Birth and Newborn Infant

Labor: The Process of Birth Begins

• Corticotropin-Releasing Hormone (CRH)
  • protein is triggered by some unknown reason to release various hormones, and the process that leads to birth begins
• Oxytocin
  • love hormone
  • in childbirth, oxytocin is increased
  • released by the mother’s pituitary gland
  • when concentration of oxytocin becomes high enough, the mother’s uterus begins periodic contractions
• Contractions
  • Braxton Hicks or “False Labor”
  • irregular contraction of the womb (the uterus) occurring towards the middle of pregnancy in the first pregnancy and, earlier and more intensely, in subsequent pregnancies
  • tend to occur during physical activity
  • contract, baby is pushed to the cervix and prepare the baby in coming out of the womb; some cases, baby is still not yet pushed down the cervix (mother less activity or first pregnancy)
• Neonate: term used for newborn
• Labor Initiation
  • the stimulation of uterine contraction during pregnancy before labor begins on its to achieve a vaginal birth
  • insert something to make contractions faster
  • if tried first time but less movement on the baby, caesarian or manual push

Development of a Baby in the Womb

• Inner Cell: baby; Outer Cell: amniotic sac
• Week 5
  • sesame seed; giving shape and primitive organs; circulatory system, heart beats, brain, and spinal cord
• Week 9
  • grape; tail is gone
• Week 10
  • fetal stage'; facial features defined; fingerprints are developing
• Week 12
  • urine → amniotic fluid, second trimester of pregnancy
• Week 15-20
  • nervous system maturing; brain to the rest of the body; soft cartilage (arms and legs first) are hardening; baby may be able to hear heartbeat and voice
• Week 18
  • feeling baby’s movement
• Week 20
  • more than 10 ounces; halfway point in pregnancy
• Week 21-27
  • sense of touch and unique fingerprints are developing
• Week 23
  • swallow; baby hiccups are normal several times a day; practice breathing
• Week 27
  • eyelids may open as reflex and tiny taste buds

Labor and Vaginal Birth

• 12 to 19 hours (first stage of labor)
• 5 to 20 minutes (normal contractions; back pain)
• mucus plug on the cervix
• Second Stage of Labor
  • Active Segment: contractions
  • Passive Segment: stretching for baby to pass through
• Third Stage of Labor: push placenta out of the uterus

Stages of Labor

• First Stage of Labor
  • Uterine contractions initially occur every 8 to 10 minutes and last 30 seconds. Toward the end of labor, the contractions may occur every 2 minutes and last almost 2 minutes.
  • Transition: a period during the final part of the first stage of labor; the contractions increase to their greatest intensity
  • As contractions increase, the cervix, which separates the uterus from the vagina, becomes wider, eventually expanding to allow the baby’s head to pass through
  • longest; takes 16-24 hours for firstborn children, but there are wide variation. Births of subsequent children usually involve shorter periods of labor
  • duration varies significantly, depending on the mother’s age, race, ethnicity, number of prior pregnancies, and a variety of other factors involving both the fetus and the mother
• Second Stage of Labor
  • typically lasts around 90 minutes
  • the baby’s head starts to move through the cervix and birth canal
  • Episiotomy: an incision sometimes made to increase the size of the opening of the vagina to allow the baby to pass
  • can potentially cause more harm than good
  • end when the baby has completely left the mother’s body
• Third Stage of Labor
  • the child’s umbilical cord (still attached to the neonate) and the placenta are expelled from the mother
  • the placenta should be removed, mother is at risk of cervical cancer and other infections
  • quickest and easiest , taking just a few minutes

Birth: From Fetus to Neonate

• Apgar Scale: a standard measurement system that looks for a variety of indications of good health in newborns
  • each quality: 0-2; total of 10; average should be 7 or above
  • newborns under 4 need immediate, life-saving intervention

