5.1: Chapter 9- Heredity, Prenatal Development, and Birth

Chapter 9 Learning Objectives

• Distinguish between mitosis and meiosis, genotype and phenotype, homozygous and heterozygous, and dominant and recessive.
• Describe some genetic disorders, due to a gene defect, and chromosomal disorders.
• Define behavioral genetics, describe genotype-environment correlations and genotype-environmental interactions, and define epigenetics.
• Describe the changes that occur in the three periods of prenatal development
• Describe what occurs during prenatal brain development
• Define teratogens and describe the factors that influence their effects
• Explain maternal and paternal factors that affect the developing fetus
• Explain the types of prenatal assessment
• Describe both the minor and major complications of pregnancy
• Describe how expectant parents prepare for childbirth
• Describe the stages of vaginal delivery
• Explain why a cesarean or induced birth is necessary
• Describe the two common procedures to assess the condition of the newborn
• Describe problems newborns experience before, during, and after birth

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Prenatal Development

The Germinal Period

zygote.

blastocyst. The blastocyst consists of both an inner and an outer group of cells. The inner group of cells or embryonic disk will become the embryo, while the outer group of cells, or trophoblast, becomes the support system that nourishes the developing organism. This stage ends when the blastocyst fully implants into the uterine wall (U.S. National Library of Medicine, 2015a). Approximately 50-75% of blastocysts do not implant in the uterine wall (Betts et al., 2019).

The Embryonic Period

embryo. Now blood vessels grow forming the placenta. The placenta is a structure connected to the uterus that provides nourishment and oxygen from the mother to the developing embryo via the umbilical cord. During this period, cells continue to differentiate. Growth during prenatal development occurs in two major directions: from head to tail called cephalocaudal development and from the midline outward referred to as proximodistal development. This means that those structures nearest the head develop before those nearest the feet and those structures nearest the torso develop before those away from the center of the body (such as hands and fingers). The head develops in the fourth week and the precursor to the heart begins to pulse. In the early stages of the embryonic period, gills and a tail are apparent. However, by the end of this stage, they disappear and the organism takes on a more human appearance. Some organisms fail during the embryonic period, usually due to gross chromosomal abnormalities. As in the case of the germinal period, often the mother does not yet know that she is pregnant. It is during this stage that the major structures of the body are taking form making the embryonic period the time when the organism is most vulnerable to the greatest amount of damage if exposed to harmful substances. Potential mothers are not often aware of the risks they introduce to the developing embryo during this time. The embryo is approximately 1 inch in length and weighs about 8 grams at the end of eight weeks (Betts et al., 2019). The embryo can move and respond to touch at this time.

The Fetal Period

fetus. During this stage, the major structures are continuing to develop. By the third month, the fetus has all its body parts including external genitalia. In the following weeks, the fetus will develop hair, nails, teeth and the excretory and digestive systems will continue to develop. The fetus is about 3 inches long and weighs about 28 grams.

age of viability is reached at about 24 weeks (Morgan, Goldenberg, & Schulkin, 2008). Many practitioners hesitate to resuscitate before 24 weeks. The majority of the neurons in the brain have developed by 24 weeks, although they are still rudimentary, and the glial or nurse cells that support neurons continue to grow. At 24 weeks the fetus can feel pain (Royal College of Obstetricians and Gynecologists, 1997).

Prenatal Brain Development

neural plate. By the end of the third week, two ridges appear along the neural plate first forming the neural groove and then the neural tube. The open region in the center of the neural tube forms the brain’s ventricles and spinal canal. By the end of the embryonic period, or week eight, the neural tube has further differentiated into the forebrain, midbrain, and hindbrain.

Neurogenesis, or the formation of neurons, is largely completed after five months of gestation. One exception is in the hippocampus, which continues to develop neurons throughout life. Neurons that form the neocortex, or the layer of cells that lie on the surface of the brain, migrate to their location in an orderly way. Neural migration is mostly completed in the cerebral cortex by 24 weeks (Poduri & Volpe, 2018). Once in position, neurons begin to produce dendrites and axons that begin to form the neural networks responsible for information processing. Regions of the brain that contain the cell bodies are referred to as the gray matter because they look gray in appearance. The axons that form the neural pathways make up the white matter because they are covered in myelin, a fatty substance that is white in appearance. Myelin aids in both the insulation and efficiency of neural transmission. Although cell differentiation is complete at birth, the growth of dendrites, axons, and synapses continue for years.

