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Birth and the Newborn Infant
Chapter 3
Robert S. Feldman

Looking Ahead
What is the normal process of labor?

What complications can occur at birth, and what are their causes, effects, and treatments?

What capabilities does the newborn have?


BIRTH
In the beginning
Neonate



Labor: The Process of Birth Begins
Contractions
Braxton-Hicks (“false labor”)

Labor initiation: about 266 days after conception, corticotropin-releasing hormone (CRH) triggers release of oxytocin from mother’s pituitary gland, causing contractions
Stages of Labor
From Fetus to Neonate
When is the moment of birth?

What causes a baby to cry after birth?

What cultural differences surround the birth of children worldwide?

APGAR SCALE



More About APGAR Scores
Low scores
Existing fetal problems or birth defects
Difficulties related to process of birth
Temporary deprivation of oxygen (anoxia)
Wrapped umbilical cord
Pinched umbilical cord

Initial Encounters
True or false:
Newborns who do not spend time bonding with their parent or parents immediately after birth will automatically suffer long-term social and emotional consequences.

Messages from Massage
Physical stimulation after birth
Touch stimulates production of brain chemicals that instigate growth
Approaches to Childbirth
Variety of strategies and approaches

No universally accepted single procedure

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


What birthing procedures would you choose?
Alternative Birthing Procedures
Lamaze birthing techniques

Bradley Method

Hypnobirthing




Childbirth Attendants: Who Helps?
Obstetrician
M.D.
Midwife
(nurses) with specialized training, used primarily when no complications expected
Doula
Trained to provide emotional & educational support during birth

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.
Use of Anesthesia and Pain-Reducing Drugs
Kinds
Epidural anesthesia
Walking epidural or dual spinal-epidural

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
And so…?
Only minimal risks to the fetus and neonate

Woman’s request for pain relief at any stage of labor should be honored

Proper use has no significant effect on 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

Post-delivery Hospital Stay
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
BIRTH COMPLICATIONS
What do you think?

Why is infant survival less likely in the United States than in other, less developed countries?
International Infant Mortality






Problems During Labor and Delivery
Preterm infants – before 38 weeks
Low birth-weight infants
Average weight 3400 gm (7.5 lb)
“Low” is < 2500 gm (5.5 lb)
7% of infants but majority of deaths
Small-for-gestational-age infants – 90% or less of expected weight for age
Very low birth-weight infants
Most vulnerable; immaturity of their organ systems
Weigh less than 1250 grams (around 2 1/4 pounds), or regardless of weight are < 30 weeks
Average monthly cost of medical care for 1st 3 years: 3-50 times higher


Survival of the Smallest
What causes preterm and low-birth-weight deliveries?
Half are 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

(See Table 3-2)
Post-mature Babies: Too Late, Too Large
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

True or False?

Cesareans are effective medical interventions?
International Incidence Rate: Cesarean Deliveries
Mortality and Stillbirth: The Tragedy of Premature Death
Stillbirth: the delivery of a child who is not alive
Rate: less than 1 out of 100 deliveries
Effects on parents:
Loss and grief similar to death of older child
Combination of birth and death makes especially difficult
Depression
Infant Mortality
Overcoming Racial and Cultural Differences in Infant Mortality
Infant Mortality
U.S. infant mortality rate higher than many other countries
Due to higher rate of low-birth weight and preterm deliveries
1 out of every 6 pregnant women has insufficient prenatal care.
20 percent of white women and close to 40 percent of African American women receive no prenatal care early in pregnancy.
5 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.
Higher U.S. mortality rate relates to economic diversity: less prenatal care, insurance, paid maternity leave

Importance of Maternity Leave
Mothers who spend more time on leave may have better mental health & higher quality interactions with their infants.

Typical U.S. leave: 12 weeks unpaid

European countries offer more leave, paid leave, often paternity leave as well.

Moving From the Heights of Joy to the Depths of Despair
Postpartum Depression
Incidence rate – 10%, 1/500 cases severe
Symptoms and Causes
Consequences

When Mothers Are Depressed
Depressed mothers
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
Review and Apply
REVIEW
Largely because of low birth weight, preterm infants may have substantial difficulties after birth and later in life.

Very-low-birth weight infants are in special danger because of the immaturity of their organ systems.
Review and Apply
REVIEW
Preterm and low-birth weight deliveries can be caused by health, age, and pregnancy-related factors in the mother. Income (and, because of its relationship with income, race) is also an important factor.
Review and Apply
REVIEW
Cesarean deliveries are performed with post mature babies or when the fetus is in distress, in the wrong position, or unable to progress through the birth canal.

Infant mortality rates can be affected by the availability of inexpensive health care and good education programs for mothers-to-be.

Postpartum depression affects about 10 percent of new mothers.
Review and Apply
APPLY
What are some ethical considerations relating to providing intensive medical care to very-low-birth weight babies?

Do you think such interventions should be routine practice? Why or why not?

Review and Apply
APPLY
Why do you think the United States lacks educational and health care policies that could reduce infant mortality rates overall and among poorer people?

What arguments would you make to change this situation?
THE COMPETENT NEWBORN
The Competent Newborn
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
Coughing & sneezing
Blinking
The Newborn Digestive System
Meconium – initial feces, greenish-black material that is the remnant of life as a fetus
Neonatal jaundice – yellowish tinge to body and eyes, caused by immature liver
Most common in preterm and low-weight babies
Typically not dangerous
Sensory Capabilities: Experiencing the World
Seeing
Visual acuity not fully developed but can see to some extent
Attend to visual field highest in information (i.e., contrast) and brightness
Possess some sense of size constancy
Distinguish and show preference for certain colors (blue and green)
Sensory Capabilities: Experiencing the World
Hearing
Clearly capable of hearing, but auditory acuity not completely mature
Also have amniotic fluid in middle ear
React to and show familiarity with certain kinds of sounds
From Research to Practice Circumcision of Newborn Male Infants
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
Infants are capable of learning very early through classical conditioning

Operant conditioning functions from the earliest days of life

What is habituation?
Decrease in response to stimulus that occurs after repeated presentations of same stimulus
Most primitive form of learning that occurs in every sensory system
Table 3-5
Social Competence: Responding to Others
Newborns have capability to imitate others’ behavior (i.e., stick out tongue)
Also discriminate between expressions in early months
This provides them with important foundation for social interaction later in life
Review and Apply
REVIEW
Neonates are in many ways helpless, but studies of what they can do, rather than what they can’t do, have revealed some surprising capabilities.

Newborns’ respiratory and digestive systems begin to function at birth. They have an array of reflexes to help them eat, swallow, find food, and avoid unpleasant stimuli.
Review and Apply
REVIEW
Newborns’ sensory competence includes the ability to distinguish objects in the visual field and to see color differences; the ability to hear and to discern familiar sounds; and sensitivity to touch, odors, and tastes.

The processes of classical conditioning, operant conditioning, and habituation demonstrate infants’ learning capabilities.

Infants develop the foundations of social competence early.