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Lesson 4

Learning Objectives

· Upon completion of this Lesson, you should be able to:

· Describe the three stages of childbirth and the infant's adaptation to labour and delivery, and the newborn infant's appearance;

· Discuss natural childbirth and home delivery, noting benefits and concerns associated with each;

· List common medical interventions used during childbirth, circumstances that justify their use, and discuss any danger associated with each;

· Explain the purpose and main features of the Apgar Scale;

· Understand the risks of oxygen deprivation, premature birth, and low birth weight and identify the factors that can help infants survive a traumatic birth;

· Describe the newborn's reflexes and states of arousal, including sleep characteristics and ways to soothe a crying infant;

· Understand the newborn's sensory capacities;

· Discuss the benefits of neonatal behavioural assessment;

· Describe typical changes in the family after the birth of a new baby, along with interventions that foster the transition to parenthood

· Understand the effects of premature birth and low birth weight on the infant's behavior and developmental outcomes.

Childbirth as a Developmental Task

The birth process prepares the fetus to leave its special and protective prenatal environment, and be transformed into a neonate who must adapt to life outside the womb. Thus, the complex task of being born can be seen as a transitional stage, from a fetus within the womb to a neonate outside the womb. Indeed, this transition is a major developmental achievement for the newborn infant and a major accomplishment for the birthing mother.

Please go to our textbook and read The Stages of Childbirth, on pages 126-129 in the 2012 edition, pages 123-126 in the 2016 edition, and pages 117-119 in the 2020 edition. These stages include the "Dilation and Effacement of the Cervix", "Delivery of the Baby", "Birth of the Placenta", "Baby's Adaptation to Labor and Delivery", "Newborn Baby's Appearance", and "Assessing the Newborn's Physical Condition: The Apgar Scale (Links to an external site.)". https://medlineplus.gov/ency/article/003402.htmBefore moving on, take a few minutes to read the "Ask Yourself" section, on page 129 in the 2012 edition, page 127 in the 2016 edition, and page 121 in the 2020 edition.

Return to pages 129-132 in the 2012 edition, and pages 127-129 in the 2016 edition, and pages pages 121-123 in the 2020 edition, and read Approaches to Childbirth where you will learn more about "Natural, or Prepared Childbirth" and "Home Delivery".

Then, read about Medical Interventions, on pages 132-135 in the 2012 edition, pages 129-132 in the 2016 edition, and pages 123-125 in the 2020 edition, where you will learn about "Fetal Monitoring", "Labor and Delivery Medication", "Instrument Delivery", "Induced Labor", and "Cesarean Delivery". You will realize that while these interventions may help save the lives of many infants, they can also be problematic and may have long-lasting consequences on the newborn baby.

Next, to learn more about the British Columbia experience and newborn testing, go to this section (Links to an external site.) https://www.healthlinkbc.ca/pregnancy-parenting/parenting-babies-0-12-months/newborns/newborn-screening-test of the HealthLink BC website. There you will learn about " Newborn Screening" in BC. Please note that the information presented in this section of the HealthLink BC webiste is available in a number of languages.

Currently, most Canadian infants are born in hospitals that are well equipped to deal with maternal or infant complications during childbirth. However, many hospitals are trying to balance these safety concerns with the socio-emotional needs of mothers, infants and their families. The strains of trying to address all these issues have caused a number of provinces to explore the feasibility of midwife-attended births. In fact, according to the website of the Midwives Association of B.C. (Links to an external site.) https://www.bcmidwives.com/faq.html , there is a large number of practicing midwives in B.C., and indeed, all of Canada. Please take a moment to visit this website, in order to learn more about midwives, and what they do. Now, please read the article entitled " Aboriginal Midwifery (Links to an external site.)". https://indigenousmidwifery.ca/ It tells you about midwifery in Aboriginal societies and also gives you a glimpse of the Aboriginal Philosophy of Health. Very interesting and informative read.