Teratogens

Teratogens are environmental factors that can contribute to birth defects, and include some maternal diseases, pollutants, drugs and alcohol.

Factors influencing prenatal risks: There are several considerations in determining the type and amount of damage that might result from exposure to a particular teratogen (Berger, 2005). These include:

• The timing of the exposure: Structures in the body are vulnerable to the most severe damage when they are forming. If a substance is introduced during a particular structure’s critical period (time of development), the damage to that structure may be greater. For example, the ears and arms reach their critical periods at about 6 weeks after conception. If a mother exposes the embryo to certain substances during this period, the arms and ears may be malformed.
• The amount of exposure: Some substances are not harmful unless the amounts reach a certain level. The critical level depends in part on the size and metabolism of the mother.
• The number of teratogens: Fetuses exposed to multiple teratogens typically have more problems than those exposed to only one.
• Genetics: Genetic make-up also plays a role in the impact a particular teratogen might have on the child. This is suggested by fraternal twins exposed to the same prenatal environment, but they do not experience the same teratogenic effects. The genetic make- up of the mother can also have an effect; some mothers may be more resistant to teratogenic effects than others.
• Being male or female: Males are more likely to experience damage due to teratogens than are females. It is believed that the Y chromosome, which contains fewer genes than the X, may have an impact.

Alcohol: One of the most commonly used teratogens is alcohol, and because half of all pregnancies in the United States are unplanned, it is recommended that women of child-bearing age take great caution against drinking alcohol when not using birth control or when pregnant (CDC, 2005). Alcohol use during pregnancy is the leading preventable cause of intellectual disabilities in children in the United States (Maier & West, 2001). Alcohol consumption, particularly during the second month of prenatal development but at any point during pregnancy, may lead to neurocognitive and behavioral difficulties that can last a lifetime.

Fetal Alcohol Spectrum Disorders (FASD), which is an umbrella term for the range of effects that can occur due to alcohol consumption during pregnancy (March of Dimes, 2016a). The most severe form of FASD is Fetal Alcohol Syndrome (FAS). Children with FAS share certain physical features such as flattened noses, small eye holes, and small heads. Cognitively, these children have poor judgment, poor impulse control, higher rates of ADHD, learning issues, and lower IQ scores. These developmental problems and delays persist into adulthood (Streissguth, Barr, Kogan, & Bookstein, 1996) and can include criminal behavior, psychiatric problems, and unemployment (CDC, 2016a). Based on animal studies, it has been hypothesized that a mother’s alcohol consumption during pregnancy may predispose her child to like alcohol (Youngentob, Molina, Spear, & Youngentob, 2007). Binge drinking, or 4 or more drinks in 2 to 3 hours, during pregnancy increases the chance of having a baby with FASD (March of Dimes, 2016a).

Tobacco: Another widely used teratogen is tobacco as more than 7% of pregnant women smoked in 2016 (Someji & Beltrán-Sánchez, 2019). According to Tong et al. (2013) in conjunction with the Centers for Disease Control and Prevention, data from 27 sites in 2010 representing 52% of live births, showed that among women with recent live births:

• About 23% reported smoking in the 3 months prior to pregnancy.
• Almost 11% reported smoking during pregnancy.
• More than half (54.3%) reported that they quit smoking by the last 3 months of pregnancy.
• Almost 16% reported smoking after delivery.

