Chapter 1: Introduction

Module 1.3

Birth and the Newborn Infant

Labor: The Process of Birth Begins

• Contractions:– Braxton-Hicks – hardening of the uterus,

“false labor” – usually happen in late pregnancy

– Labor initiation - CRH: at 266 days after conception; corticotropin-releasing hormone triggers hormone releaseoxytocin from mother’s pituitary gland causes contractions

Stages of Labor• First stage: The uterine contractions initially occur around every 8 to 10

minutes and last about 30 seconds. As labor proceeds, the contractions occur more frequently and last longer. Toward the end of labor, the contractions may occur every 2 minutes and last almost 2 minutes. During the final part of the first stage of labor, the contractions increase to their greatest intensity, a period known as transition. The mother’s cervix fully opens, eventually expanding enough (usually to around 10cm) to allow the baby’s head (the widest part of the body) to pass through.

• Second stage: Typically lasts around 90 minutes, the baby’s head emerges further from the mother with each contraction, increasing the size of the vaginal opening; second stage of labor ends when the baby has completely left the mother’s body

• Third stage: Occurs when the child’s umbilical cord (still attached to the

neonate) and the placenta are expelled from the mother.

Stages of Labor (cont.)

From Fetus to Neonate• When is the moment of birth?

• The exact moment of birth occurs when the fetus, having left the uterus through the cervix, passes through the vagina to emerge fully from its mother’s body.

• What cultural differences surround the birth of children worldwide?• The situation after birth varies from situation to situation and

from culture to culture. In Western cultures, health care workers are almost always on hand to assist with the birth. In the United States, 99 percent of births are attended by professional health care workers, but worldwide only about 50 percent of births have professional health care workers in attendance.

• Neonate - term used for newborns

Apgar Scale

• APGAR - a standard measurement system that looks for a variety of indications of good health

• Measurement system that looks for a variety of indications of good health.

• Developed by physician Virginia Apgar, the scale directs attention to five basic qualities, recalled most easily by using Apgar’s name as a guide: appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (respiratory effort).

Apgar Scale (cont.)

Apgar Scale (cont.)

• Low scores may be cause by:– Existing fetal problems or birth defects– Difficulties related to process of birth– Temporary deprivation of oxygen (anoxia)

• Wrapped umbilical cord• Pinched umbilical cord

Research about Early Bonding• Bonding became part of normal birth routine in many hospitals

due to the combined efforts of La Leche League and other childbirth activists, and to the concerted pleas of two pediatricians, Marshall Klaus and John Kennell. In Parent-Infant Bonding, first published in 1976, Klaus and Kennell point out the existence of a "sensitive period" immediately after birth during which maternal-infant attachment seems to occur much more readily than if mother and child are separated after the birth, as used to be standard hospital practice (Redshaw, 1997; Else-Quest, Hyde, & Clark, 2003; Weinberg, 2004; Miles et al., 2006).

• Some researchers believe that there are no physiological effects of early bonding, that it is in fact a "scientific fiction" (Eyer 1992). On the other hand, proponents of bonding suggest that the physiological benefits of early "bonding" may be numerous (Trevathan, 1997).

Approaches to Childbirth

• Variety of strategies and approaches

• No universally accepted single procedure

• No conclusive research evidence that one procedure significantly more effective than another

Alternative Birthing Procedures• Lamaze birthing techniques - makes use of breathing techniques

and relaxation training; allows women to cope with painful contractions by concentrating on their breathing and producing relaxation response, rather than by tensing up, which can make the pain more acute; goal is to learn how to deal positively with pain and to relax at the onset of a contraction.

• Bradley Method - sometimes known as “husband-coached childbirth,” is based on the principle that childbirth should be as natural as possible and involve no medication or medical interventions. Women are taught to “tune into” their bodies in order to deal with the pain of childbirth.

• Hypnobirthing - Hypnobirthing is a new, but increasingly popular, technique. It involves a form of self-hypnosis during delivery which produces a sense of peace and calm, thereby reducing pain. The basic concept is to produce a state of focused concentration in which a mother relaxes her body while focusing inward.

Childbirth Attendants

• Obstetrician - physicians who specialize in delivering babies.

• Midwife - most often nurses specializing in child birth—are used primarily for pregnancies in which no complications are expected

• Doula - trained to provide emotional, psychological, and educational support during birth.

Use of Anesthesia and Pain-Reducing Drugs• Kinds:

– Epidural anesthesia - produces numbness from waist down– Walking epidural or dual spinal-epidural - uses smaller

needles and a system for administering continuous doses of anesthetic. It permits women to move about more freely during labor and has fewer side effects than traditional epidural anesthesia.

• Effects:– Mother

• Reduces/eliminates pain associated with labor• Sometimes slows labor

– Neonate• Drug strength related to effects on fetus• May temporarily depress the flow of oxygen to fetus • Less physiologically responsive, show poorer motor control during

the first days of life after birth, cry more, and may have more difficulty in initiating breastfeeding

Use of Anesthesia and Pain-Reducing Drugs (cont.)

