Labor Birth and the Neonate OT 500 Spring

Labor, Birth and the Neonate OT 500 Spring 2016

Waiting for Baby…. . 40 weeks plus or minus 2 weeks = full term Events Occurring Just Prior to the Beginning of Childbirth Dropping or Lightening: head of fetus settles in pelvis Braxton-Hicks contractions (false labor) are the first uterine contractions; they may be experienced as early as the 6 th month Blood spotting in vaginal secretions due to pelvic pressure a day or so before labor Rush of amniotic fluid from vagina (water breaks) in 10 women Placenta and uterus secrete prostaglandins which cause the muscles of the uterus to contract As labor progresses, oxytocin is also released stimulating uterine contractions

3 Stages of Childbirth Stage 1 – cervix opens to 4 inches (10 centimeters); Contractions increase in strength, frequency, and regularity; fetal monitoring Lasts from a few hours to a couple of days; Ends with transition: head of the fetus moves into the birth canal/vagina Stage 2 – baby’s head, then body, pushed into, through, and out of the birth canal; mucus suctioned, umbilical cord clamped and cut about 3 inches Stage 3 – contractions expel placenta (can last from a few minutes to an hour)

The Stages of Childbirth Figure 4. 1

What Happens at the end of Second Stage of Childbirth? Newborn often removed by a nurse to be washed, foot-printed; given an ID bracelet Antibiotic ointment or drops are applied to baby’s eyes; Baby receives Vitamin K injection

Clamped and Severed Umbilical Cord Figure 4. 2

Methods of Childbirth

How Is Anesthesia Used in Childbirth? General anesthesia Puts mother to sleep Negative effects of general anesthesia on infant Abnormal patterns of sleep and wakefulness Decreased attention and social responsiveness for at least 6 weeks Local anesthetics Deadens pain without putting mother to sleep Minor depressive effects on neonates shortly after birth Natural childbirth No anesthesia is used

What Is Prepared Childbirth? Lamaze method Utilize breathing and relaxation exercises to lessen fear and pain Teaches women to associate relaxation with contractions Coach Aids the mother in the delivery room Provides social support to mother during labor

What Is the C-section? Cesarean Section Physicians prefer C-section to vaginal delivery when: Delivered by abdominal surgery 1 in 3 births in the US Mother has small pelvis Maternal weakness or fatigue Baby is too large Baby is in distress Prior C section (VBAC not an option) May be used to bypass infections in birth canal May be used when baby is facing the wrong direction http: //www. mylifetime. com/shows/one-born-everyminute/video/season-2/episode-5/c-sections

Other Newborn procedures Cutting the cord, bathing, anti-biotic eye ointment; Vitamin K Weight, height and head circumference Circumcision PKU test Newborn infant hearing test Breastfeeding

Birth Problems

Oxygen deprivation (hypoxia, anoxia) Prenatal oxygen deprivation Can impair development of central nervous system Cognitive, motor problems, and psychological disorders Oxygen deprived at birth Can occur due to maternal disorders, infant’s immature respiratory system; prolonged constriction of umbilical cord during birth; breech presentation Predicted problems in learning and memory Can cause health problems such as early-onset schizophrenia and cerebral palsy

Premature or preterm baby Occurs before 37 weeks gestation (normal is 40 weeks) Low-birth-weight baby Weighs less than 5. 5 pounds

What Risks Are Connected with Being Born Prematurely or with Low-Birth-Weight? Infant mortality Delayed neurological development Neonates weighing 3. 25 to 5. 5 pounds are 7 times more likely to die than infants of normal weight Those weighing less than 3. 3 pounds are nearly 100 times as likely to die Lower birth weight – poorer performance throughout school years Delayed motor development, such as walking

What Signs Are Connected with Being Born Prematurely or with Low-Birth-Weight? Preterm babies show signs of immaturity Relatively thin Fine, downy hair (lanugo) Oily, white substance on skin (vernix) Preterms born six weeks or more prior to full term Nipples not yet emerged Testicles of boys not yet descended into scrotum Muscles immature and reflexes are weak Respiratory distress syndrome Walls of air sacs in lungs stick together