• Women <20, 13.6% smoked during pregnancy
• Women 20–24,17.6% smoked during pregnancy
• Women 25–34, 8.8% smoked during pregnancy
• Women ≥35, 5.7% smoked during pregnancy

ectopic pregnancy (fertilized egg implants itself outside of the uterus), placenta previa (placenta lies low in the uterus and covers all or part of the cervix), placenta abruption (placenta separates prematurely from the uterine wall), preterm delivery, stillbirth, fetal growth restriction, sudden infant death syndrome (SIDS), birth defects, learning disabilities, and early puberty in girls (Center for Disease Control, 2015d).

thirdhand smoke, or toxins from tobacco smoke that linger on clothing, furniture, and in locations where smoking has occurred, results in a negative impact on infants’ lung development. Rehan, Sakurai, and Torday (2011) found that prenatal exposure to thirdhand smoke played a greater role in altered lung functioning in children than exposure postnatally.

Prescription/Over-the-counter Drugs: About 70% of pregnant women take at least one prescription drug (March of Dimes, 2016e). A woman should not be taking any prescription drug during pregnancy unless it was prescribed by a health care provider who knows she is pregnant. Some prescription drugs can cause birth defects, problems in overall health, and development of the fetus. Over-the-counter drugs are also a concern during the prenatal period because they may cause certain health problems. For example, the pain reliever ibuprofen can cause serious blood flow problems to the fetus during the last three months.

Illicit Drugs: Common illicit drugs include cocaine, ecstasy and other club drugs, heroin, marijuana, and prescription drugs that are abused. It is difficult to completely determine the effects of a particular illicit drug on a developing child because most mothers who use, use more than one substance and have other unhealthy behaviors. These include smoking, drinking alcohol, not eating healthy meals, and being more likely to get a sexually transmitted disease. However, several problems seem clear. The use of cocaine is connected with low birth weight, stillbirths and spontaneous abortion. Heavy marijuana use is associated with problems in brain development (March of Dimes, 2016c). If a baby’s mother used an addictive drug during pregnancy that baby can get addicted to the drug before birth and go through drug withdrawal after birth, also known as neonatal abstinence syndrome (March of Dimes, 2015d). Other complications of illicit drug use include premature birth, smaller than normal head size, birth defects, heart defects, and infections. Additionally, babies born to mothers who use drugs may have problems later in life, including learning and behavior difficulties, slower than normal growth, and die from sudden infant death syndrome. Children of substance abusing parents are also considered at high risk for a range of biological, developmental, academic, and behavioral problems, including developing substance abuse problems of their own (Conners, et al., 2003).

Pollutants: There are more than 83,000 chemicals used in the United States with little information on the effects of them during pregnancy (March of Dimes, 2016b).

• Lead: An environmental pollutant of significant concern is lead poisoning, which has been linked to fertility problems, high blood pressure, low birth weight, prematurity, miscarriage, and slowed neurological development. Grossman and Slutsky (2017) found that babies born in Flint Michigan, an area identified with high lead levels in the drinking water, were premature, weighed less than average, and gained less weight than expected.
• Pesticides: The chemicals in certain pesticides are also potentially damaging and may lead to birth defects, learning problems, low birth weight, miscarriage, and premature birth (March of Dimes, 2014).
• Bisphenol A: Prenatal exposure to bisphenol A (BPA), a chemical commonly used in plastics and food and beverage containers, may disrupt the action of certain genes contributing to certain birth defects (March of Dimes, 2016b).
• Radiation: If a mother is exposed to radiation, it can get into the bloodstream and pass through the umbilical cord to the baby. Radiation can also build up in body areas close to the uterus, such as the bladder. Exposure to radiation can slow the baby’s growth, cause birth defects, affect brain development, cause cancer, and result in a miscarriage.
• Mercury: Mecury, a heavy metal, can cause brain damage and affect the baby’s hearing and vision. This is why women are cautioned about the amount and type of fish they consume during pregnancy.

Toxoplasmosis: The tiny parasite, toxoplasma gondii, causes an infection called toxoplasmosis. According to the March of Dimes (2012d), toxoplasma gondii infects more than 60 million people in the United States. A healthy immune system can keep the parasite at bay producing no symptoms, so most people do not know they are infected. As a routine prenatal screening frequently does not test for the presence of this parasite, pregnant women may want to talk to their health-care provider about being tested.

