Childbirth and neonatal environment

• The normal process of labour is a complex and orchestrated event that begins around 266
days after conception initiated
• Braxton hicks false contractions occur in 2nd and 3rd trimester do not increase in frequency or
intensity
• Contractions occur intermittently and with increasing intensity and frequency. This pushes
the fetus’ head against cervix, causing dilation of cervix and allowing baby to pass through
their birth canal.

1st stage of labor

• Contractions: initially every 8-10 minutes, lasting 30 seconds

• Transition: the most intense part, where the cervix dilates fully to around 10 centimeters.
• Duration: longest, lasting 16-24 hrs. for first-time mothers, though it varies widely.
• Early labour mild contraction
• Active labour intense more frequent contractions
• Transition when cervix dilates completely 10cm

Second stage:

• Baby’s descent: the baby head emerges with each contraction, stretching the vaginal
opening
• Completion: this stage ends when the baby has fully exited the mother’s body
• Duration: Usually lasts around 50 minutes

3rd stage of labor:

• Afterbirth: the umbilical cord and placenta are expelled

• Duration: This stage is brief taking just 15 mins

Types of Childbirth:

● Natural Childbirth: Emphasizes minimal medical intervention and the use of relaxation techniques
to manage pain.

● Prepared Childbirth: Involves education and training (e.g., Lamaze method) to help women
manage pain and anxiety during labor.

● Medicated Childbirth: Involves the use of analgesics, anesthetics, or other medications to manage
pain during labor and delivery.

● Cesarean Delivery (C-section): Surgical procedure in which the baby is delivered through an
incision in the mother's abdomen and uterus.

Factors Influencing Childbirth:

● Maternal health and age.

● Prenatal care quality.

● Birth settings (hospital, home, birthing centre).

● Support during labor (e.g., doulas, midwives).

Neonatal Assessment

Critical events and assessments mark the first few hours of a newborn’s life to ensure the baby’s
health and well-being. These events vary depending on cultural practices and the presence of
healthcare workers.

Transition to breathing

Moment of birth

Exact moment of birth occurs when baby fully emerges from mother’s body through the vagina

Most newborns automatically transition due to high levels of stress hormones from receiving oxygen
via the placenta to using their lungs to breathe air. This is often accompanied by the newborn’s first
cry which helps clear the lungs and initiate independent breathing.

Post- birth care;

Cultural and medical practices

Usually, medical practitioners are present during birth and provide immediate care. 99% of births in
US are guided by prof. health care workers.

Apgar scale:

Quick visual assessment, scale assesses the appearance, pulse, grimace, activity, and respiration.
Each parameter is scored from 0 to 2 with a total score from 0 to 10.

7 to 10 is considered a normal score.

Appearance Pulse Grimace Activity Respiration

Newborn Medical Screening

Screening

Shortly after birth newborns are tested for a variety of diseases and genetic conditions the American
College of medical Genetics recommends screening for 29 disorders such as hearing difficulties
sickle-cell anemia and rare metabolic disorders like isovaleric acidemia, disorder where body is
unable to break down amino acid.

These screenings involve a small blood sample drawn from the infant’s heel allowing early treatment
of the underlying condition

Physical appearance and initial encounters.

Cleaning and appearance:

The newborn is cleaned, removing vernix (a thick, greasy substance that facilitated passage through
the birth canal) and other fluids. The baby may be covered in lanugo- dark, fuzzy fine hair- that soon
disappears

The newborns eyelids maybe puffy due to fluid accumulation during birth.

Bonding:

The cleaned newborn is returned to mother and father, initial skin contact is crucial and helps
mothers to be more responsive to babies in short term.
Brazelton Neonatal Behavioral Assessment Scale

A comprehensive tool used to assess behavioral and neurological development of newborns from
birth to 2 months old.

evaluates the baby’s reflexes, muscle tone, state changes, responsiveness to physical and social
stimuli, and other reactions

Developed by Dr. t berry Brazelton in 1970s.