• Most research suggests that drugs, as they are currently employed during labor, produce only minimal risks to the fetus and neonate.

• Guidelines issued by the American College of Obstetricians and Gynecologists suggest that a woman’s request for pain relief at any stage of labor should be honored.

• Proper use of minimal amounts of drugs for pain relief is reasonable and has no significant effect on a child’s later well-being.

Do neonates feel pain during birth?

Objective indications of neonate pain at birth:

• Crying• Facial expressions • Body movement• Vital signs • Serum cortisol, tissue and blood oxygen levels• Neurobehavioral assessments

Newborn Medical Screening

• American College of Medical Genetics recommendations:– All newborns be screened for 29 disorders, ranging from hearing

difficulties and sickle cell anemia to extremely rare conditions such as isovaleric academia, a disorder involving metabolism

– Permits early intervention and treatment

• In some states, only three tests are mandated, while in others over 30 are required. – In jurisdictions with only a few tests, many disorders go

undiagnosed. – Each year around 1,000 infants in the United States suffer from

disorders that could have been detected at birth if appropriate screening had been conducted at birth.

Problems During Labor and Delivery• Although the average newborn weighs around 3,400

grams (about 7 1/2 pounds), these conditions can contribute to problems:

• Preterm infants - or premature infants, are born prior to 38 weeks after conception.

• Low birth-weight infants - weigh less than 2,500

grams (around 5 1/2 pounds). Although only 7 percent of all newborns in the United States fall into the low-birth weight category, they account for the majority of newborn deaths.

• Small-for-gestational-age infants - are infants who, because of delayed fetal growth, weigh 90 percent (or less) of the average weight of infants of the same gestational age. Small-for-gestational-age infants are sometimes also preterm, but may not be.

Very low birth-weight infants

• Very-low-birth weight infants weigh less than 1250 grams (around 2 1/4 pounds) or, regardless of weight, have been in the womb less than thirty weeks.

• Average monthly cost of medical care for such infants during the first 3 years of life may be between 3 and 50 times higher than the medical costs for a full-term child.

• Preterm infants who receive more responsive, stimulating, and organized care are apt to show more positive outcomes than those children whose care is not as good.

• Most vulnerable; in grave danger from the moment they are born, due to the immaturity of their organ systems.– Eyes may be fused shut and earlobes may look like flaps of skin

on the sides of their heads; skin is a darkened red color, whatever their race.

Survival of the Smallest

What causes preterm and low-birth-weight deliveries?

• Half of births unexplained

• Difficulties related to mother’s reproductive system

• Immaturity of mother’s reproductive system

• General health of mother

Factors Associated with Increased Risk of Low Birth weight

• Demographic risk• Medical risks predating pregnancy• Medical risks in current pregnancy• Behavioral and environmental risks• Healthcare risks• Evolving concepts of risks

Factors Associated with Increased Risk of Low Birth weight

Post-mature Babies

• Post-mature - 2 weeks or more overdue– Blood supply from placenta may become

insufficient– Blood supply to brain may be decreased,

leading to the potential of brain damage– Labor becomes riskier for larger fetus to pass

through birth canal

Cesarean Delivery

• Baby is surgically removed from uterus

• Occur most frequently when fetal stress appears

• More prevalent in older mothers

• Related to position in birth canal: breech, transverse

Cesarean Delivery (cont.)

• Risks for mother:• Cesarean deliveries carry dangers.• Cesarean delivery represents major surgery, and the mother’s

recovery can be relatively lengthy, particularly when compared to a normal delivery.

• Risk of maternal infection is higher with Cesarean deliveries.• Mothers who deliver by Cesarean are less satisfied with birth

experience, although their dissatisfaction does not influence quality of mother–child interactions.

• Risk for baby:• Deter normal release of certain stress-related hormones, such

as catecholamines, into newborn’s bloodstream.• Babies born by Cesarean delivery who, have not experienced

labor are more likely to experience breathing problems upon birth than those who experience at least some labor prior to being born via a Cesarean delivery.

International Incidence Rate: Cesarean Deliveries

Mortality and Stillbirth: The Tragedy of Premature Death

• Stillbirth - the delivery of a child who is not alive, occurs in less than 1 delivery out of 100.

• Effects on parents:• Sense of loss and grief similar to death of older child.• Juxtaposition of the first dawning of life and an unnaturally early

death may make the death particularly difficult to accept and deal with.

• Depression.

• Resources:– March of Dimes

– National Stillbirth Society

– MISS Foundation

Infant Mortality

Why is infant survival less likely in the UnitedStates than in other, less developed countries?

• The infant mortality rate in Washington, D.C., capital of the richest country in the world, is 12.2 deaths per 1,000 births, exceeding the rate of countries such as Hungary, Cuba, Kuwait, and Costa Rica.