You may also be interested in investigating doula care, which is another emerging option for pregnant women in Canada. The birth doula is trained and experienced in childbirth, and can provide physical, emotional, and informational support to a woman during labor, birth, and the immediate postpartum period. Postpartum doulas can provide emotional support for new parents in the first weeks after birth. They can also provide household help, and give advice about a variety of topics, including breastfeeding and newborn care. To learn more about the doulas, please take a moment to read visit their BC website (Links to an external site.). https://www.bcdoulas.org/ To learn about doulas in First Nations society, please visit this website (Links to an external site.). https://www.fnha.ca/what-we-do/maternal-child-and-family-health/maternal-and-child-health

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Birth Complications

As we discussed in previous lessons, the birth process and newborn period may not be a smooth transition for the birth mother or her infant. This transition may be fraught with stress, fear, and disappointment for the birth mother if her infant is born premature, with low birth weight, small for gestational age, or medically fragile due to a particular syndrome. Also, the infant may simply be traumatized from a difficult birth. Some infants could experience varying combinations of the above conditions, and a number of these infants will have atypical development with long-term, and sometimes permanent difficulties and/or developmental delays.

According to Berk & Meyer (2016) the term "premature" has been used for many years to describe newborns who weigh less than 2500 gms and/or infants born "3 weeks or more before the end of a full 38 week pregnancy" (Berk & Meyer, 2016, pp. 134-135). They go on to say that birth weight is the best predictor of survival and typical development. In other words, as birth weight decreases, the negative impact on the infant's overall development increases. Consequently, today there is more emphasis in the literature on different levels of low birth weights and their subsequent impacts on development.

Keep these comments in mind as you read the next section of your text, Birth Complications, on pages 135-142 in the 2012 edition, pages 132-140 in the 2016 edition, and pages 126-131 in the 2020 edition. In this section, the author reviews "Oxygen Deprivation", "Preterm & Low Birth-Weight Infants", and "Birth Complications, Parenting, and Resilience".

As you read the section about "Oxygen Deprivation", you will notice that the author mentions cerebral palsy, a disorder that can be caused by anoxia as well as genetic or developmental disorders, injury or disease. You will be learning more about cerebral palsy in Lesson 8.

As you read through the section on Preterm and Low-Birth-Weight Infants, ensure that you understand the various definitions : Preterm/Premature (born several weeks or more before the due date), Small for Date, (below expected weight for length of pregnancy), and Low Birth Weight (weighing< 2500 gms). Please note that medically speaking, children with Low Birth Weight can be divided into three different sub-categories: Low Birth Weight, Very Low Birth Weight, and Extremely Low Birth Weight. Please check out the this article (Links to an external site.), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710991/#:~:text=1.3.-,1.,%3C1000%20g%20%5B1%5D . and please go to section 1.3, to learn about these different categories.

Next, please go to the Statistics Canada website, where you will learn about Infant Mortality Rates. You can learn about I nfant Mortality Rates in different provinces and territories https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310071001

A Closer Look: Born Too Early, Born Too Small

In this section, we are going to take a closer look at the vulnerability of infants who are born too early and/or born too small. We will be visiting the Encyclopedia on Early Childhood Development (Links to an external site.) https://www.child-encyclopedia.com/ website, where there are a number of current and excellent articles on premature infants, their characteristics, and development. While there is some overlap of content, each author does present his/her own way of looking at this topic, based on the discipline from which he/she comes.

Before you start to read these articles, stop and think about the following questions. Why has the survival rate for premature infants been increasing over the past 20 years? The effects of prematurity on the infant fall into several developmental domains. Can you identify them? What health and developmental difficulties fall within these domains? What is the Newborn Individualized Developmental Care and Assessment Program? What are the advantages of such a program for the infant and mother? Now, please visit the Premature Infants (Links to an external site.) https://www.child-encyclopedia.com/prematuritysection of the above-mentioned website, in order to learn more about premature infants. You can read the "What Do We Know", "What Can Be Done" and "According to the Experts" sections.