• Apgar Score
  • a score is given for each sign at one minutes and 5 minutes after the birth
  • if there are problems with the baby, an additional score is given at 10 minutes
  • Low Scores
  • existing fetal problems or birth defects
  • difficulties related to process of birth
  • Anoxia: a restriction of oxygen to the baby, lasting a few minutes during the birth process, that can produce brain damage
  • temporary deprivation of oxygen: wrapped umbilical cord and pinched umbilical cord
• Newborn Medical Screening
  • all newborns should be screened for 29 disorders, ranging from hearing difficulties and sickle cell disease to extreme rare conditions such as isovaleric acidemia, a disorder involving metabolism
  • can be detected from a tiny quantity of blood drawn from an infant’s heel
  • permits early treatment of problems that might go undetected for years
• Physical Appearance and Initial Encounters
  • Vernix: “greasy cottage cheese”; dry skin
  • smooths the passage through the birth canal
  • no longer needed once the child is born and is quickly cleaned away
  • Lanugo: fine, dark fuzz
  • small hair on the body of the baby
  • Puffy Eyelids: accumulation of fluids during delivery
  • baby may have blood of other fluids on parts of its body
  • Bonding: close physical and emotional contact between parent and child during the period immediately following birth, argued by some to affect later relationship strength

Approaches to Childbirth: Where Medicine and Attitudes Meet

Alternative Birthing Procedures

• Lamaze Birthing Techniques or Lamaze Technique or Lamaze
  • began as a prepared childbirth technique, popularized in the 1950s by French obstetrician Dr. Fernand Lamaze
  • makes use of breathing techniques and relaxation training
  • allows women to cope with painful contraction by concentrating on their breathing and producing a relaxation response, rather than by tensing up, which can make the pain more acute
  • Goal: to learn how to deal positively with pain and to relax at the onset of a contraction
• Bradley Method or Husband Coached Childbirth
  • method of natural childbirth developed in 1947 by Robert A. Bradley, MD
  • childbirth should be as natural as possible and involve no medication or medical interventions
  • taught muscle relaxation techniques and good nutrition and exercise during pregnancy are seen as important to prepare for delivery
  • use of physicians is viewed as unnecessary and sometimes even dangerous
  • cut small insertion in the cervix
• Hypnobirthing
  • involves a form of self-hypnosis during delivery that produces a sense of peace and calm, thereby reducing pain
  • produce a state of focused concentration in which a mother relaxes her body while focusing inward
  • method of pain management that can be used during labor and birth
  • involves using a mixture of visualization, relaxation, and deep breathing techniques
  • prior to birth
• Water Birthing
  • practice in which a woman enters a pool of warm water to give birth
  • person remains in the water during the pushing phase and actual birth of the baby
  • baby is then brought to the surface of the water after he or she is born
  • waterbirth may be followed by the birth of the placenta in or out of the water
  • the theory is that the warmth and the buoyancy of the water is soothing, easing the length and pain of labor and childbirth, and the entry into the world is soothed for the infant , who moves from the watery environment of the womb to the birthing pool
  • tub is sanitized; water temperature is similar to placenta

Childbirth Attendants

• Obstetrician: physicians who specialize in delivering babies have been the childbirth attendants of choice
  • more male teachers
• Midwife: a childbirth attendant who stays with the mother throughout labor and delivery
  • often nurses specializing in childbirth
  • used primarily for pregnancies in which no complications are expected
• Doula: a trained companion who is not a healthcare professional and who supports another individual through a significant health-related experience, such as childbirth, miscarriage, induced abortion or stillbirth, or non-reproductive experiences such as dying

Pain and Childbirth

Interpretation of pain is subjective:

• amounts of pain experienced by women during childbirth vary
• for some women, the perceived pain is intense and agonizing; for other women there is little to no perceived pain
• many factors affect pain perception, including cultural ideas of childbirth, fear, number of previous births, fetal presentation, birthing position, and a woman’s natural pain threshold
• Twilight: semi-induced anesthesia; before contraction happens before birth; more localized; normal delivery
• pain depends on the baby; if the gap is too log; body is not ready to have a baby again (1-2 years interval for less preparation)

Use of Anesthesia and Pain-Reducing Drugs

• Kinds
  • Epidural Anesthesia: produces numbness from the waist down
  • traditional epidurals produce an inability to walk and in some cases prevent women from helping to push the baby out during delivery (slow labor)
  • Walking Epidural or Dual Spinal-Epidural
  • uses smaller needles and a system for administering continuous doses of anesthetic
  • permits women to move about more freely during labor and has fewer side effects than traditional epidural anesthesia
• Effects
  • Mother
  • reduces or 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

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, and neurobehavioral assessments

