CHAPTER 4 Birth and the Newborn Baby: In the New World

CHAPTER 4

Birth and the Newborn Baby:

In the New World

Learning Outcomes

LO1 Identify the stages of childbirth.LO2 Examine different methods of

childbirth.LO3 Discuss potential problems with

childbirth.LO4 Describe the postpartum period.LO5 Describe the characteristics of a

neonate.

© Monalyn Gracia/Photolibrary

TRUTH OR FICTION?• T F After birth, babies are held upside down and

slapped on the buttocks to stimulate independent breathing.

• T F The way the umbilical cord is cut determines whether the baby’s “belly button” will be

an “innie” or an “outie.”• T F Women who give birth according to the

Lamaze method do not experience pain.• T F In the U.S., about 3 births in 10 are by

cesarean section.• T F It is abnormal to feel depressed following

childbirth.• T F Parents much have extended early contact

with their newborn children if adequate bonding is to take place.

• T F More children die from Sudden Infant Death Syndrome (SIDS) than from cancer, heart

disease, pneumonia, child abuse, AIDS, cystic fibrosis, and muscular dystrophy combined.

Countdown to Childbirth• Fetal position

– Early in last month, fetus settles with head in pelvis: referred to as “dropping or lightening”

• First contractions– Braxton-Hicks contractions: false labor– Can start at 6 mos. and tend to increase in later mos.

• Amniotic fluid1 in 10 women experience a bursting of the amniotic sac, usually at end of 1st stage labor

• Other common signs– Indigestion; diarrhea; abdominal cramps; back ache

• Fetal hormones– Stimulate placenta and uterus to secrete

PROSTAGLANDINS & OXYTOCIN to stimulate contractions

LO1 The Stages of Childbirth


Three Stages of Childbirth

• STAGE ONE process…– Contractions efface & dilate the cervix

• Needs to be 4 inches (10 centimeters) for passage

• Contractions start about 10-20 minutes apart at 20-40 seconds; when reaching 4-5 minutes, advised to go to hospital or birthing center

– Average length of time for Stage One• About half a day to one day: 1st deliveries are

usually longer– “Prepping”

• Pubic area shaved (enema) intended to lower chances of infection; not mandatory, up to the attending physician


• STAGE ONE process…(cont.)– Fetal monitoring

• Electronic sensors measure fetal heart rate to alert staff of problem

– Helpful equipment• If speeding up delivery is needed, staff may use

forceps or vacuum extraction tube.– Transition

• Fetus moves through birth canal; approx. 30 minutes for birth


• STAGE TWO…– Crowning

• When the babies head begins to emerge • Baby will normally completely emerge within minutes

– Average length of time for Stage Two• Shorter than 1st stage: from a few minutes to hours

– Epistiotomy• Surgically cutting area between birth canal and anus to

prevent random tearing• Like prepping (enema) is controversial and optional• Use in U.S. dropped: 70% in 1983 to 19% in 2000


• STAGE TWO…(cont.)– How baby looks

• Head and facial features can be distorted from trauma; return to normal in time

– What happens to baby now• Mucus suctioned from mouth as soon as head emerges• When breathing on own, umbilical cord is clamped and cut

to 3 inches (stump will dry and fall off in about 7-10 days).• Baby is foot-printed.• ID bracelet is placed on wrist.• Erythromycin (antibiotic ointment) or drops of silver nitrate

placed in eyes to prevent bacterial infections.• Vitamin K injected to help blood clot (newborns do not

make own V-K).

Figure 4.2 – A Clamped and Severed Umbilical Cord

Stages of Childbirth

• STAGE THREE…– a.k.a “placental” stage– Length of time

• Few minutes to an hour or more

– During this final stage:• Placenta separates from wall of uterus and is

expelled through birth canal.• Some bleeding is normal.• Obstetrician stitches episiotomy if it was

performed.

LO2 Methods of Childbirth


Methods of Childbirth

• Historically– Usually took place in the home, involved family and

perhaps a midwife

• Currently– Home births still pattern in less developed nations– In U.S. now in hospitals or birthing centers

• Some argue this “depersonalizes” the experience.

• Methods– Anesthesia– Prepared Childbirth– Doulas– Cesarean Section


• ANESTHESIA used to lessen pain.– General Anesthesia

• Injection of barbiturate puts mother to sleep.– Reduces initial responsiveness of baby; no long-term effects

– Tranquilizers• Oral barbiturates and narcotics• Reduces anxiety and perception of pain without inducing

sleep

– Local anesthetics• Pudenal block external genitals deadened with injection• Epidural & Spinal Block: injection to spinal cord that numbs

body below the waist

– No anesthetics• Natural childbirth: no drugs or anesthetics; uses relaxation

and breathing exercises


• LAMAZE METHOD = Prepared Childbirth– Mother and “Coach”

• Mother learns breathing and relaxation methods to lessen fear and pain and distract from pain.

