What you’ll learn to do: describe approaches to childbirth and the labor and delivery process

What comes to your mind when you think about a woman giving birth? Some may describe it as beautiful, a miracle, and a rite of passage. Others may think of pain, fear, and discomfort. Labor and delivery is not an easy feat. It is called labor after all because it is a lot of work! In this section, you’ll learn more about the various approaches to childbirth as well as the actual process.

Childbirth

Approaches to Childbirth

Prepared childbirth refers to being not only physically in good condition to help provide a healthy environment for the baby to develop, but also helping a couple to prepare to accept their new roles as parents and to get information and training that will assist them for delivery and life with the baby as much as possible. The more a couple can learn about childbirth and the newborn, the better prepared they will be for the adjustment they must make to a new life. Nothing can prepare a couple for this completely. Once a couple finds that they are to have a child, they begin to conjure up images of what they think the experience will involve. Once the child is born, they must reconcile those images with reality (Galinsky, 1987). Knowing more of what to expect does help them in forming more realistic images thus making the adjustment easier. Let’s explore some of the methods of prepared childbirth.

HypnoBirthing

Grantley Dick-Read was an English obstetrician and pioneer of prepared childbirth in the 1930s. In his book Childbirth Without Fear, he suggests that the fear of childbirth increases tension and makes the process of childbearing more painful. He believed that if mothers were educated, the fear and tension would be reduced and the need for medication could frequently be eliminated. The Dick-Read method emphasized the use of relaxation and proper breathing with contractions as well as family support and education. Today this method is known as the Mongan Method or HypnoBirthing. Women using this method report feeling like they are lost in a daydream, but focused and in control.

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 through 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. The Lamaze Method is still the most commonly taught method in the U.S. today.

The Bradley Method

This method originated in the late 1940’s and helps women deliver naturally, with few or no drugs. There are a series of courses that emphasize excellent nutrition and exercise, relaxation techniques to manage pain, and the involvement of the partner as a coach. Parents-to-be are taught to be knowledgeable consumers of birth services and to take responsibility in making informed decisions regarding procedures, attendants and the birthplace. In turn, this will lead to keeping mothers healthy and low-risk in order to avoid complications that may lead to medical intervention.

Nurse Midwives

Historically in the United States, most babies were born under the care of lay midwives. In the 1920s, middle-class women were increasingly using doctors to assist with childbirth but rural women were still being assisted by lay midwives. The nursing profession began educating nurse-midwives to assist these women. Nurse-midwives continued to assist most rural women with delivery until the 1970s and 1980s when their growth is thought to have posed a threat to the medical profession (Weitz, 2007). Women who are at low risk for birth complications can successfully deliver under the care of nurse-midwives. Some hospitals give privileges to nurse-midwives to deliver there. They may also deliver babies at home or in birthing centers.

Home Birth

Because one out of every 20 births involves a complication, most medical professionals recommend that delivery take place in a hospital. However, some couples choose to have their baby at home. About 1 percent of births occur outside of a hospital in the United States. Two-thirds of these are home births and more than half of these are assisted by midwives. In the United States, women who have had previous children, who are over 25 and who are white are most likely to not give birth in a hospital (MacDorman et al., 2010).

Birthing Centers

A birthing center presents a more home-like environment than a hospital labor ward, typically with more options during labor: food/drink, music, and the attendance of family and friends if desired. Other characteristics can also include non-institutional furniture such as queen-sized beds, large enough for both mother and father and perhaps birthing tubs or showers for water births. The decor is meant to emphasize the normality of birth. In a birth center, women are free to act more spontaneously during their birth, such as squatting, walking or performing other postures that assist in labor. Active birth is encouraged. The length of stay after a birth is shorter at a birth center; sometimes just 6 hours after birth the mother and infant can go home. One-third of out-of-hospital births occur in freestanding clinics, birthing centers, or in physicians offices or other locations.

Water Birth

Laboring and/or giving birth in a warm tub of water can help a woman relax. The buoyancy of the water can help alleviate discomfort and pressure for the mother. Many hospitals have birthing tubs that allow women to labor in them. However, only some hospitals allow for the birth to take place in the water. Some believe that water birth gives a more calm and tranquil transition for the baby from the womb. Water births are more common to occur at home or in birthing centers.