Toxoplasmosis can cause premature birth, stillbirth, and can result in birth defects to the eyes and brain. While most babies born with this infection show no symptoms, ten percent may experience eye infections, enlarged liver and spleen, jaundice, and pneumonia. To avoid being infected, women should avoid eating undercooked or raw meat and unwashed fruits and vegetables, touching cooking utensils that touched raw meat or unwashed fruits and vegetables, and touching cat feces, soil or sand. If women think they may have been infected during pregnancy, they should have their baby tested.

Sexually Transmitted Diseases: Gonorrhea, syphilis, and chlamydia are sexually transmitted infections that can be passed to the fetus by an infected mother. Mothers should be tested as early as possible to minimize the risk of spreading these infections to their unborn child. Additionally, the earlier the treatment begins, the better the health outcomes for mother and baby (CDC, 2016d). Sexually transmitted diseases (STDs) can cause premature birth, premature rupture of the amniotic sac, an ectopic pregnancy, birth defects, miscarriage, and still births (March of Dimes, 2013). Most babies become infected with STDS while passing through the birth canal during delivery, but some STDs can cross the placenta and infect the developing fetus.

Human Immunodeficiency Virus (HIV): One of the most potentially devastating teratogens is HIV. HIV and Acquired Immune Deficiency Syndrome (AIDS) are leading causes of illness and death in the United States (Health Resources and Services Administration, 2015). One of the main ways children under age 13 become infected with HIV is via mother-to-child transmission of the virus prenatally, during labor, or by breastfeeding (CDC, 2016c). There are some measures that can be taken to lower the chance the child will contract the disease. HIV positive mothers who take antiviral medications during their pregnancy greatly reduce the chance of passing the virus to the fetus. The risk of transmission is less than 2 percent; in contrast, it is 25 percent if the mother does not take antiretroviral drugs (CDC, 2016b). However, the long-term risks of prenatal exposure to the medication are not known. It is recommended that women with HIV deliver the child by c-section, and that after birth they avoid breast feeding.

German measles (or rubella): Rubella, also called German measles, is an infection that causes mild flu-like symptoms and a rash on the skin. However, only about half of children infected have these symptoms, while others have no symptoms (March of Dimes, 2012a). Rubella has been associated with a number of birth defects. If the mother contracts the disease during the first three months of pregnancy, damage can occur in the eyes, ears, heart or brain of the unborn child. Deafness is almost certain if the mother has German measles before the 11th week of prenatal development and can also cause brain damage. Women in the United States are much less likely to be afflicted with rubella, because most women received childhood vaccinations that protect her from the disease.

Maternal Factors

Mothers over 35: Most women over 35 who become pregnant are in good health and have healthy pregnancies. However, according to the March of Dimes (2016d), women over age 35 are more likely to have an increased risk of:

• Fertility problems
• High blood pressure
• Diabetes
• Miscarriages
• Placenta Previa
• Cesarean section
• Premature birth
• Stillbirth
• A baby with a genetic disorder or other birth defects

Teenage Pregnancy: A teenage mother is at a greater risk for having pregnancy complications including anemia, and high blood pressure. These risks are even greater for those under age 15. Infants born to teenage mothers have a higher risk for being premature and having low birthweight or other serious health problems. Premature and low birthweight babies may have organs that are not fully developed which can result in breathing problems, bleeding in the brain, vision loss, and serious intestinal problems. Very low birthweight babies (less than 3 1/3 pounds) are more than 100 times as likely to die, and moderately low birthweight babies (between 3 1/3 and 5 ½ pounds) are more than 5 times as likely to die in their first year, than normal weight babies (March of Dimes, 2012c). Again, the risk is highest for babies of mothers under age 15. Reasons for these health issues include that teenagers are the least likely of all age groups to get early and regular prenatal care. Additionally, they may engage in negative behaviors including eating unhealthy food, smoking, drinking alcohol, and taking drugs. Additional concerns for teenagers are repeat births. About 25% of teen mothers under age 18 have a second baby within 2 years after the first baby’s birth.