Each child is an individual and will grow and develop at his/her own rate. However, broad guidelines for development can be helpful in understanding what is realistic to expect a child to accomplish by certain ages. If a child is born prematurely it is very important that you use his/her corrected age when looking at developmental milestones. For example, at birth, a prematurely born baby's muscles and nervous system do not function at the same level as do a full-term infant's. It takes a number of weeks for all systems in an infant's body to be at the point of maturity we associate with a newborn. Experiencing the world prematurely will not accelerate the typical progression of development, and perhaps the child's development may be somewhat slower than it might have been in the womb. As you will read, in several of these articles, the environments of Neonatal Intensive Care Units can have a significant effect on the infant's developmental maturation and progress – both positive and negative.

Now, please go back to the March of Dimes website that we visited in previous lessons, and check out their " Premature Baby (Links to an external site.)" https://www.marchofdimes.org/complications/premature-babies.aspx section. There, you will find a lot of practical information for parents and caregivers of premature babies.

Finally, it may be worth your while to visit the website of the Canadian Premature Babies Foundation (Links to an external site.). https://www.cpbf-fbpc.org/ There, you can learn about different initiatives regarding premature babies and their parents. From that website, you can also learn about " Skin to Skin" or "Kangaroo care (Links to an external site.)", https://my.clevelandclinic.org/health/treatments/12578-kangaroo-care a method that is widely used in some parts of the world, to promote the development and well-being of premature infants.

Newborn Baby's Capacities

Adaptation to life outside the womb requires the infant to gradually obtain the rudiments of living independently of his/her mother, or primary caregiver. Although dependency remains a reality for a very long time, in some ways the newborn infant is already a separate being with a bio-physiological system designed to promote its own survival and adaptation. Thus the primary developmental tasks for newborns are to learn to self-regulate and self-modulate their bio-physiological responses so that they can integrate, process, and respond to the sights, sounds, and sensations of their world. This period also involves laying the groundwork for the other developmental tasks of infancy and early childhood. In the first month of life, while the infant is in the neonatal stage of development, specific competencies emerge which enable the newborn to master his/her earliest developmental tasks.

· Please go to pages 142-153 in the 2012 edition, pages 140-151 in the 2016 edition, and pages 133-143 in the 2020 edition, and read the fascinating discussion of Precious Moments After Birth, and The Newborn Baby's Capacities. The discussion covers the topics of Reflexes, States, Sensory Capacities, and Neonatal Behavioral Assessment. Before moving on, stop at the Ask Yourself section on page 153 in the 2012 edition, page 151 in the 2016 edition, and page 144 in the 2020 edition, and answer the questions in Review, Apply, Connect and Reflect.

· Now, return to page 147 in the 2012 edition, page 145 in the 2016 edition, and pages 138 in the 2020 edition, and read the Social Issues: Health – The Mysterious Tragedy of Sudden Infant Death Syndrome section. Sudden Infant Death Syndrome (SIDS) is a cause of death for some infants during the neonatal period. While the specific cause of SIDS remains unknown, we do have some knowledge of certain risk factors. For current information, take a look at the Joint Statement on Safe Sleep (Links to an external site. https://www.canada.ca/en/public-health/services/health-promotion/childhood-adolescence/stages-childhood/infancy-birth-two-years/safe-sleep/joint-statement-on-safe-sleep.html ) section of the Public Health Agency of Canada website. You may also wish to visit the Canadian Foundation for the Study of Infant Deaths (Links to an external site.) https://www.babysbreathcanada.ca/ website (now known as Baby's Breath), where you can get additional information about SIDS and how it can be prevented.

Impact of Birth Related Problems on Later Development

The nature and extent of an infant's compromised birth history do not necessarily predict long-term outcomes. Research comparing premature infants in Canada and the United States consistently demonstrates the importance of associated factors such as accessible prenatal care, universal health care, neonatal intensive care, postnatal follow-up, early intervention, and social support services to infants and their families in determining short-term and long-term outcomes. These factors would, of course, be intertwined with the individual infant's capacities and resilience. Therefore, it is misleading to focus on a single risk factor when forecasting outcomes for this population of children.

