Download Preterm Infants

CHAPTER 3
BIRTH AND THE NEWBORN
INFANT
Learning Objectives
Labor: The Process of Birth Begins
Corticotropin-releasing hormone (CRH)
• Oxytocin and other hormones triggered
• Uterus contracts
Contractions
• Braxton-Hicks
• Labor initiation
Stages of Labor
APGAR SCALE
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A score is given for each sign at one minute and five minutes after the birth.
If there are problems with the baby, an additional score is given at ten
minutes.
A score of seven to ten is considered normal, whereas four to seven might
require some resuscitative measures, and a baby with an Apgar score
under four requires immediate resuscitation.
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
You must have been a beautiful baby…
or were you?
Introducing the neonate
• Vernix
• Lanugo
• Puffy eyelids
• Blood/other substances
• Highly variable “presentation”
Approaches to Childbirth:
Where Medicine and Attitudes Meet
• Variety of strategies and approaches
• No universally accepted single procedure
• No conclusive research evidence that one procedure
significantly more effective than another
Childbirth Attendants: Who Delivers?
• Obstetrician
• Midwife
• Doula
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
• Proper use has no significant effect on child’s later wellbeing
Neonate
 Latin ‘natus’ meaning born
 A baby 4 weeks old or younger.
 Also called a “newborn”
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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
• By 1990s, average stay for normal birth is 2 days
– Changes prompted by medical insurance companies
• American Academy of Pediatrics recommendation
– Stay in hospital should be no less than 48 hours after
giving birth
What are the advantages and disadvantages
of early dismissal?
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
What does this have to do with developmental psych?
Becoming an Informed Consumer of
Development
Dealing with Labor
Be flexible
Communicate
Remember
with health
that labor is . .
care providers
. laborious
Accept
support
Be realistic
and honest
about
reactions to
pain
Focus on the
big picture
BIRTH COMPLICATIONS
International Infant Mortality
While the United States
has greatly reduced its
infant mortality rate in the
past 25 years, it ranks
only twenty-third
among industrialized
countries as of 2009.
What are some of the
reasons for this?
(Source: The World
Factbook, 2009.)
Preterm Infants: Too Soon, Too Small
Preterm infants
– Respiratory distress syndrome (RIDS)
Low birth-weight infants
Small-for-gestational-age infants
Outcomes
• Majority of preterm infants eventually develop normally in
long run
• Tempo of development often proceeds more slowly
Preterm Infants: Too Soon, Too Small
• Preterm infants, or premature infants, are born prior to
38 weeks after conception.
• The average newborn weighs around 3,400 grams
(about 7 1/2 pounds)
• low-birth weight infants weigh less than 2,500 grams
(around 5 1/2 pounds).
• 7 percent of all newborns in the USA fall into the lowbirth weight category but 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
Smallest survivors
• Most vulnerable; immaturity of their organ systems
• Weigh less than 1250 grams (around 2 1/4 pounds)
• Or, in womb less than 30 weeks
• Eyes may be fused shut, earlobes may look like flaps of skin
on the sides of their heads; skin a darkened red color,
whatever their race.
Risk-reduction strategies
• High-quality care
• Responsive, stimulating and organized care
• Massage
Survival and Gestational Age
#/1000 babies born in USA after specified lengths of gestation
who survive the first year of life. WHAT?
This chart is crap. CDC wants $19 to see original data.
Could it actually mean # who die w/ in first year?
Population base skews data. Scotland may have had only 2 preemies per year.
In USA death in first year is 7/1000 live births
A Better Chart
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6205a6.htm
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What causes preterm and low-birth-weight
deliveries?
• Half of preterm/low birth-weight births unexplained
• Difficulties related to mother’s reproductive system
• Immaturity of mother’s reproductive system
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General health of mother
Smoking
Drugs
Illness
Factors Associated with Increased Risk of Low
Birth weight
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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
Cesarean Delivery: Intervening in the Process
of Birth
Procedure
• Baby is surgically removed from uterus
Rationale
• Occur most frequently when fetal stress appears
• More prevalent in older mothers
• In some cases, related to position in birth canal: breech, transverse
• Cultural
• Routine use of fetal monitor
• Increased profit for MD & hospital due to reimbursement rates
• Lower lawsuit risk
Risks
• Major surgery for mother, longer recovery
• Reduced stress-related hormones for neonate
• May not trigger normal hormonal release in mothers and babies
• Bonding issues
Cesarean Deliveries
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
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 (or 115 depending on source).
• Joy that accompanies the birth of a child is completely
reversed when a newborn dies
• U.S. infant mortality generally declining since 1960s
• Effects on parents:
• Enormous impact on family lack of support common;
• 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
• Sometimes PTSD
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
• affects some 10 percent of all new mothers
Symptoms
Main symptom: 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.