Postdelivery Hospital Stay

• By the 1990s , the average stay for normal birth was 2 days
  • changes prompted by medical insurance companies
• American Academy of Pediatrics recommendation
  • stay in hospital should be no less than48 hours after giving birth
• Public Hospital: if baby has no complications, within the day
• will not let mom stay longer for the possibility of infection
• ^^48 hours to 1 week ^^if it has complications (baby stays at neonatal until stable)

Preterm Infants: Too Soon, Too Small

• Preterm Infants or Premature Infants
  • infants who are born prior to 38 weeks after conception
  • at high risk for illness and death
  • 7 months most preferable (neonatal facility)
  • ^^Respiratory Distress Syndrome (RDS)^^
• Low Birthweight Infants
  • infants who weigh less than 2,500 g or 5.5 pounds at birth
• Small-for-Gestational-Age Infants
  • infants who, because of delayed fetal growth, weigh 90% of less of the average weight of infants of the same gestational age
  • may be caused by inadequate nutrition during pregnancy
• Outcomes
  • majority of preterm infants eventually develop normally in the long run
  • tempo of development often proceeds more slowly
• Very-Low-Birthweight Infants
  • Smallest Survivors
  • most vulnerable; immaturity of organ systems
  • weigh less than 1250 g (around 2.25 pounds)
  • in womb less than 30 weeks
  • Risk-Reduction Strategies
  • high quality care
  • responsive, stimulating, and organized care
  • massage (usually in provinces)

What Causes Preterm and Low-Birthweight 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 Birthweight

• Demographic Risks
  • age (less than 17; over 34)
  • race (minority)
  • low socioeconomic status
  • unmarried
  • low level of education
• Medial Risks Predating Pregnancy
  • number of previous pregnancies (0 or more than 4)
  • low weight for height
  • genitourinary anomalies or surgery
  • selected diseases such as diabetes, chronic hypertension
  • nonimmune status for selected infections such as rubella
  • poor obstetric history, including previous low-birthweight infant, multiple spontaneous abortions
  • maternal genetic factors (such as low maternal weight at own birth)
• Medical Risks in Current Pregnancy
  • multiple pregnancy
  • poor weight gain
  • short interpregnancy interval
  • low blood pressure
  • hypertension or preeclampsia or toxemia
  • selected infections such as asymptomatic bateriuria, rubella, and cytomegalovirus
  • first or second trimester bleeding
  • placental problems such as placenta previa
  • severe morning sickness
  • anemia or abnormal hemoglobin
  • severe anemia in a developing baby
  • fetal anomalies
  • incompetent cervix
  • spontaneous premature rupture of membrane
• Behavioral and Environmental Risks
  • smoking
  • poor nutritional status
  • alcohol and other substance abuse
  • DES exposure and other toxic exposure, including occupational hazards
  • high altitude
• Health Care Risks
  • absent or inadequate prenatal care
  • latrogenic prematurity
• Evolving Concepts of Risks
  • stress (physical and psychosocial)
  • uterine irritability
  • events triggering uterine contractions
  • cervical changes detected before onset of labor
  • selected infections such as mycoplasma and chlamydia trachomatis
  • inadequate plasma volume expansion
  • progesterone deficiency

Postmature Babies: Too Late, Too Large

• Postmature Babies
  • infants still unborn 2 weeks after the mother’s due date
• 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

Caesarian Delivery: Intervening in the Process of Birth

• Caesarian Delivery (C-Section): a birth in which the baby is surgically removed from the uterus, rather than traveling through the birth canal
• Fetal Monitor: a device that measures the baby; heartbeat during labor
• Procedure
  • baby is surgically removed from the uterus
• Rationale
  • occurs most frequently when fetal stress appears
  • more prevalent in older mothers
  • In some cases, related to position in birth canal
  • Breech Position: baby is positioned feet first in the birth canal
  • Transverse Position: baby lies crosswise in the uterus or when the baby’s head is so large it has trouble moving through the birth canal
  • routine use of fetal monitor
• Risks
  • major surgery for mother, longer recovery
  • reduced stress-related hormones for neonate

Stillbirth and Infant Mortality: The Tragedy of Premature Death

• Stillbirth: delivery of a child who is not alive
• Infant Mortality: death within the first year in life
• joy accompanies the birth of a child is completely reversed when a newborn dies
• 1 out of 115 deliveries in US
• enormous impact on family; depression and lack of support common; sometimes PTSD experienced
  • PTSD: death of baby inside the womb; unknown pregnancy or baby is weak from the start
• US infant mortality generally declining since 1960s