• Overall, the United States ranks 22nd among

industrialized countries, with 6.37 deaths for every 1,000 live births

International Infant Mortality

Developmental DiversityOvercoming Racial and Cultural Differences in Infant Mortality

• About one out of every six pregnant women has insufficient prenatal care.• Some 20 percent of white women and close to 40

percent of African American women receive no prenatal care early in their pregnancies.

• Five percent of white mothers and 11 percent of African American mothers do not see a health care provider until the last three months of pregnancy; some never see a health care provider at all.

• Higher U.S. mortality rate relates to economic diversity. Less prenatal care, insurance, paid maternity leave.

Developmental DiversityOvercoming Racial and Cultural Differences in Infant Mortality

Postpartum Depression• Postpartum depression, a period of deep depression following the

birth of a child, affects some 10 percent of all new mothers. Although it takes several forms, its main symptom is an enduring, deep feeling of sadness and unhappiness, lasting in some cases for months or even years.

• In about 1 in 500 cases, the symptoms are even worse, evolving into a total break with reality.

• In extremely rare instances, postpartum depression may turn deadly.

• Postpartum depression may be triggered by the pronounced swings in hormone production that occur after birth. During pregnancy, the production of the female hormones of estrogen and progesterone increase significantly. However, within the first 24 hours following birth, they plunge to normal levels. This rapid change may result in depression.

Postpartum Depression (cont.)

• Depressed mothers who have postpartum depression Display little emotion and to act detached and withdrawn

• Infants display fewer positive emotions and withdraw from contact not only with their mothers but with other adults

• Children of depressed mothers are more prone to anti-social activities such as violence.

Neonate Capabilities

• Earliest views of newborns focused on the things that they could not do, comparing them rather unfavorably to older members of the human species.

• Today there is more favorable view. As developmental researchers have begun to understand more about nature of newborns, they have come to realize that infants enter this world with an astounding array of capabilities in all domains of development: physical, cognitive, and social.

Neonate Capabilities

• Neonates emerge practiced in many types of physical activities

• Reflexes - unlearned, organized involuntary responses that occur automatically in the presence of certain stimuli. • Breathing• Swallowing• Rooting• Swallowing• Coughing and sneezing• Blinking

Newborn Digestive System

• Meconium - Because the liver, a critical component of the digestive system, does not always work effectively at first, almost half of all newborns develop a distinctly yellowish tinge to their bodies and eyes.– This change in color is a symptom of neonatal

jaundice. It is most likely to occur in preterm and low-weight neonates, and it is typically not dangerous.

– Treatment most often consists of placing the baby under fluorescent lights or administering medicine.

Sensory Capabilities: Vision

• Visual acuity not fully developed but can see to some extent

• Attend to visual field highest in information and brightness

• Possess some sense of size constancy

• Distinguish and show preference for different colors

Sensory Capabilities: Hearing

• Clearly capable of hearing, but auditory acuity not completely mature

• React to and show familiarity with certain kinds of sounds

• Especially voice of parents

Sensory Capabilities

• In addition to sight and hearing, the other senses also function quite adequately in the newborn.

• Senses of touch, smell, and taste are not only present at birth, but are reasonably sophisticated.

Circumcision of Newborn Male Infants:

• Circumcision is the surgical removal of part or all of the foreskin from the penis.

• Parents usually choose to have their newborn sons circumcised for a combination of health, religious, cultural, or traditional reasons.

• One of the most commonly performed surgical procedures in US

• National medical associations such as the American Medical Association, the American Academy of Pediatrics, and the American Academy of Family Physicians have long maintained that circumcision is not medically necessary and do not recommend that it be performed routinely.

Circumcision of Newborn Male Infants: From Research to Practice

PRO• Routinely performed on

many US infants• More recently found to

protect against future STDs

• Risk reduction for urinary track infection and penile cancer

CON• Deemed medically

unnecessary by national medical associations

• Can cause bleeding and infection

• May reduce sensation and sexual pleasure later in life

Early Learning Capabilities

• Classical conditioning

• Operant conditioning

• Habituation

Early Learning Capabilities

• Classical conditioning an baby learns to respond in a particular way to a neutral stimulus that normally does not bring about that type of response.• Key feature of classical conditioning is

stimulus substitution, in which a stimulus that doesn’t naturally bring about a particular response is paired with stimulus that does evoke that response.

Early Learning Capabilities

• Operant conditioning is a form of learning in which a voluntary response is strengthened or weakened, depending on its association with positive or negative consequences.

Early Learning Capabilities

• Habituation is a decrease in response to stimulus that occurs after repeated presentations of same stimulus

• Most primitive form of learning that occurs in every sensory system

Early Learning Capabilities:Examples

Social Competence: Responding to Others

• Newborns have capability to imitate others’ behavior

• This provides them with important foundation for social interaction later in life

• Developmental researchers found that, when exposed to adult modeling behavior that infant already performed spontaneously, such as opening mouth or sticking out tongue, newborn appeared to imitate behavior.

Social Competence: Responding to Others

• The ultimate outcome of the social interactive capabilities of the newborn infant, and the responses such behavior brings about from parents, is to pave the way for future social interactions.