Designed to provide a detailed understanding of a newborn’s capabilities and to identify any areas
that may require further attention or intervention.

Key features of NBAS

Behavioral items: 28 behavioral items that assess the infant’s abilities in several areas such as;

Habituation: ability to decrease response to repeated stimuli

Orientation: the ability to respond to auditory and visual stimuli

Motor behavior: muscle tone and coordination

State regulation: ability to regulate states of consciousness

Autonomic Stability: Physiological responses to stress such as skin color changes and tremors

Reflex items: 18 reflex items that evaluate neurological and reflexive responses providing insight into
the integrity of the central nervous system.

Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS)

Assesses at-risk infants for neurological and stress responses

Adjustments in infancy:

Refers to the process through which newborns adapt to life outside the womb.

This critical period involves various physiological, psychological and behavioral changes that enable
infants to function

Key areas of Adjustment in infancy:

Physiological Adjustments

Respiration: newborns must transition from receiving oxygen through placenta

Behavioral adjustment:

Sleep patterns newborns sleep for 16-18 hours a day, but divided into short periods. They gradually
develop more regular sleep-wake cycle

Sleep States: Newborns sleep 16-18 hours a day in cycles of active (REM) and quiet sleep. o Alert
States: Periods of quiet alertness and active alertness when the baby is awake and attentive. o
Crying: Communication method indicating hunger, discomfort, or other needs.

Sensory responses: infants begin to respond to sensory stimuli they show preferences for certain
sounds and visual patterns. E.g.: mothers voice, faces, etc.
Newborns can see objects best at 8-12 inches away, prefer high-contrast patterns, and can track
moving objects.

o Hearing: Well-developed at birth; babies can recognize their mother's voice.

o Taste and Smell: Preferences for sweet tastes and the ability to recognize the mother's scent.

o Touch: Highly sensitive, particularly to pain and temperature.

Motor skills: Reflexes present at birth such as the rooting and sucking reflex are essential for feeding
and initial interactions with the environment. Over time these reflexes integrate into the voluntary
motor skills.

Rooting Reflex: When the baby’s cheek is stroked, they turn their head toward the touch and open
their mouth. ● Sucking Reflex: When something touches the roof of the baby’s mouth, they start
sucking. ● Moro Reflex: When startled, the baby throws their arms out and then pulls them back in.
● Grasping Reflex: When the baby's palm is touched, they grasp tightly.

Psychological and emotional Adjustments:

Attachment: the process of forming emotional bonds with caregivers is crucial for the infant’s
psychological development. Secure attachment fosters a sense of safety and security.

Bonding: The initial connection between parents and newborns is crucial for emotional
development. o Attachment Theory (Bowlby and Ainsworth): Secure attachment develops through
consistent, responsive caregiving.

Emotional Regulation: Newborns gradually develop the ability to regulate their emotions with the
help of their caregivers. This includes soothing themselves and expressing basic needs.

Social Interactions: Infants begin to recognize and respond to social cues, such as smiles and voices.
Early social interactions lay the groundwork for later communication and social skills.

Reflexes at Birth:

The reflex is an inborn, automatic response to a particular form of stimulation. Reflexes are the
neonate’s most obvious organized pattens of behavior

For instance, if a father accidentally bumps the side of the table the newborn may fling her arms
wide, then bring back towards her body.

Similarly, when a mother softly strokes her infant’s cheek,

Adaptive Value of Reflexes:

Survival Reflexes:

Rooting Reflex: Helps a breastfed baby find the mother’s nipple. Babies display it only when hungry
and touched by another person

Sucking reflex Essential for feeding, adjusting sucking pressure to how easily milk flow from nipple

Swimming Reflex: helps the baby stay afloat if accidentally dropped into water.

Evolutionary Reflexes:
Moro Reflex (Embracing Reflex): Believed to have helped infants cling to their mothers in the
evolutionary past, assisting in survival of infant lost support.

Palmar grasp Reflex: So strong during the first week that it can support the baby’s entire weight,
possibly aiding in regaining hold on the mother’s body.