Gestational Diabetes: Seven percent of pregnant women develop gestational diabetes (March of Dimes, 2015b). Diabetes is a condition where the body has too much glucose in the bloodstream. Most pregnant women have their glucose level tested at 24 to 28 weeks of pregnancy. Gestational diabetes usually goes away after the mother gives birth, but it might indicate a risk for developing diabetes later in life. If untreated, gestational diabetes can cause premature birth, stillbirth, the baby having breathing problems at birth, jaundice, or low blood sugar. Babies born to mothers with gestational diabetes can also be considerably heavier (more than 9 pounds) making the labor and birth process more difficult. For expectant mothers, untreated gestational diabetes can cause preeclampsia (high blood pressure and signs that the liver and kidneys may not be working properly) discussed later in the chapter. Risk factors for gestational diabetes include age (being over age 25), being overweight or gaining too much weight during pregnancy, family history of diabetes, having had gestational diabetes with a prior pregnancy, and race and ethnicity (African-American, Native American, Hispanic, Asian, or Pacific Islander have a higher risk). Eating healthy and maintaining a healthy weight during pregnancy can reduce the chance of gestational diabetes. Women who already have diabetes and become pregnant need to attend all their prenatal care visits, and follow the same advice as those for women with gestational diabetes as the risk of preeclampsia, premature birth, birth defects, and stillbirth are the same.

High Blood Pressure (Hypertension): Hypertension is a condition in which the pressure against the wall of the arteries becomes too high. There are two types of high blood pressure during pregnancy, gestational and chronic. Gestational hypertension only occurs during pregnancy and goes away after birth. Chronic high blood pressure refers to women who already had hypertension before the pregnancy or to those who developed it during pregnancy and it continued after birth. According to the March of Dimes (2015c) about 8 in every 100 pregnant women have high blood pressure. High blood pressure during pregnancy can cause premature birth and low birth weight (under five and a half pounds), placental abruption, and mothers can develop preeclampsia.

Rh Disease: Rh is a protein found in the blood. Most people are Rh positive, meaning they have this protein. Some people are Rh negative, meaning this protein is absent. Mothers who are Rh negative are at risk of having a baby with a form of anemia called Rh disease (March of Dimes, 2009). A father who is Rh-positive and mother who is Rh-negative can conceive a baby who is Rh-positive. Some of the fetus’s blood cells may get into the mother’s bloodstream and her immune system is unable to recognize the Rh factor. The immune system starts to produce antibodies to fight off what it thinks is a foreign invader. Once her body produces immunity, the antibodies can cross the placenta and start to destroy the red blood cells of the developing fetus. As this process takes time, often the first Rh positive baby is not harmed, but as the mother’s body will continue to produce antibodies to the Rh factor across her lifetime, subsequent pregnancies can pose greater risk for an Rh positive baby. In the newborn, Rh disease can lead to jaundice, anemia, heart failure, brain damage and death.

Weight Gain during Pregnancy: According to March of Dimes (2016f) during pregnancy most women need only an additional 300 calories per day to aid in the growth of the fetus. Gaining too little or too much weight during pregnancy can be harmful. Women who gain too little may have a baby who is low-birth weight, while those who gain too much are likely to have a premature or large baby. There is also a greater risk for the mother developing preeclampsia and diabetes, which can cause further problems during the pregnancy. Putting on the weight slowly is best. Mothers who are concerned about their weight gain should talk to their health care provider.

Stress: Feeling stressed is common during pregnancy, but high levels of stress can cause complications including having a premature baby or a low-birthweight baby. Babies born early or too small are at an increased risk for health problems. Stress-related hormones may cause these complications by affecting a woman’s immune systems resulting in an infection and premature birth. Additionally, some women deal with stress by smoking, drinking alcohol, or taking drugs, which can lead to problems in the pregnancy. High levels of stress in pregnancy have also been correlated with problems in the baby’s brain development and immune system functioning, as well as childhood problems such as trouble paying attention and being afraid (March of Dimes, 2012b).