Hospital Birth

Most births in the U.S. occur in hospitals. Mothers have the choice to have a medicated or unmedicated delivery. Some women do fine with “natural methods” of pain relief alone. Many women blend “natural methods” with medications and medical interventions that relieve pain. Building a positive outlook on childbirth and managing fear may also help some women cope with the pain. Labor pain is not like pain due to illness or injury. Instead, it is caused by contractions of the uterus that are pushing the baby down and out of the birth canal. In other words, labor pain has a purpose.

The most common pain relief method used during labor and delivery is an epidural. An epidural is a procedure that involves placing a tube into the lower back, into a small space outside the spinal cord. Small doses of medicine can be given through the tube as needed throughout labor. With an epidural, pain relief starts 10 to 20 minutes after the medicine has been given. The degree of numbness felt can be adjusted. An epidural can prolong the first and second stages of labor. If given late in labor or if too much medicine is used, it might be hard to push when the time comes.

Another form of pharmacologic pain relief available for laboring mothers is inhaled nitrous oxide. This is typically a 50/50 mixture of nitrous oxide with air that is an inhaled analgesic and anesthetic. Nitrous oxide has been used for pain management in childbirth since the late 1800’s. The use of inhaled analgesia is commonly used in the UK, Finland, Australia, Singapore, and New Zealand, and is gaining in popularity in the United States.

The Process of Delivery

The first stage of labor is typically the longest. 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 should 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.

During this stage, the cervix or opening to the uterus dilates to 10 centimeters or just under 4 inches. This may take around 12-16 hours for first children or about 6-9 hours for women who have previously given birth. It takes one woman in 9 over 24 hours to dilate completely. Labor may also begin with a discharge of blood or amniotic fluid. If the amniotic sack breaks, which happens for one out of eight pregnancies, labor will be induced if necessary to reduce the risk of infection.

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. The baby’s mouth and nose are suctioned out. The umbilical cord is clamped and cut.

The third stage is relatively painless in comparison to the other stages. During this stage, the placenta or afterbirth is delivered. This typically occurs within 20 minutes after delivery of the baby. If tearing of the vagina occurred during birth, the tear may be stitched at this time.

Cesarean Section

Cesarean section, also known as C-section, or cesarean delivery, is the use of surgery to deliver babies. A cesarean section is often necessary when a vaginal delivery would put the baby or mother at risk. This may include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, or problems with the placenta or umbilical cord. Cesarean delivery may be performed based upon the shape of the mother’s pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that cesarean section be performed only when medically necessary. Some C-sections are performed without a medical reason, upon request by someone, usually the mother.

The Newborn

The average newborn weighs approximately 7.5 pounds, although a healthy birth weight for a full-term baby is considered to be between 5 pounds, 8 ounces and 8 pounds, 13 ounces. The average length of a newborn is 19.5 inches, increasing to 29.5 inches by 12 months and 34.4 inches by 2 years old (WHO Multicentre Growth Reference Study Group, 2006).

For the first few days of life, infants typically lose about 5 percent of their body weight as they eliminate waste and get used to feeding. This often goes unnoticed by most parents, but can be cause for concern for those who have a smaller infant. This weight loss is temporary, however, and is followed by a rapid period of growth.

Newborn Assessment and Risks

Complications of the Newborn

Assessing the Neonate

There are several ways to assess the condition of the newborn. The most widely used tool is the Neonatal Behavioral Assessment Scale (NBAS) developed by T. Berry Brazelton. This tool has been used around the world to help parents get to know their infants and to make comparisons of infants in different cultures (Brazelton & Nugent, 1995). The baby’s motor development, muscle tone, and stress response are assessed.

The APGAR is conducted one minute and five minutes after birth. This is a very quick way to assess the newborn’s overall condition. Five measures are assessed: the heart rate, respiration, muscle tone (quickly assessed by a skilled nurse when the baby is handed to them or 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.

Low Birth Weight

We have been discussing a number of teratogens associated with a low birth weight such as cocaine, tobacco, etc. A child is considered to have a low birth weight if they weigh less than 5.8 pounds. In 2016, about 8.17 percent of babies born in the United States were of low birth weight and 1.4 percent were born with very low birth weight. 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 of infection. And 67 percent of these babies are also preterm which can make them more at risk for a respiratory infection. Very low birth weight babies (2 pounds or less) have an increased risk of developing cerebral palsy. Many causes of low birth weight are preventable with proper prenatal care.