How Are Preterm Infants Treated Following Birth? Usually remain in hospital incubators/isolette Temperature-controlled environment with protection from infection; Oxygen; close monitoring of vital signs Bonding with preterm infants may be challenged because Less attractive than full-term baby High-pitched, grating cries More irritable

How Are Preterm Infants Treated Following Birth? Carefully controlled external/environmental stimulation Massage Kangaroo care Parental support Feeding interventions if necessary

The Postpartum Period

What Kinds of Problems in Mood Do Women Experience During Postpartum Period? Baby blues Transient – about 10 days Do not impair mother’s functioning Postpartum depression (PPD) Present in as many as 1 in 5 -10 women Begins one month after delivery and may linger for weeks/months Major depressive disorder rare but can occur involving psychotic features (1 woman in 500 – 1, 000)

How Critical Is Parental Interaction with Neonates in the Formation of Bonds of Attachment? Bonding Formation of bonds of attachment between parent and child, but hours after birth are just one aspect of bonding process Extended early contact is not essential for adequate bonding Parent – child bonding is a complex process involving the desire to have a child; ability of the caregiver to read infant cues and be responsive in a consistent, timely, sensitive, appropriate manner

Characteristics of Neonates

How Do Health Professionals Assess the Health of Neonates? Apgar scale (taken at 1 and 5 minutes) based on 5 signs: appearance (color); heart rate; grimace/reflex irritability; activity level/muscle tone; respiration Brazelton Neonatal Behavioral Assessment Scale Interpretation of scores 7 or above – no danger Below 4 – critical condition Based on four areas of behaviors Measures reflexes, motor behavior, and muscle tone Neonatal Intensive Care Unit Network Neurobehavioral Scale (assesses infants at risk)

Primitive Reflexes Simple, unlearned stereotypical responses, elicited by certain types of stimulation Serve some survival functions Neural functioning is determined by testing reflex; neurodevelopment age

Reflexes Shown by Neonates Rooting Reflex Sucking Reflex Baby turns head and mouth toward stimulus that strokes the cheek, chin, or corner of mouth Babies will suck almost any object that touches the lips; eventually replaced by voluntary sucking Moro or startle reflex Occurs when baby’s position is suddenly changed or head and neck support is lost; Can also be elicited by loud noises or bumping the baby Back arches, legs and arms are flung out and then brought back toward chest into a hugging motion Usually lasts for 6 to 7 months after birth

More Reflexes Grasping or palmar reflex Stepping reflex Mimics walking when held under arms Usually disappears by 3 or 4 months Babinski reflex Using four fingers, babies grasp fingers/objects pressed against the palms of their hands Usually lost by 3 to 4 months and replaced by voluntary grasping at 5 to 6 months Fans or spreads toes in response to stroking foot Usually disappears at end of first year Asymmetrical Tonic-neck reflex (ATNR) While lying on back, baby turns head to one side. Arm and leg on that side extend, while opposite side flex.

Asymmetrical Tonic Neck Reflex (Archer’s, Fencing Pose) http: //library. med. utah. edu/pedineur ologicexam/

Vision Visual acuity Estimate of 20/600 Best see objects 7 to 9 inches from eyes Lack peripheral vision of older child Able to track movement within one day of birth; Preference for moving objects Visual accommodation Self-adjustments made by eye lens to bring objects into focus Neonates show little or no visual accommodation; can focus on objects 7 to 9 inches away Convergence does not occur until 7 or 8 weeks Color perception: At birth, not sure how well infants see color; Cones which perceive color are less developed than rods, which transmit light/dark

Convergence of the Eyes Figure 4. 5

Hearing Fetuses respond to sound, and neonates respond to various amplitudes and pitches Show preference for mothers’ voices Responsive to sounds and rhythms of speech Show no preference for specific languages