In an earlier section of this lesson, your readings through the website of the Encyclopedia on Early Childhood Development indicated that many premature infants struggle with learning and/or behavioural disorders later in life. We must return to this website and delve more deeply into the issue of outcomes. As you look through the articles in that section, please pay particular attention to the " Behavioral and Emotional Functioning in Preterm Infants (Links to an external site.)" https://www.child-encyclopedia.com/prematurity/according-experts/behavioural-and-emotional-functioning-preterm-infants article, as it contains important information about the social/emotional development of premature babies.

More importantly, please go to the " According to the experts (Links to an external site. https://www.child-encyclopedia.com/prematurity/according-expert s)" section of this same website, in order to see what some of the consequences of premature birth are, but also in order to see how applicable and relevant Sameroff's Transactional Model (2009) and Bronfenbrenner's Ecological Model (1994) are, to our study of human development.

Now, please go to the Library Course Reserves and read the article entitled " Preventive Interventions for Preterm Infants". This article is written by Michael Guralnick (Links to an external site. http://depts.washington.edu/chdd/guralnick.html ), a giant in the field of early intervention. In this article, you will see Guralnick echoing, from a clinical perspective, what Sameroff (2009) and Bronfenbrenner (1994) have stated, from a theoretical perspective, and which is the following: the developmental outcome of premature children (and indeed possibly all children) is the result of nature and nurture, and it is very much dependent on the environment in which these children grow.

Processes Important to All Infants

Given the important differences in these groups of infants (i.e., small for gestational age, low birth weight, premature birth), can we make any valid generalizations about interventions that will make a difference to outcomes? While it is extremely important to take account of each child's unique history and birth status, there is considerable research to support for the importance of the following:

· Developmental tasks. Many have theorized that the pathway from newborn status to outcome later in childhood is strongly determined by the ability of the care-giving environment to respond in a facilitative way to enhance the infant's immature or weakened self-regulatory abilities. Researchers see this as equally true for the term or healthy infant with regulatory difficulties.

· The Role of Early Intervention. Early Intervention programs can provide families of these babies with invaluable and much-needed information, support and possible therapies. In BC, most children who are born prematurely, with Low Birth Weight or Small for Date, are followed by the Infant Development (Links to an external site. https://www.develop.bc.ca/programs/infant-development/ ) or Aboriginal Infant Development (Links to an external site. https://www.aidp.bc.ca/ ) Programs of BC.

· The Role of Medical and Community Care. There is increasing understanding of the impact of hospital practices, invasive procedures, therapeutic methods, and specific medications on the short and long-term outcomes of these infants. The experiences of infants and their parents with the medical system vary according to the technology available, the type of follow-up, the availability of early intervention services, and the availability of support systems.

Lesson 4 Summary, References & Assignment

Summary

In this lesson, we reviewed the process of childbirth, the incipient competencies of the typical newborn infant, and the effects on development when an infant is born prematurely, with Low Birth Weight or Small for Age. Finally, we examined the complicated factors that are associated with the different types of short and long-term outcomes that occur in this vulnerable group of children.

In the following lesson, we begin to follow how differences in specific domains can shape the course of a child's development.

References

Bronfenbrenner, U. (1994). Ecological models of development. M. Gauvain & M. Paul (Eds.), International Encyclopedia of Education (2nd Ed., Volume 3, pp. 37-43). Oxford, England: Elsewier Publishers.

Sameroff, A. (2009). The transactional model. In A. Sameroff (Ed.), The Transactional Model of Development (pp. 3-22). Washington, DC: American Psychological Association.

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Lesson 3

Learning Objectives

Upon completion of this Lesson, you should be able to:

· Review current trends in family size and childbearing age, and discuss their impact on child development;

· Describe three phases of prenatal development, and describe the major milestones of each;

· Identify teratogens associated with atypical fetal development;

· List agents known to be or suspected of being teratogens, and discuss evidence supporting their harmful effects;

· Describe the impact of other maternal factors on prenatal development;

· Recognize the critical importance of nutrition and prenatal healthcare on the mother and developing fetus;

· Investigate factors, such as parental adjustment, cultural values, and public health policies that contribute to the preparation for parenthood.