Premature Birth

A child might also have a low birth weight if it is born at less than 37 weeks gestation (which qualifies it as a preterm baby). In 2016, 9.85 percent of babies born in the U.S. were preterm. Early birth can be triggered by anything that disrupts the mother’s system. For instance, vaginal infections or gum disease can actually 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 also lead to preterm birth.

Anoxia and Hypoxia

One of leading causes of infant brain damage is lack of oxygen shortly after birth. Hypoxia occurs when the infant is deprived of the adequate amount of oxygen, leading to mild to moderate brain damage. Apoxia occurs when the infant undergoes a total lack of oxygen, which can lead to severe brain damage. This lack of oxygen is typically caused by umbilical cord problems, birth canal problems, blocked airways, and placenta abruption. Both hypoxia and anoxia can lead to cerebral palsy and a host of other medical disorders.

Postpartum Period

The postpartum (or postnatal) period begins immediately after childbirth as the mother’s body, including hormone levels and uterus size, returns to a non-pregnant state. The terms puerperium, puerperal period, or immediate postpartum period are commonly used to refer to the first six weeks following childbirth. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.

A woman giving birth in a hospital may leave as soon as she is medically stable, which can be as early as a few hours postpartum, though the average for a vaginal birth is one to two days. The average caesarean section postnatal stay is three to four days. During this time, the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant’s health is also monitored. Early postnatal hospital discharge is typically defined as discharge of the mother and newborn from the hospital within 48 hours of birth.

The postpartum period can be divided into three distinct stages; the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. Various organizations recommend routine postpartum evaluation at certain time intervals in the postpartum period.

Acute phase

The greatest health risk in the acute phase is postpartum bleeding. Following delivery the area where the placenta was attached to the uterine wall bleeds, and the uterus must contract to prevent blood loss. After contraction takes place the fundus (top) of the uterus can be palpated as a firm mass at the level of the navel. It is important that the uterus remains firm and the nurse or midwife will make frequent assessments of both the fundus and the amount of bleeding. Uterine massage is commonly used to help the uterus contract.

Following delivery if the mother had an episiotomy or tearing at the opening of the vagina, it is stitched. In the past, an episiotomy was routine. However, more recent research shows that routine episiotomy, when a normal delivery without complications or instrumentation is anticipated, does not offer benefits in terms of reducing perineal or vaginal trauma. Selective use of episiotomy results in less perineal trauma. A healthcare professional can recommend comfort measures to help to ease perineal pain.

Physical recovery in the subacute postpartum period

In the first few days following childbirth, the risk of DVT is relatively high as hypercoagulability increases during pregnancy and is maximal in the postpartum period, particularly for women with C-section with reduced mobility. Anti-coagulants or physical methods such as compression may be used in the hospital, particularly if the woman has risk factors, such as obesity, prolonged immobility, recent C-section, or first-degree relative with a history of thrombotic episode. For women with a history of thrombotic event in pregnancy or prior to pregnancy, anticoagulation is generally recommended.

The increased vascularity (blood flow) and edema (swelling) of the woman’s vagina gradually resolves in about three weeks. The cervix gradually narrows and lengths over a few weeks. Postpartum infections can lead to sepsis and if untreated, death. Postpartum urinary incontinence is experienced by about 33% of all women; women who deliver vaginally are about twice as likely to have urinary incontinence as women who give birth via a cesarean. Urinary incontinence in this period increases the risk of long term incontinence. Kegel exercises are recommended to strengthen the pelvic floor muscles and control urinary incontinence. Discharge from the uterus, called lochia, will gradually decrease and turn from bright red, to brownish, to yellow and cease at around five or six weeks.  An increase in lochia between 7–14 days postpartum may indicate delayed postpartum hemorrhage. In the subacute postpartum period, 87% to 94% of women report at least one health problem.

Infant caring in the subacute period

At two to four days postpartum, a woman’s breastmilk will generally come in. Historically, women who were not breastfeeding (nursing their babies) were given drugs to suppress lactation, but this is no longer medically indicated. In this period, difficulties with breastfeeding may arise. Maternal sleep is often disturbed as night waking is normal in the newborn, and newborns need to be fed every two to three hours, including during the night. The lactation consultant, health visitor, or postnatal doula,  may be of assistance at this time.