• “Coach” (usually Dad but can be anyone) aids in delivery room by supporting Mother.


• DOULAS– A non-professional person offering social

support during labor.– Women with Doulas appear to have

shorter labor.


• CESAREAN SECTION (C-Section)– Process:

• Physician delivers baby by abdominal surgery.• Cut through abdomen and uterus and removes

baby

– Possible indications for performing:• If mother has small pelvis or weakened from

long labor• Very large baby or multiples• Prevention of circulatory mixing between mother

and baby (prevention of AIDS, genital herpes)• If baby is facing in wrong direction (not head

first: breach birth)

LO3 Birth Problems


Birth Problems

• OXYGEN DEPRIVATION– Anoxia: without oxygen– Hypoxia: “under” oxygen– Implications:

• PRENATTALY: Impaired CNS development; can cause cognitive & motor skills problems and psychological disorders

• DELIVERY: schizophrenia, cerebral palsy - death

– Causes:• Diabetes (mother)• Accidents to umbilical cord• Immature respiratory system in baby

Birth Problems

• PRETERM AND LOW-BIRTH-WEIGHT INFANTS– APPROX. 7% OF ALL BABIES BORN– Preterm: Birth before 37 weeks (40 normal)

gestation• Common in multiple births

– Low-birth-weight: Less than 5 lbs– Small for dates: full term but underweight

• Mothers who smoke, do drugs, and receive improper nutrition place babies at risk.

• Babies tend to remain smaller throughout life.• Preterms seem to catch up more.

Preterm & Low-birth-weight Infants• Risks:

– 3.25 - 5.5 lbs.• 7 times more likely to die

– Less than 3.3 lbs.• Nearly 100 times more likely to die

– 1.65 lbs.– Sex differences

• Girls seem to improve more readily than boys

– Overall deficiencies• Severity of disabilities reflects extent of deficiencies• Most experience cognitive and motor skills deficiencies

– Corticosteriods• Administering to women at risk may increases chances of

survival

Preterm & Low-birth-weight Infants

• Characteristics:– Relatively thin: no baby fat– Lanugo: fine downy hair– Vernix: oily white substance

on skin– If more than 6 weeks early, no

nipples & testicles in boys have not descended but will do so after birth

– Muscles are immature; sucking and breathing reflexes are weak

– If more than a month early, may display respiratory distress syndrome (irregular or cessation of breathing).

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• Treatment:– Due to physical frailty, often remain

hospitalized in incubators.– They maintain a temperature-controlled

environment and afford protection from disease.

– Some may receive oxygen, but over-oxygenation may cause permanent eye injury.


• Parents & Preterm Neonates– Physically less attractive babies– Cries are high pitched and grating– More irritable, passive, and less social– Mothers may feel alienated, harbor guilt, and

sense of failure and low self-esteem– Fear of hurting may discourage handling– Preterms fare better with responsive caring

parents


• Intervention Programs– Stimulation helps preterms develop

• Cuddling, rocking, talking, singing, music, mobiles

• Massage and “kangaroo care” (skin to skin, chest to chest, with parent)

• Stimulated preterms show fewer respiratory problems, gain weight more rapidly, and make greater advances in motor, intellectual, and neurological development than those not receiving stimulation

Figure 4.3 – Stimulating a Preterm Infant

It was once believed that preterm infants should be left as undisturbed as possible. Today, however, it is recognized that preterm infants usually profit from various kinds of stimulation.

© Louie Psihoyos/Science Faction

LO4 The Postpartum Period


Postpartum Period• There is no definitive time period; generally

considered the few weeks following delivery• Maternal Depression

– 70% of new mother’s worldwide experience the “baby blues,” generally last about 10 days

– 1 in 5 may experience postpartum depression (PPD), a serious mood disorder.

• Triggered by sudden drop in estrogen; drugs that increase estrogen levels can help symptoms

• Symptoms include: serious sadness, hopelessness, helplessness, worthlessness, poor concentration, loss of appetite, and insomnia

• 1 in 500 may experience psychotic symptoms that place child at risk.

Postpartum Period

• Bonding– Attachment bonds are crucial to the

survival and well-being of children.– Parent-child bonding is a complex process

requiring parent/child familiarization. – Serious maternal depression can delay

bonding. – Women with history of rejection by own

parents can also interfere with bonding.– Parents can adopt children at advanced

ages and still bond with them.