Depression: Depression is a significant medical condition in which feelings of sadness, worthlessness, guilt, and fatigue interfere with one’s daily functioning. Depression can occur before, during, or after pregnancy, and 1 in 7 women is treated for depression sometime between the year before pregnancy and year after pregnancy (March of Dimes, 2015a). Women who have experienced depression previously are more likely to have depression during pregnancy. Consequences of depression include the baby being born premature, having a low birthweight, being more irritable, less active, less attentive, and having fewer facial expressions. About 13% of pregnant women take an antidepressant during pregnancy. It is important that women taking antidepressants during pregnancy discuss the medication with a health care provider as some medications can cause harm to the developing organism. In fact, birth defects happen about 2 to 3 times more often in women who are prescribed certain Selective Serotonin Reuptake Inhibitors (SSRIs) for their depression.

Paternal Impact: The age of fathers at the time of conception is also an important factor in health risks for children. According to Nippoldt (2015) offspring of men over 40 face an increased risk of miscarriages, autism, birth defects, achondroplasia (bone growth disorder) and schizophrenia. These increased health risks are thought to be due to accumulated chromosomal aberrations and mutations during the maturation of sperm cells in older men (Bray, Gunnell, & Smith, 2006). However, like older women, the overall risks are small.

Prenatal Assessment

Ultrasound is one of the main screening tests done in combination with blood tests. The ultrasound is a test in which sound waves are used to examine the fetus. There are two general types. Transvaginal ultrasounds are used in early pregnancy, while transabdominal ultrasounds are more common and used after 10 weeks of pregnancy (typically, 16 to 20 weeks). Ultrasounds are used to check the fetus for defects or problems. It can also find out the age of the fetus, location of the placenta, fetal position, movement, breathing and heart rate, amount of amniotic fluid, and number of fetuses. Most women have at least one ultra sound during pregnancy, but if problems are noted, additional ultrasounds may be recommended.

Amniocentesis is a procedure in which a needle is used to withdraw a small amount of amniotic fluid and cells from the sac surrounding the fetus and later tested. Chorionic Villus Sampling is a procedure in which a small sample of cells is taken from the placenta and tested. Both amniocentesis and chorionic villus sampling have a risk of miscarriage, and consequently they are not done routinely.

Complications of Pregnancy

Minor complications: There are a number of common side effects of pregnancy. Not everyone experiences all of these, nor to the same degree. And although they are considered “minor” this is not to say that these problems are not potentially very uncomfortable. These side effects include nausea (particularly during the first 3-4 months of pregnancy as a result of higher levels of estrogen in the system), heartburn, gas, hemorrhoids, backache, leg cramps, insomnia, constipation, shortness of breath or varicose veins (as a result of carrying a heavy load on the abdomen).

Major Complications: The following are some serious complications of pregnancy which can pose health risks to mother and child and that often require hospitalization.

Ectopic Pregnancy occurs when the zygote becomes attached to the fallopian tube before reaching the uterus. About 1 in 50 pregnancies in the United States are tubal pregnancies and this number has been increasing because of the higher rates of pelvic inflammatory disease and Chlamydia (Carroll, 2007). Abdominal pain, vaginal bleeding, nausea and fainting are symptoms of ectopic pregnancy.

Preeclampsia, also known as Toxemia, is characterized by a sharp rise in blood pressure, a leakage of protein into the urine as a result of kidney problems, and swelling of the hands, feet, and face during the third trimester of pregnancy. Preeclampsia is the most common complication of pregnancy. It is estimated to affect 5% to 10% of all pregnancies globally and accounts for 40% to 60% of maternal deaths in developing countries (National Institute of Child Health and Human Development, 2013). Rates are lower in the United States and preeclampsia affects about 3% to 5% of pregnant women.

eclampsia, which is the second leading cause of maternal death in the United States. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. Treatment is typically bed rest and sometimes medication. If this treatment is ineffective, labor may be induced.

Maternal Mortality: Acording to the CDC (2019), about 700 American women die from complications related to pregnancy each year, and this number is rising. Further, 60% of those deaths could have been prevented. Bleeding, infections, and heart-related problems are the main causes. Possible contributing factors include the high caesarean section rate and obesity. Compared to other developed nations, this number is considered high. Approximately 1000 women die in childbirth around the world each day (World Health Organization, 2010). Rates are highest in Subsaharan Africa and South Asia, although there has been a substantial decrease in these rates. The campaign to make childbirth safe for everyone has led to the development of clinics accessible to those living in more isolated areas and training more midwives to assist in childbirth.