Interactive Reflexes:

Reflexes and Development of Motor skills

Tonic Neck reflex: May prepare the baby for voluntary reaching as the fencing position encourages
combining vision with arm movements.

Stepping Reflex:

Importance of Assessing Reflexes

Indicator of Nervous System Health

Reflexes are carefully tested by pediatricians as they can reveal the health of the baby’s NS. Weak,
absent overly rigid or exaggerated reflexes can signal brain damage.

Reflexes that persist beyond the normal developmental period can also indicate neurological issues.

Individual Differences:

While individual differences in reflexive responses exist, they are not always cause for concern.
Reflexes must be assessed along with other characteristics to distinguish normal from abnormal CNS
functioning.

Development of Motor Functions

Motor development in infancy refers to the progression of muscular coordination required for
physical activities

It encompasses the emergence and refinement of both gross and fine motor skills.

It is crucial for infant’s interaction with their environment and for their overall growth and
development

Motor development in infancy is a source of great excitement and pride for parents as their babies
achieve new skills such as holding up their heads, reaching for objects, sitting independently and
walking.

These milestones represent significant steps in an infant’s ability to interact with and understand
their environment and they also influence social interactions and relationships.

Impact on Social Relationships

Crawling and walking: as infants start crawling and walking parents often begin to impose
boundaries using words like no and showing mild impatience when babies explore restricted areas.
This period can introduce the first ‘testing of wills’ where infants begin to understand and react to
parental limits.

Social Interaction: Newly walking babies tend to engage more actively in social interactions, seeking
out parents for greeting, hugs or play and using gestures such as pointing and reaching to
communicate
Parental Response: In response to these developments, parents increase their verbal
communications playful activities and expressions of affection. They also provide guidance and
warnings to help infants navigate risky situations.

Sequence of Motor Development

• Motor skills can be categorized as 2 types:

• Gross-motor Development: involves large movements like crawling standing and walking
• Fine-motor Development: Involves smaller more precise movements like reaching and
grasping

Motor Development Milestones:

• Holding head erect: 6 weeks

• Lifting self by arms when prone: 2 months
• Rolling from side to back: 2 months
• Grasping cube: 3 months, 3 weeks
• Sitting alone: 7 months
• Crawling: 7 months
• Pulling to stand: 8 months
• Standing alone: 11 months

Perceptual Development

Perceptual Development In infancy:

The ability to perceive the world through our senses.

Perception helps us take in, combine and integrate information using our senses Perceptual skills
include vision, hearing, smell, taste and touch.

Piaget called this the sensorimotor stage of development because they were sensing and moving.

Perception helps children apply new and prior learning from one sense to another which allows them
to begin to classify and make assumptions about objects and materials.

In infancy, perception and motor skills are not separate entities but are deeply interconnected. For
example, when a baby reaches out to grab an object, they rely on their visual perception to guide
their hand accurately

This coordination is crucial as it helps infants learn new skills by constantly integrating what they see
with what they do.

Research by Adolph &

Aspects of Perceptual Development:

Touch:

Touch is one of the first senses to develop, and it plays a crucial role in how infants explore their
environment. Even newborns use touch to investigate objects around them.

Initially they may rely on the basic reflexes but as they grow their use of touch becomes
sophisticated.
They can differentiate between shapes and textures, which helps them develop fine motor skills. This
progression form simple touch responses to more complex exploration is key to their overall motor
development.

Touch plays a crucial role in encouraging physical and emotional development. Sensitive areas such
as mouth, palms, soles of feet, and genitals area among the first to develop touch sensitivity during
the prenatal period.

Positive affective relationships, facilitated by touch, are essential for the growth of an infant’s brain,
with emotional communication during attachment impacting brain maturation.

Newborns can perceive pain and touch can be soothing skin to skin contact during painful
procedures can reduce crying due to the release of endorphins which are pain killing chemicals in the
brain.

Taste and Smell:

Sensitivity to taste is present before birth. As study shows that when saccharin was added to
amniotic fluid of a near term fetus, the fetus increased swallowing, indicating a response to taste.