LO5 Characteristics of Neonates


Characteristics of Neonates

• Assessing the Health of Neonates– APGAR Scale

• Administered at birth• Measures 5 signs of health

– Appearance, Pulse, Grimace, Activity level, Respiratory effort

• Scores vary from 0-10• 7 or above = no danger - 4 or below = critical, needs

immediate attention• By one minute after birth, most babies reach 8-10.

– Brazelton Neonatal Behavioral Assessment Scale

• Measures reflexes and behaviors in 4 areas– Motor behavior, Response to Stress, Adaptive behavior,

Control over physiological state.

Table 3.2 – The Apgar Scale


• REFLEXES: Simple, unlearned responses to stimuli; adaptive and are normally replaced with other learned behaviors within a few months.– ROOTING

• Sucking reflex, stimulated by touching baby’s cheek

– MORO• When babies position is suddenly

changed (dropping, loud noises, bumping, etc.), the back arches and legs and arms fling outward and back into chest with hugging motion.

– GRASPING or PALMAR• Grabbing or fingers other objects

using 4 fingers (not thumbs)

Characteristics of Neonates• REFLEXES:

– STEPPING• Mimics walking; when held up, baby will place

one foot in front of the other as if attempting to walk

– BABINSKI• When bottom of foot is stroked, toes spread in a

fan motion then curl inward.– TONIC-NECK

• When lying on back with head to one side, arm and leg will extend toward direction head is turned, other side will flex.


• Sensory Capabilities– VISION - SIGHT

• Nearsighted: see best at 7-9 inches• Prefer moving objects: no peripheral

vision• Visual accommodation (automatic

adjustment of lens for focusing): neonates show little or none: view as if through fixed-focus camera

• Convergence (inward movement of eyes to focus on close object): neonates may exhibit cross-eyes or wall-eyes when looking at objects at close ranges

• Degree of color perception remains open for neonates by 4 mos., however, most infants can see all visible colors

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• Sensory Capabilities, cont– AUDITION - HEARING

• Hearing is present in utero; may play a part in bonding– Prefer sound of mother’s voice over all others after birth; no

preference for father’s voice

• Most newborns respond to unusual sounds.• Will respond to different amplitude (height of sound wave -

higher = louder) and pitch (frequency of sound wave - higher frequencies make high pitches, low make low sounds); singing in low tones is soothing

• Particularly responsive to sounds and rhythms of speech but don’t display preference for any specific language; can discriminate differences in speech sounds; appear to be “pre-wired” for language acquisition


• Sensory Capabilities, cont– OLFACTORY - SMELL

• Can discriminate distinct odors• Show rapid breathing patterns and increased

movement in response• Turn away from unpleasant odors• Sensitive to smell of mother’s milk and mother’s

underarm odor, which may contribute to early development of recognition and attachment.


• Sensory Capabilities, cont– TASTE

• Sensitive to different tastes evident from facial expressions

• Discriminate between salty, sour, and bitter• Exhibit preference for sweet tastes which seem

to be calming – Sweet solution increase heart rate but also slow

sucking indicating an effort to savor and make the flavor last

Figure 4.4 – Facial Expressions Elicited by Sweet, Sour, and Bitter Solutions


• Sensory Capabilities, con’t– TOUCH & PAIN

• Important to learning and communication for babies

• Sensation of skin to skin contact appears to provide comfort and contribute to bonding with caregivers

• Many reflexes are activated

by pressure against the skin– Rooting, Sucking, Babinski,

and Grasping © I

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Learning: Really Early Childhood “Education”

• Classical conditioning– Involuntary responses are conditioned to

new stimuli.• Newborns taught to blink in response to a tone.• Blinking (UR) caused by puff of air to eye as a

tone was sounded (CS). • After repeated pairings, sound of tone caused

babies to blink (CR).• Conditioned stimuli are specific; capacity to learn

is universal.

Learning: Really Early Childhood “Education”

• Operant conditioning– Positive or Negative Reinforcement tends to

increase the incidence of a behavior.– Use of “reinforcers” to illicit learned behavior

• Experiments using sound of mother’s voice as a positive reinforcement were found to modify babies sucking reflexes with a pacifier.

• Baby learns through operant conditioning.

Sleeping & Waking• Neonates spend about 2/3 (16 hrs) a day

sleeping.– Adults spend about 1/3 day. – But baby does NOT sleep 16 consecutive hours

which becomes a challenge for parents.– There are a number of differing sleep/wake

patterns; individual infants vary but…• Most all distribute sleep throughout day and

night• Typically show 6 cycles of sleep/wake in 24-hrs• Naps usually about 4.5 hrs and awake about 1

hr in between• Sleep time will increase as baby grows, and by 6

mos to 1 yr most will sleep through the night.

