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Birth and the Newborn Baby: In the New World

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1 Birth and the Newborn Baby: In the New World
CHAPTER 4 Birth and the Newborn Baby: In the New World Title page.

2 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

3 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. Helpful to open class discussion and stimulate ideas on topics within Chapter 4. Answers are found in notes sections as they are encountered throughout the chapter.

4 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 fluid 1 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 Certain bodily functions take place prior to the onset of labor.

5 LO1 The Stages of Childbirth
© Monalyn Gracia/Photolibrary

6 Three Stages of Childbirth
STAGE ONE process… Contractions efface & dilate the cervix Needs to be 4 inches (10 centimeters) for passage Contractions start about minutes apart at 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 EXPLANATION OF TERMS: EFFACE = TO THIN OUT DILATE = WIDEN OR ENLARGE FORCEPS = INSTUMENT THAT FITS AROUND BABY’S HEAD TO PULL IT THROUGH BIRTH CANAL VACUUM EXTRACTION TUBE = INSTRUMENT THAT USES SUCTION TO PULL THE BABY THROUGH THE BIRTH CANAL.

7 Three Stages of Childbirth
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

8 Three Stages of Childbirth
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

9 Three Stages of Childbirth
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). ANSWER TO T-F? #1 = After birth, babies are held upside down and slapped on the buttocks to stimulate independent breathing. FICTION; We may see newborns slapped on the buttocks to stimulate breathing in old movies, but suction is the method used in the U.S. today. ANSWER TP T-F? #2 = The way the umbilical cord is cut determines whether the baby’s “belly button” will be an “innie” or an “outie.” FICTION: Belly-button status, is unrelated to the methods of your obstetrician.

10 Figure 4.2 – A Clamped and Severed Umbilical Cord
This is Figure 4.2 on p. 60 of CDEV

11 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.

12 LO2 Methods of Childbirth
© Monalyn Gracia/Photolibrary

13 Methods of Childbirth Historically Currently Methods
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 MIDWIFE: A PERSON WHO HELPS WOMEN IN CHILDBIRTH Each of the methods listed will be explained in separate slides

14 Methods of Childbirth 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

15 LAMAZE METHOD = Prepared Childbirth
Methods of Childbirth 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. ANSWER TO T-F? #3: Women who give birth according t the Lamaze method do not experience pain. Fiction: Women who use Lamaze do experience pain, but they often report less pain and ask for less medication.

16 Methods of Childbirth DOULAS
A non-professional person offering social support during labor. Women with Doulas appear to have shorter labor.

Methods of Childbirth 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) ANSWER TO T-F? # 4 = In the U.S., about 3 births in 10 are by C-Section. TRUE: Some 31% of deliveries at C-sections, whereas they accounted for only 1 in 20 births (5%) in Some of the increase is due to advances in medicine. For example, fetal monitors now allow physicians to more readily detect fetal distress. But physicians also perform C-sections because they are concerned about the possibility of malpractice suits if something goes wrong during a v aginal delivery.

18 LO3 Birth Problems © Monalyn Gracia/Photolibrary

19 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

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.

21 Preterm & Low-birth-weight Infants
Risks: 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

22 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). © Tracy Dominey/Photo Researchers

23 Preterm & Low-birth-weight Infants
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.

24 Preterm & Low-birth-weight Infants
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

25 Preterm & Low-birth-weight Infants
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

26 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. This is Figure 4.3 on p. 66 of CDEV © Louie Psihoyos/Science Faction

27 LO4 The Postpartum Period
© Monalyn Gracia/Photolibrary

28 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. ANSWER TO T-F? # 5 - It is abnormal to feel depressed following childbirth. FICTION: Actually it is normal to feel depressed following childbirth. The baby blues affect most women in the weeks after delivery. Baby blues and other postpartum mood problems are so common that they are statistically normal.

29 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. ANSWER TO T-F? # 6 - Parents must have extended early contact with their newborn children if adequate bonding is to take place. FICTION: Despite the Klaus and Kennell studies, which made a brief splash in the 1970’s it is not necessary that parents have extended early contact with their newborn children for adequate bonding to occur.

30 LO5 Characteristics of Neonates
© Monalyn Gracia/Photolibrary

31 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.

32 Table 3.2 – The Apgar Scale It is placed in the Clipboard as shown on page 57 of CDEV

33 Characteristics of Neonates
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)

34 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.

35 Characteristics of Neonates
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 © Design Pics/Leah Warkentin

36 Characteristics of Neonates
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

37 Characteristics of Neonates
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.

38 Characteristics of Neonates
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

39 Figure 4.4 – Facial Expressions Elicited by Sweet, Sour, and Bitter Solutions
Is Figure 4.4 on pg 72 of CDEV

40 Characteristics of Neonates
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 © Image Source Black/Jupiterimages

41 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. UR = Unconditioned Response CS = Conditioned Stimulus CR = Conditioned Response

42 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.

43 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.

44 Table 4.3 – States of Sleep and Wakefulness in Infancy
this is table 3.3 on p. 62 of CDEV

45 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/

46 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

47 Figure 4.5 – REM Sleep and Non-REM Sleep
This is Figure 3.5 on p. 63 of CDEV - this should be a chart showing States of Sleep and Wakefulness in Infancy (in print out it was labeled 4.3)

48 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. ©

49 Sleeping & Waking Crying, cont Causes Recognizing types
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.

50 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.

51 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. ANSWER TO T-F? # 7: TRUE: More children die from Sudden Infant Death Syndrome (SIDS) than from cancer, heart disease,, pneumonia, child abuse, AIDS, cystic fibrosis, and muscular dystrophy combined. (Lipsitt, 2003)

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

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

54 Figure 4.6 – The Medulla THE MEDULLA - This is Figure 4.6 on p. 76 of CDEV

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

56 Sudden Infant Death Syndrome (SIDS) a.k.a Crib Death
Lowering Risk: “The Safe Sleep Top 10” 4. Do not allow smoking around the baby 5. 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

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

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