Newborns, even at 2 hrs. old, can distinguish between different tastes such as bitter, sweet and sour,
making different facial expressions for each taste infants prefer sweet taste

Along with taste, odor preferences are also present at birth. Infants like the smell of vanilla and
strawberry but dislike the smell of rotten eggs and fish. They start recognizing their mother’s smell
very early even within the first hour of life.

By 4 days old, babies prefer the smell of their own mother’s breast over that of an unfamiliar
lactating woman.

Both breastfed and bottle-fed infants prefer the smell of human milk indicating a natural preference
for human milk.

Hearing

Hearing becomes functional while the fetus is still in the womb, allowing it to hear the mother’s
voice and music. Studies show that newborns prefer their mother’s voice over another woman’s
voice as indicated by changes in their heart rate when exposed to recordings of their mother’s voice
compared to a stranger.

Infants tend to listen longer to human speech than non- human speech sounds, even those that are
structurally similar to speech. They can also differentiate among various speech sounds.

Newborns can make fine distinctions between many speech sounds and their ability to perceive
these sounds is more precise than that of adults. This ability is gradually refined to focus on the
sounds of their native language between 6 and 8 months, marketing a sensitive period for language
acquisition.

Sound Perception and preferences

In a study, infants were given a nipple that activated the “be” sound when they sucked on it. Initially
they sucked vigorously but then habituated. To the sound. When the sound was changed to “ga”, the
infants resumed vigorous sucking indicating they could detect subtle differences in sound.
At birth infants prefer complex sounds like voices and noises over pure tones. They can differentiate
between various sound patterns, including rhythmic beats and the stress patterns of words.

By 2 and 4 months, they recognize changes in tempo and by 4 to 7 months they start distinguishing
musical phrasing. By 12 months they can recognize the same melody played in different keys.

Learning and Cultural Adaptation:

Infants use statistical learning to analyses speech patterns, helping them learn the structure of their
language.

They can detect regularities in speech sequences such as syllable patterns, and begin to understand
basic grammar

This learning is supported by multisensory experiences such as synchronized visual and auditory
stimuli from caregivers which enhance their ability to process language.

E.g.: introducing fruit while emphasizing on the word banana or singing lullabies or traditional
rhymes.

Vision Perception:

Underdeveloped vision at birth

At birth an infant’s vision is the least developed sense.

Visual structures in the eye (like the retina) and the brain are not fully formed.

Infants cannot focus well and their visual acuity is limited, seeing objects at 20 feet away with the
clarity of adults at 600 ft.

Rapid Visual Development

Around 2 months, infants can focus on objects almost as well as adults.

By 4 months infants develop adult-like color discrimination

Visual acuity improves to 20/80 by 6 months and becomes20/20 by around 4 years.

Active exploration despite limited vision:

Despite poor vision, newborns actively scan their environment, seeking interesting sights.

Eye movements in newborns are slow and inaccurate but improve over the first 6 months.

As infants develop, they scan their surroundings more thoroughly and systematically, enhancing their
perception.

Depth Perception:

Depth Perception allows infants to judge distances and understand the layout of their environments,

The visual cliff experiment demonstrated that crawling infants avoid drop-offs, showing depth
perception.

Motion cues, such as objects growing larger as they approach are the first depth cues infants detect
around 3-4 weeks
Sensitivity to binocular depth cues differences in the visual fields seen by each eye) emerges
between 2-3 months

Pictorial depth cues like overlapping lines develop last, improving significantly between 5-7 months.

The role of independent movement:

Crawling experience enhances infants’ understanding of depth and spatial awareness.

Infants with ore crawling experience are better at detecting drop-offs and avoiding falls

Crawling promotes brain organization especially in areas related to vision and spatial understanding.

Pattern Perception

Newborns prefer patterned stimuli over plain ones, and their preference for complexity increases
with age.

Contrast sensitivity: Infants prefer patterns with more contrast however, due to their limited vision
very young infants can only detect bolder, larger patterns.