Table 4.3 – States of Sleep and Wakefulness in Infancy

Sleeping & Waking• REM and Non-REM Sleep

– REM: periods of sleep where eye movement is observed under closed eyelids

– 80% of adults report dreaming when in this stage of sleep and are difficult to awaken

© Adam Przezak/iStockphoto.com

Sleeping & Waking• REM and Non-REM Sleep

– EEG brain waves resemble waking states• a.k.a = Paradoxical Sleep• Neonates spend about 1/2 sleep time in REM

– Preterm babies spend even more time in REM– By 6 mos., about 30%; and 2-3 yrs about 20-25%– Function in neonates: REM may be used to stimulate

brain activity needed for creation of proteins for development of neurons and synapses.

– Non-REM: all other stages of sleep in sleep cycle

Figure 4.5 – REM Sleep and Non-REM Sleep

Sleeping & Waking

• Crying– Frequency & times of

day• Most crying bouts

occur late p.m. & early evenings

• Most will produce same amount for first 9 months but they gradually decrease in length of time

• If crying is ignored first 9 wks, it appears to decrease 2nd 9 wks.

© iStockphoto.com

Sleeping & Waking

• Crying, cont– Causes

• Main reason is pain but also helps clear respiratory systems of fluids and stimulate the circulatory system

– Recognizing types– Most parents soon learn to interpret different

types of crying patterns for hunger, anger or..• PAIN: sudden, loud, insistent, accompanied by flexing

and kicking legs– Can indicate colic (gas & distress in digestive tract)– Can be severe and persistent; lasting hours sometimes– Colic generally disappears by 3-6 mos.– Some high-pitched cries indicate other serious problems

» Chromosomal abnormalities, infections, malnutrition, exposure to narcotics, etc.

Sleeping & Waking• Soothing

– Methods• Pacifier: sucking appears to be an innate tranquilizer; as is

sucking on something sweet• Caregivers: soothe by picking up the baby, patting,

caressing, rocking, swaddling, and speaking in low tones– Try to ascertain cause of distress– Learn by trial and error what each baby prefers– Some parents worry that responding to cries will

“spoil” the baby and they will not learn to engage in “self-soothing” behaviors to go to sleep

– As infants mature, crying is replaced by verbal requests for intervention.

Sudden Infant Death Syndrome (SIDS) a.k.a Crib Death

• Defined:– A disorder of infancy that strikes while baby

sleeps.– Typically baby is in perfect health and is

found dead next morning with no sign that baby struggled or was in pain

– Baby just stops breathing for unknown reasons.


• Most Prevalent in:– Babies age 2-4 months– Babies put to sleep on tummies or sides– Premature and low-birth-weight babies– Male babies– Babies in lower socioeconomic status families– Babies in African American families

• African American babies twice as likely

– Babies of teenage mothers– Babies whose mothers smoked during or after

pregnancy or used drugs during pregnancy


• Causes:– Still unknown but recent (2006) study at Boston

Children’s Hospital show:• Medullas of SIDS victims were less sensitive to the

chemical serotonin • Serotonin is chemical that keeps the medulla responsive.• The medulla is an area in the brainstem involved in basic

functions such as breathing and sleep/wake cycles.• The problem was seen more in brains of boys, accounting

for the higher incidence in male babies.

Figure 4.6 – The Medulla


• Lowering Risk: “The Safe Sleep Top 10”– Prevention should begin during pregnancy

• Don’t smoke or use drugs– National Institute of Child Health and Human

Development (NICHD,2006) suggest:• 1. Always place baby on back to sleep• 2. Place baby on firm sleep surface free of

quilts, pillows, or other soft surfaces• 3. Keep toys and loose bedding out of crib

and keep any other items away from babies face


• Lowering Risk: “The Safe Sleep Top 10”4. Do not allow smoking around the baby5. Keep baby’s sleep area close to, but

separate from, others’ sleep areas. Baby should not sleep in a bed or on a couch or armchair with anyone.

6. Use a clean, dry pacifier when putting baby to sleep; don’t force baby to take it

7. Do not let baby get too warm or overheat during sleep; dress in light clothing and keep temperature comfortable


• Lowering Risk: “The Safe Sleep Top 10”8. Avoid products that claim to reduce risk

of SIDS; most have not been tested for effectiveness or safety

9. Do not use home monitors to reduce risk of SIDS. Refer questions to your health care provider.

10. Reduce the chance that flat spots will develop on baby’s head: provide “tummy time” while baby is awake and being watched. Change direction baby sleeps in crib weekly.

Documents

CHAPTER 4 Birth and the Newborn Baby: In the New World