Postpartum Depression: Moving from the Heights of Joy to the Depths of Despair

• Postpartum Depression: a period of deep depression following the birth of a child
  • Incidence Rate: increasing compared to old times
  • Old Times: with support systems from relatives
  • Today: difficulty balancing work and baby and hard to have someone with you because they live away from family = less support
  • Symptoms and Causes
  • 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
  • may be triggered by the pronounced swings in hormone production that occur after birth
  • rapid change of the production of the female hormones of estrogen and progesterone may result in depression
  • Consequences
  • when depressed mothers interact with their infants, they are likely to display little emotion and to act detached with withdrawn
    • lack of responsiveness leads infants to display fewer positive emotions and to withdraw from contact not only with their mothers but with other adults as well
    • babies are more prone to antisocial activities such as violence

The Competent Newborn

Physical Competence: Meeting the Demands of a New Environment

• neonates emerge practiced in many types of physical activities
• Reflexes
  • unlearned, organized, involuntary responses that occur automatically in the presence of certain stimuli
  • sucking reflex
    • takes over when touched in the face
  • swallowing reflex
    • if lips are touched with something wet
  • rooting reflex
  • coughing, sneezing, blinking
  • not all, autistic baby cannot do grasping; reflexes for grasping is slow
  • Special Need: some do not respond to touch
  • Grasping Reflex: pressure on hand
  • Babinski: feet touching, baby’s feet will curl
  • Moro Reflex: if suddenly dropped
  • walking reflex

Newborn Digestive System

• sucking and swallowing reflexes help infants to consume their mother’s milk and are coupled with the newfound ability to digest nutriments
• Meconium
  • first stool of the infants
  • a greenish-black material that is a remnant of the neonate’s days as a fetus
  • nutrients from the umbilical cord
• Neonatal Jaundice
  • newborns develop a distinctly yellowish tinge to their bodies and eyes
  • most likely to occur in preterm and low-weight neonates
  • typically not dangerous
  • treatment most often consists of placing the baby under fluorescent lights or administering medicine
  • common in premature babies
• Incubator: for premature babies for at least 2 months

Sensory Capabilities: Experiencing the World

• Seeing
  • 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
  • whole spectrum of vision: 2 to 3 years old
  • more color the better
  • not healthy for the baby’s eyes if they see a lot of movements
• Hearing
  • clearly capable of hearing, but auditory acuity not completely mature
  • react to and show familiarity with certain kinds of sounds
  • amniotic fluid, which is initially trapped in the middle ear, must drain out before the newborn can fully hear
• Other Senses
  • senses of touch, smell, and taste are not only present at birth, but are reasonably sophisticated
  • sensitive in terms of taste and smell: survival; can smell the milk
  • can easily recognize if the milk is not mom’s
  • sense of smell and taste are also well developed
  • suck and increase other physical activity when odor of peppermint is placed near the nose
  • pucker their lips when a sour taste is placed on them
  • suitable facial expressions to other tastes as well

Early Learning Capabilities

• Classical Conditioning
  • infants are capable of learning very early through classical conditioning
  • a situation in which an organism learns to respond in a particular way to a neutral stimulus that normally does not bring about that type of response
  • ^^A hungry baby stops crying when her mother picks her up because she has learned to associate being picked up with subsequent feeding.^^
• Operant Conditioning
  • functions from the earliest days of life
  • a form of learning in which a voluntary response is strengthened or weakened, depending on its positive or negative consequences
  • ^^An infant who learns that smiling at his or her parents brings positive attention may smile more often.^^
• Habituation
  • decrease in response to a stimulus that occurs after repeated presentations of the same stimulus
  • most primitive form of learning that occurs in every sensory system
  • ^^A baby who showed interest and surprise at first seeing a novel toy may show no interest after seeing the same toy several times.^^

Social Competence: Responding to Others

• Newborns have the capability to imitate others’ behavior.
• 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
• jury is out on exactly when true imitation begins
• this provides them with an important foundation for social interaction later in life

Factors that Encourage Social Interaction Between Full-Term Newborns and their Parents

• more talking with adults; the more social