Spontaneous abortion is experienced in an estimated 20-40 percent of undiagnosed pregnancies and in another 10 percent of diagnosed pregnancies. Usually the body aborts due to chromosomal abnormalities, and this typically happens before the 12th week of pregnancy. Cramping and bleeding result and normal periods return after several months. Some women are more likely to have repeated miscarriages due to chromosomal, amniotic, or hormonal problems, but miscarriage can also be a result of defective sperm (Carrell et. al., 2003).

Birth

Preparation for Childbirth

The Lamaze Method. This method originated in Russia and was brought to the United States in the 1950s by Fernand Lamaze. The emphasis of this method is on teaching the woman to be in control in the process of delivery. It includes learning muscle relaxation, breathing though contractions, having a focal point (usually a picture to look at) during contractions and having a support person who goes through the training process with the mother and serves as a coach during delivery (Eisenberg, Murkoff, & Hathaway, 1996).

Choosing Where to Have the Baby and Who Will Deliver: The vast majority of births occur in a hospital setting. However, one percent of women choose to deliver at home (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015). Women who are at low risk for birth complications can successfully deliver at home. More than half (67%) of home deliveries are by certified nurse midwifes. Midwives are trained and licensed to assist in delivery and are far less expensive than the cost of a hospital delivery. However, because of the potential for a complication during the birth process, most medical professionals recommend that delivery take place in a hospital. Despite the concerns, in the United States women who have had previous children, who are over 25, and who are white are more likely to have out-of-hospital births (MacDorman, Menacker, & Declercq, 2010). In addition to home births, one-third of out-of-hospital births occur in freestanding clinics, birthing centers, in physician’s offices, or other locations.

Stages of Birth for Vaginal Delivery

The First Stage of labor begins with uterine contractions that may initially last about 30 seconds and be spaced 15 to 20 minutes apart. These increase in duration and frequency to more than a minute in length and about 3 to 4 minutes apart. Typically, doctors advise that they be called when contractions are coming about every 5 minutes. Some women experience false labor or Braxton-Hicks contractions, especially with the first child. These may come and go. They tend to diminish when the mother begins walking around. Real labor pains tend to increase with walking. Labor may also be signaled by a bloody discharge being expelled from the cervix. In one out of 8 pregnancies, the amniotic sac or water in which the fetus is suspended may break before labor begins. In such cases, the physician may induce labor with the use of medication if it does not begin on its own in order to reduce the risk of infection. Normally this sac does not rupture until the later stages of labor.

The Second Stage involves the passage of the baby through the birth canal. This stage takes about 10-40 minutes. Contractions usually come about every 2-3 minutes. The mother pushes and relaxes as directed by the medical staff. Normally the head is delivered first. The baby is then rotated so that one shoulder can come through and then the other shoulder. The rest of the baby quickly passes through. At this stage, an episiotomy or incision made in the tissue between the vaginal opening and anus, may be performed to avoid tearing the tissue of the back of the vaginal opening (Mayo Clinic, 2016). The baby’s mouth and nose are suctioned out. The umbilical cord is clamped and cut.

The Third Stage is relatively painless. During this stage, the placenta or afterbirth is delivered. This is typically within 20 minutes after delivery. If an episiotomy was performed it is stitched up during this stage.

epidural block is a regional analgesic that can be used during labor and alleviates most pain in the lower body without slowing labor. The epidural block can be used throughout labor and has little to no effect on the baby. Medication is injected into a small space outside the spinal cord in the lower back. It takes 10 to 20 minutes for the medication to take effect. An epidural block with stronger medications, such as anesthetics, can be used shortly before a C-section or if a vaginal birth requires the use of forceps or vacuum extraction.