• Causes
may be triggered by the pronounced swings in hormone production that
occur after birth. During pregnancy, the production 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.
• Consequences
In extremely rare instances, postpartum depression may turn deadly.
When Mothers Are Depressed
Depressed Mothers
• Display little emotion and act detached and withdrawn
Infants
• Display fewer positive emotions and withdraw from
contact not only with their mothers but with other adults
Long term effects
• Children of depressed mothers are more prone to antisocial activities such as violence.
Developmental Diversity
First year mortality by race
Largest cause: low birth weight
THE COMPETENT NEWBORN
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.
Physical Development and
Learning in Infancy
Neonate focus:
 Perceptual Development
 Learning
 Motor Development
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Neonate
Reflexes: Built-In Responses
 Sucking, swallowing, coughing, and blinking
 Moving an arm, a leg, or other body part
away from a painful stimulus
 Attempting to remove a blanket or cloth
placed over the face.
 Rooting reflex—the baby opens its mouth
and actively searches for a nipple.
 Responses to voices – Pitch perception
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Neonate
Reflexes: Changes
 Neonates also have some reflexes that serve no
apparent function
 These reflexes are believed to be remnants of
humans’ evolutionary past.
 During development, some reflexive behaviors
(controlled by the lower brain centers) gradually come under the
voluntary control of the higher brain centers.
 Presence of these reflexes at birth and their
disappearance between the 2nd & 4th months allow
assessment of CNS development.
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The Newborn Digestive System
Sucking and swallowing reflexes help infants consume mother’s
milk & are coupled with the ability to digest nutriments
Neonatal jaundice
• 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.
The Newborn Digestive System
cont.
Sucking and swallowing reflexes help infants consume mother’s
milk & are coupled with the ability to digest nutriments
Meconium
• Earliest stools composed of materials ingested during the time
in the uterus: intestinal epithelial cells, lanugo, mucus,
amniotic fluid, bile, and water.
• Viscous and sticky like tar, its color usually being a very dark
olive green; it is almost odorless. It should be completely
passed by the end of the first few days after birth.
• Around half of the samples appeared to be dominated by
bacteria that produce lactic acid, such as lactobacillus, while
the other half mostly contained a family of so-called enteric
bacteria, such as Escherichia coli
Neonate
Perceptual Development
 The five senses, although not fully
developed, are functional at birth.
 The newborn already has preferences
for certain odors, tastes, sounds, and
visual configurations.
 Hearing is much better developed than
vision in the neonate and is functional
even before birth.
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Infant
Perceptual Development – Fantz Findings
 Fantz’s & others have shown that:
– newborns have clear preferences
– powers of discrimination
– memory recognition
– learning ability
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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
Infant
Perceptual Development - Vision
 At birth, an infant’s vision is about 20/600
 Typically reaches 20/20 about 2 years old
 Newborns focus best on objects about 9
inches away, and they can follow a slowly
moving object.
 Infants 22 to 93 hours old indicate a
preference for their own mother’s face over
that of an unfamiliar female.
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Infant
Perceptual Development - Vision
 Newborns prefer colored to gray stimuli
 Infants can’t distinguish all colors
perceived by adults until about 2
months
 Then prefer red, blue, green, & yellow
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Sensory Capabilities: Experiencing the World
Hearing
• Clearly capable of hearing, but auditory acuity
not completely mature
• React to and show familiarity with certain kinds
of sounds
Neonate
Perceptual Development
 A newborn is able to turn the head in
the direction of a sound and shows a
general preference for female voices.
 Shortly after birth, infants prefer their
own mother’s voice to that of an
unfamiliar female.
 A preference for the father’s voice over
a strange male voice does not develop
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until later.
What about other senses?
Other senses
• Senses of touch, smell, and taste are not only
present at birth, but are reasonably
sophisticated.
Neonate
Perceptual Development
 Newborns are able to discriminate among
and show preferences for certain odors and
tastes.
 They show a favorable response to sweet
tastes and are able to differentiate between
salty, bitter, and sour solutions.
 Newborns are also sensitive to pain and are
particularly responsive to touch, reacting
positively to stroking and fondling.
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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
Three Basic Processes of Learning
Social Competence: Responding to Others
• Newborns have capability to imitate others’ behavior
• Jury is out on exactly when true imitation begins
• This provides them with important foundation for social
interaction later in life
• 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
When Neonates and New Parents Jive
Review the information in Table 3.6 and consider
• 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.
Factors That Encourage Social Interaction
between Full-Term Newborns and Their Parents