Motivations for Parenthood

Today, couples from all walks of life (e.g. hetero-sexual, members of the LGBTQ2+ community, of somewhat advanced child-bearing age) weigh the pros and cons of having children more than they did in previous generations. As well, families have declined in size over time, and births to women over 35 have increased. In the previous lesson, you read about the increase of multiple births in this population of women over 35, who have pursued fertility treatments. All of these changes have been associated with both advantages and disadvantages for child development during the prenatal period. As you begin to cover the readings in Chapter 3 of our textbook, Prenatal Development, consider how the motivations for having children today differ, as compared with one or two generations ago.

· Please read pages 92-95 in the 2012 edition, 91-94 in the 2016 edition, and 87-90 in the 2020 edition, where you will focus on Motivations of Parenthood, specifically Why Have Children?, How Large a Family?, Is There a Best Time During Adulthood to Have a Child? On page 95 of the 2012 edition and 94 of the 2016 edition, and page 90 in the 2020 edition, check in at "Ask Yourself" for some Review, Apply, Connect.

· Now, visit the March of Dimes ( https://www.marchofdimes.org/index.aspx ) website, where couples contemplating parenthood can have many of their questions answered at a basic level. Start at the " Prenatal care ( https://www.marchofdimes.org/pregnancy/prenatal-care.aspx )" section. There, you can peruse some short articles related to your first prenatal care checkup; prenatal tests. Another excellent article is " A Mommy After 35 ( https://www.marchofdimes.org/complications/pregnancy-after-age-35.aspx )". Be sure to read it! You can also compare this information with the information in your textbook. How do the risks of childbearing after age 35 compare to the benefits mentioned in the text? Now, go to the " During Your Pregnancy ( https://www.marchofdimes.org/search-results.aspx?search-text=during%20your%20pregnancy )" section, where you can read about exercise during pregnancy, as well as many different and very important topics about mother and fetus health.

Prenatal Development

We will now turn our attention to prenatal development itself. As you review this next section in your textbook, make particular note of the three trimesters of prenatal growth, and the major developmental milestones or events that occur within each trimester. Also note that there are three significant periods of development within the first trimester – the zygote, embryo and fetus periods. It is in the embryo period, for example, that the primitive brain and spinal cord begin to develop at 3-4 weeks. The development of the brain leads to the unfolding of the nervous system and then the somato-sensory system, followed by the emergence of the vestibular, auditory and finally visual systems. Then, by 24 weeks of gestation, most of the brain's neurons are present, the eyes are sensitive to light, and the fetus reacts to sound. These important structures provide the basic foundations for the remarkable abilities in perception and cognition that we know to be present in the newborn child.

· First, let's go directly to Table 3.3 on page 97 of the 2012 edition, and Table 3.2 on page 96 of the 2016 edition and page 92 in the 2020 edition. There we see the three trimesters and periods, within which all the major milestones are identified along with specific times, sizes, and pictures. All within one framework. Take time to study this!

· Then, return to read pages 95-102 in the 2012 edition, and pages 95-101 in the 2016 edition, and pages 90-96 in the 2020 edition, Prenatal Development, which includes Conception, Period of the Zygote, Period of the Embryo, and Period of the Fetus. During the period of the fetus, it may be necessary to conduct diagnostic fetal ultrasounds in order to gather important medical information such as size, age, and health status of the fetus. To see what Health Canada has to say about this topic, please go to the following website. ( https://www.canada.ca/en/health-canada/services/health-risks-safety/radiation/medical/ultrasound.html )

· Next, read pages 102-119 in the 2012 edition, and pages 101-118 in the 2016 edition, and pages 97- in the 2020 edition, Prenatal Environment Influences, specifically reading about Teratogens and Other Maternal Factors. Teratogen

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