Cesarean section (C-section) is surgery to deliver the baby by being removed through the mother’s abdomen. In the United States, about one in three women have their babies delivered this way (Martin et al., 2015). Most C-sections are done when problems occur during delivery unexpectedly. These can include:
• Health problems in the mother
• Signs of distress in the baby
• Not enough room for the baby to go through the vagina
• The position of the baby, such as a breech presentation where the head is not in the downward position

Induced birth: Sometimes a baby’s arrival may need to be induced or delivered before labor begins. Inducing labor may be recommended for a variety of reasons when there is concern for the health of the mother or baby. For example:
• The mother is approaching two weeks beyond her due date and labor has not started naturally
• The mother’s water has broken, but contractions have not begun
• There is an infection in the mother’s uterus
• The baby has stopped growing at the expected pace
• There is not enough amniotic fluid surrounding the baby
• The placenta peels away, either partially or completely, from the inner wall of the uterus before delivery
• The mother has a medical condition that might put her or her baby at risk, such as high blood pressure or diabetes (Mayo Clinic, 2014)

Assessing the Neonate

This is a very quick way to assess the newborn’s overall condition. Five measures are assessed: Heart rate, respiration, muscle tone (assessed by touching the baby’s palm), reflex response (the Babinski reflex is tested), and color. A score of 0 to 2 is given on each feature examined. An Apgar of 5 or less is cause for concern. The second Apgar should indicate improvement with a higher score.

Problems of the Newborn

Anoxia: Anoxia is a temporary lack of oxygen to the brain. Difficulty during delivery may lead to anoxia which can result in brain damage or in severe cases, death. Babies who suffer both low birth weight and anoxia are more likely to suffer learning disabilities later in life as well.

Low Birth weight: We have been discussing a number of teratogens associated with low birth weight such as alcohol, tobacco, etc. A child is considered low birth weight if he or she weighs less than 5 pounds 8 ounces (2500 grams). About 8.2 percent of babies born in the United States are of low birth weight (Center for Disease Control, 2015a). A low birth weight baby has difficulty maintaining adequate body temperature because it lacks the fat that would otherwise provide insulation. Such a baby is also at more risk for infection, and 67 percent of these babies are also preterm which can make them more at risk for respiratory infection. Very low birth weight babies (2 pounds or less) have an increased risk of developing cerebral palsy.

Preterm: A newborn might also have a low birth weight if it is born at less than 37 weeks gestation, which qualifies it as a preterm baby (CDC, 2015c). Early birth can be triggered by anything that disrupts the mother’s system. For instance, vaginal infections can lead to premature birth because such infection causes the mother to release anti-inflammatory chemicals which, in turn, can trigger contractions. Smoking and the use of other teratogens can lead to preterm
birth. The earlier a woman quits smoking, the lower the chance that the baby will be born preterm (Someji & Beltrán-Sánchez, 2019). A significant consequence of preterm birth includes respiratory distress syndrome, which is characterized by weak and irregular breathing (United States National Library of Medicine, 2015b).

Small-for-Date Infants: Infants that have birth weights that are below expectation based on their gestational age are referred to as small-for-date.
These infants may be full term or preterm, but still weigh less than 90 % of all babies of the same gestational age. This is a very serious situation for newborns as their growth was adversely affected. Regev et al. (2003) found that small-for- date infants died at rates more than four times higher than other infants. Remember that many causes of low birth weight and preterm births are preventable with proper prenatal care.

Postpartum Maternal Concerns

baby blues are feelings of sadness that occur 3 to 5 days after having a baby, and typically disappear usually within 10 days of the birth. New mothers may have trouble sleeping, be moody, and feel let-down from the birthing experience. However, postpartum depression is not the same as the baby blues. According to the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5), (American Psychiatric Association, 2013), peripartum onset of depression, also known as postpartum depression, is a type of depression that occurs during pregnancy or in the 4 weeks following pregnancy. Approximately 1 out of 8 women experience postpartum depression and symptoms can include feelings of sadness, sleeplessness, and difficulty bonding with the newborn.

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Attribution

Lifespan Development: A Psychological Perspective Second Edition by Martha Lally and Suzanne Valentine-French under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 unported license.