Face Perception:

Early interest: Infants show a strong interest in human faces from birth and prefer photos of faces
with open eyes and direct gaze.

Development of face perception: By 3 months, infants begin matching voices to faces distinguishing
between male and female faces and showing preference for faces from their own ethnic group
although this can be influenced by exposure to diverse people.

Object Perception:

Perceptual constancy: infants demonstrate size and shape constancy from a very early age. They can
perceive an object’s size and shape as constant, even when the retinal image changes due to
movement or orientation

Size Constancy: Infants perceive objects as having the same shape, even when the shape on the
retina changes due to different angles.

Occluded Objects: Initially, infants perceive only visible parts of occluded objects as whole develops
after 2 months aided by learning and experience.

Tracking Occluded Objects: By 4-5 months infants can track the path of moving objects even when
they disappear gradually.

Intermodal Perception:

Refers to the ability to integrate and coordinate information from 2 or more sensory modalities such
as sight, sound and touch, to create a unified understanding of an event or environment.

For example, when watching a game of tennis, we don’t just see the ball being hit we also hear the
sound of the racket striking the ball and these sensory inputs are combined to give us a
comprehensive
Amodal information is a key aspect of intermodal perception. It refers to information that can be
detected through multiple sensory modalities and is not a specific to one single sense.

Temporal (timing) and spatial (location) characteristics of an event, for instance, are examples of
amodal information. When we observe hand clapping the visual and auditory inputs share the same
timing and rhythm which our brains use to create a unified persevered event.

Attachment Development and pattern of Attachment

As strong affectionate bond with special people that brings pleasure and comfort during interactions,
particularly during times of stress.

Infant attachment Development: By the second half of the first year, infants become attached to
familiar caregivers who respond to their needs.

Infant Behaviors: Babies show attachment by smiling, snuggling and seeking comfort from their
caregivers, especially when anxious or afraid

Freud suggested that an infant’s emotional tie to the mother is the foundation for all later
relationships.

Harlow’s Experiment:

Conducted on rhesus monkey to study maternal deprivation and attachment

Physical contact and comfort were shown to be crucial for emotional attachment and normal
development

1st Experiment:

Harlow separated infant monkeys from their mothers shortly after birth and raised them with two
inanimate surrogate mothers.

One surrogate was made of bare wire mesh, while the other was covered with soft terry cloth.
Although both surrogates provided milk, the monkeys overwhelmingly preferred to cling to terry
cloth mother even when feeding in front of the wire mesh.

This demonstrated that attachment is not solely based on physiological needs like hunger but also on
need for comfort and security.

2nd Experiment:

Harlow explored the behavior of both monkeys when presented with strange, loud objects.

Monkeys with terry cloth mother sought comfort from it and calmed down, while those with only
the wire mesh mother displayed severe distress such as throwing themselves to the floor, clutching
themselves and screaming in terror.

This experiment further highlighted the importance of emotional attachment in infancy showing that
physical comfort from the caregiver plays an important role in how infants manage stress and
develop emotional regulation

Harlow’s findings indicated that maternal disposition could be reversed only if it lasted less than 90
days for monkey’s equivalent to 6 months in humans.
Beyond this critical period, emotional damage leads to abnormal behaviors that couldn’t be
reversed.

Attachment theory:

John Bowlby emphasized the importance of strong emotional bonds between parents and children
for survival and development

Attachment provides a sense of security enabling the child to explore the world with confidence.

Drawing from both psychoanalytic and ethological concepts like Konrad Lorenz’s work on imprinting,
Bowlby proposed that attachment is not just about meeting basic physiological needs but is rooted in
the need for security and protection.

Characteristics of Attachment:

Safe Haven: The caregiver provides comfort when the child is afraid.

Secure Base: The caregiver is a dependable base for exploration

Proximity Maintenance: The child seeks to stay close to the caregiver for safety.

Separation Distress: The child experiences distress when separated from the caregiver.

4 phases of Attachment Development:

STUDY FROM LAURA BERK.

