on the mother-child relationship that starts before and during the conceptionto the birth. The bond between mother andchild involves affection and attachment.

Once a maternal-newborn bond is made,consequences of the strong bond encompass the mother and infant. The results of those consequences are trust and love.Nurses play a crucial role in facilitating the special, close relationshipbetween the mother and her child during the complex period.

Nurses should be able to help mothers to promote bonding bydiscussing all the factors that may help them to bond with their infants suchas the bonding process. In addition, the importance of maternal–infant bondingshould be emphasized to all mothers when they plan their pregnancy and itscrucial importance for the development of the relationship between mother andinfant of both the physical and psychological impact it may have on childdevelopment.ReferencesWalker, L. O.

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Upper Saddle River, NJ: Pearson Prentice Hall.Conde, Azar, JM, B., & Rossello, D. (2003). Kangaroomother care to reduce morbidity and mortality in low birthweight infants.Sullivan, R.

, Perry, R.,Sloan, A., Kleinhaus, K., & Burtchen, N. (2011).

Infant Bonding andAttachment to the Caregiver: Insights from Basic and ClinicalScience. Clinics in Perinatology, 38(4), 643-655Furman, L., &Kennell, J. (2007).

Breastmilk and skin-to-skin kangaroo care for prematureinfants. Avoiding bonding failure. Acta Paediatrica, 89(11),1280-1283.

Wittkowski A, Wieck A,Mann S (2007) An evaluation?oftwo bonding questionnaires: a comparison of the Mother-to-Infant Bonding Scalewith the Postpartum Bonding Questionnaire in a sample of primiparous mothers.Archives Women Mental Health 10(4): 171–5 Zeitlin D, Dhanjal T, ColmseeM (1999) Maternal-fetal bonding: the impact of domestic violence on the bondingprocess between a mother and a child. Archives Womens Mental Health 2: 183–9 Klaus, M.

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(2004).Washington, DC: National Academies Press.Winston,R., & Chicot, R. B. (2016).

The importance of early bonding on thelong-term mental health and resilience of children. LONDON JOURNAL FORPRIMARY CARE, 1(8), 2016th ser.Benoit,D. (2004). Infant-parent attachment: Definition, types, antecedents,measurement and outcome. Pediatrics & Child Health, 9(8).Feldman,R., Gordon, I.

, & Zagoory-Sharon, O. (2010). Maternal and paternal plasma,salivary, and urinary oxytocin and parent-infant synchrony: considering stressand affiliation components of human bonding. Developmental Science, 14(4),752-761.Kinsey, C. B.

,Baptiste-Roberts, K., Zhu, J., & Kjerulff, K. H. (2014). Birth-related,psychosocial, and emotional correlates of positive maternal–infant bonding in acohort of first-time mothers.

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514.BRYANT, E. (2016).Attachment icebergs: Maternal and child health nurses’ evaluation ofinfant-caregiver attachment. Community Practitioner, 89(5),39-43.Husmillo, M.(2013).

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