Smell and Taste Smell Well-developed at birth Demonstrate aversion for noxious and preference for pleasant odors Recognize familiar odors Taste Sensitive to different tastes Demonstrate facial expressions in response to tastes Prefer sweet tastes

Touch and Pain Touch (tactile sense) Sensitive to touch Touch elicits many reflex behaviors Pain Past belief that neonates are not sensitive to pain; Neonates not cognitively equipped to ruminate about pain. . but they feel it! Conditionable – distress when confronted with situation that previously presented itself as painful

Can Neonates Learn? Classical Conditioning Involuntary responses are conditioned to a new stimuli Operant Conditioning Behavior (reflexes) are modified through reinforcement Requires rapid administration of reinforcers The Cat and the Hat study – modified sucking reflexes SIMPLE CAUSE AND EFFECT

Why Babies Cry? Pain and discomfort: Close physical contact most helpful maternal Universal, expressive, and functional communication response Distinct causes and patterns of cries Expressive response to unpleasant feelings; get a caregiver response Hunger, anger, pain: HALT (Hungry, Angry, Lonely or Tired) Peaks of crying in late afternoon and early evening Crying produces physiological response in others How can we stop the crying? ? Sucking serves as a built-in tranquilizer; Pacifier, sweet solutions Swaddling Shushing; Speaking to them in low voice Rhythmic movement Pick baby up, patting, caressing, rocking them Dealing with the cause

Sleep and the Newborn Neonates spend about 16 hours per day in sleep with 6 wake-sleep cycles o - By 5 -6 months, many infants begin to sleep through the night (meaning 5 – 6 hours) - Neonates spend 50% time in REM sleep; 6 months – 30%; 2 to 3 years – 20 to 25%; Neonates may utilize REM sleep to stimulate the brain - Various states of arousal or wakefulness; calm-alert is nice!

REM Sleep and Non-REM Sleep Figure 4. 8

Co-Sleeping, Bed Sharing and the Family Bed Sharing Sleeping “The in the same bed with baby Family Bed” A conscious caregiver decision to share sleep and a bed with baby Co-Sleeping Generally sleeping near baby – within reach but not necessarily in the same bed

Risks § Suffocation, Entrapment Long term co- sleeping can make transition into crib or bed more difficult, especially when breastfeeding. American Association of Pediatrics (AAP) does not endorse co-sleeping Increased risk to child Links co-sleeping to SIDS Recommends room sharing, but not bed sharing

So Why share a Bed with a baby? Sleep Deprivation – it may be the only way everyone gets some sleep; cozy; easier; baby is comforted by physical contact Easier to breastfeed during the night It’s practiced in many other cultures Behavior is hard to change, even in the face of evidence Some evidence suggests: Babies who bed share with caregivers learn to regulate their breathing from caregiver – guards against SIDS Babies who co-sleep develop secure attachment, and have other positive developmental outcomes

Shaken baby Syndrome Rapid shaking of baby resulting in damage to central nervous system; Non-accidental head injury Babies have limited neck and trunk control, and a proportionally large head in relation to their body Can not guard again rapid movement Brain bounces in the head with the shaking movement Results in long term effects on development Loss of vision or impairment Cerebral palsy Cognitive and motor delays

SIDS: Sudden Infant Death Syndrome – crib death Happens while the baby is sleeping More common among babies between ages 2 and 4 months when reflexive behavior is weakening More common among babies who sleep on their stomachs Causes of SIDS remains obscure Other risk factors: males, low birth weight; lower SES, bottle-fed, African American, teenage mothers, born to mothers who smoke or use drugs

Reducing the Risks of SIDS AAP recommends: Back to sleep, tummy to play Room sharing, not bed sharing Breastfeeding Use a pacifier Firm sleeping surface, free of soft bedding with a tight sheet Avoid overheating baby Routine immunizations Avoid exposure to tobacco smoke, alcohol or illicit drugs No use of breathing monitors (false security)