Preattachment phase:

Birth to 6 weeks

Attachment in the making phase:

6 to 8 months

Clear-cut attachment:

8 to 18 months

Formation of a reciprocal relationship:

18 to 24 months

Internal working model:

Bowlby suggested that through these experiences, children develop an internal working model- a
mental representation of their relationship with the caregiver

This model influences how they perceive relationships, their expectations of others, and their sense
of self-worth. It becomes a framework for future relationships and emotional functioning.

Measuring the Security of Attachment

In 1970’2 Mary Ainsworth a psychologist put forward the concept of strange situations.

This was a laboratory procedure to assess the quality of attachment between infants and their
caregivers.
Procedure: the strange situation involved eight episodes where infants experience brief separation
and reunions with the caregiver, as well as encounters with a stranger in an unfamiliar playroom.
Researchers observe how the infant uses the caregiver as a secure base for exploration

Secure Attachment

Infants use their caregiver as a secure base to explore. They may cry when the caregiver leaves but
are so quickly comforted when the caregiver returns

Implication: The infant trusts the caregiver and feels secure in their presence.

Avoidant Attachment

Infants are indifferent or unresponsive to the caregiver when present. They show little distress when
the caregiver leaves and avoid them upon return.

Implication: The infant may have learned that their caregiver is unavailable or unresponsive leading
to self-reliance or detachment.

Resistant Attachment (Ambivalent)

Children usually become very distressed when a parent leaves. And it is stated that ambivalent
attachment is a result of poor maternal availability. These children cannot depend on their mother to
be there when the child is in need

Implication: the infant may be unsure about the caregivers’ availability and thus remains anxious and
insecure.

Disorganized/ Disoriented Attachment:

Infants show confused, contradictory behavior such as approaching the caregiver while looking away
or showing a dazed expression. These infants may display odd postures or unexpected crying.

This pattern reflects the greatest insecurity often associated with negative or unpredictable
caregiving environments.

Factors that affect Attachment Security

Eary availability of a consistent caregiver

The presence of a consistent caregiver during early development is crucial for forming secure
attachments

Institutionalized infants who lack stable caregivers often suffer from emotional problems such as
depression withdrawal and difficulty forming relationships

Even when later placed in stable homes, these children may exhibit attachment difficulties such as
overfriendliness, social avoidance and difficulty regulating emotions.

This underscores the importance of a consistent caregiver in fostering healthy emotional

development.

Quality of Caregiving:

Sensitive caregiving, characterized by prompt, consistent and appropriate responses to an infant’s

needs, is strongly associated with secure attachment.
Interactional synchrony a form of communication where caregivers and infants engage in a well-
timed and rhythmic emotional dance, is particularly predicted of secure attachment in Western
cultures.

Infant characteristics:

The temperament and characteristics of the infants also plays a role in attachment security. Difficult
or irritable infants may be more prone to insecure attachments especially if the parents are stressed
or unable to provide sensitive care.

However, the goodness of fit between the infant’s temperament and the caregiver’s ability to meet
their needs is crucial. Even challenging infants can develop secure attachments if caregivers are
responsive and adaptable.

Family circumstances such as financial strain, marital conflict or the birth of a sibling, can indirectly
affect the attachment security by influencing the quality of caregiving

Additionally, parents’ own attachment histories and their internal working models- how they view
their own early attachment experiences – affect how they bond with their children.

Parents who reflect on their childhood experiences with balance and objectivity are more likely to
have securely attached children. Conversely parents who are dismissive, overly preoccupied or
unresolved about their past are more likely to have insecurely attached children.

Multiple attachments:

Babies can form attachments with fathers, grandparents, siblings or professional caregivers. Bowlby
suggested that infants are initially inclines to direct attachment behaviors toward a primary caregiver
they can and do form attachments to multiple significant individuals.

Mother provides physical care and comfort. Fathers are more involved in stimulating and engaging
play.

In non-distressed situations, babies interact with both parents equally.

Father’s sensitive caregiving anf interactional synchrony contribute to attachment security.

Grandparents as Primary Caregivers