Psychological disorders

During the subacute postpartum period, psychological disorders may emerge. Among these are postpartum depression, posttraumatic stress disorder, and in rare cases, postpartum psychosis. Postpartum mental illness can affect both mothers and fathers, and is not uncommon. Early detection and adequate treatment is required. Approximately 70-80% of postpartum women will experience the “baby blues” for a few days. Between 10 and 20 percent may experience clinical depression, with a higher risk among those women with a history of postpartum depression, clinical depression, anxiety, or other mood disorders. Prevalence of PTSD following normal childbirth (excluding stillbirth or major complications) is estimated to be between 2.8% and 5.6% at six weeks postpartum.

Another subtype, peripartum onset (commonly referred to as postpartum depression), applies to women who experience major depression during pregnancy or in the four weeks following the birth of their child (APA, 2013). These women often feel very anxious and may even have panic attacks. They may feel guilty, agitated, and be weepy. They may not want to hold or care for their newborn, even in cases in which the pregnancy was desired and intended. In extreme cases, the mother may have feelings of wanting to harm her child or herself. Most women with peripartum-onset depression do not physically harm their children, but some do have difficulty being adequate caregivers (Fields, 2010). A surprisingly high number of women experience symptoms of peripartum-onset depression. A study of 10,000 women who had recently given birth found that 14% screened positive for peripartum-onset depression, and that nearly 20% reported having thoughts of wanting to harm themselves (Wisner et al., 2013).

Maternal-infant postpartum evaluation

Various organizations across the world recommend routine postpartum evaluation in the postpartum period. The American College of Obstetricians and Gynecologists (ACOG) recognizes the postpartum period (the “fourth trimester”) as critical for women and infants. Instead of the traditional single four- to six-week postpartum visit, ACOG, as of 2018, recommends that postpartum care be an ongoing process. They recommend that all women have contact (either in person or by phone) with their obstetric provider within the first three weeks postpartum to address acute issues, with subsequent care as needed. A more comprehensive postpartum visit should be done at four to twelve weeks postpartum to address the mother’s mood and emotional well-being, physical recovery after birth, infant feeding, pregnancy spacing and contraception, chronic disease management, and preventive health care and health maintenance. Women with hypertensive disorders should have a blood pressure check within three to ten days postpartum. More than one half of postpartum strokes occur within ten days of discharge after delivery. Women with chronic medical (e.g., hypertensive disorders, diabetes, kidney disease, thyroid disease) and psychiatric conditions should continue to follow with their obstetric or primary care provider for ongoing disease management. Women with pregnancies complicated by hypertension, gestational diabetes, or preterm birth should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of cardiovascular disease is higher in these women. Similarly, the World Health Organization recommends postpartum evaluation of the mother and infant at three days, one to two weeks, and six weeks postpartum.

Delayed postpartum period

The delayed postpartum period starts after the subacute postpartum period and lasts up to six months. During this time, muscles and connective tissue returns to a pre-pregnancy state. Recovery from childbirth complications in this period, such as urinary and fecal incontinence, painful intercourse, and pelvic prolapse, are typically very slow and in some cases may not resolve. Symptoms of PTSD often subside in this period, dropping from 2.8% and 5.6% at six weeks postpartum to 1.5% at six months postpartum.

Approximately three months after giving birth (typically between two and five months), estrogen levels drop and large amounts of hair loss is common, particularly in the temple area (postpartum alopecia). Hair typically grows back normally and treatment is not indicated. Other conditions that may arise in this period include postpartum thyroiditis. During this period, infant sleep during the night gradually increases and maternal sleep generally improves. Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. Ongoing physical and mental health evaluation, risk factor identification, and preventive health care should be provided.

Cultures

Postpartum confinement refers to a system for recovery following childbirth. It begins immediately after the birth and lasts for a culturally variable length: typically for one month or 30 days, up to 40 days, two months, or 100 days. This postnatal recuperation can include “traditional health beliefs, taboos, rituals, and proscriptions.”The practice used to be known as “lying-in”, which, as the term suggests, centers around bed rest. (Maternity hospitals used to use this phrase, as in the General Lying-in Hospital.) Postpartum confinement customs are well-documented in China, where it is known as “Sitting the month”, and similar customs manifest all over the world. A modern version of this rest period has evolved, to give maximum support to the new mother, especially if she is recovering from a difficult labor and delivery.

In other cultures like in South Korea, a great level of importance is placed on postnatal care. Sanhujori is the term for traditional postnatal care in Korea and is a practice followed by the majority of women for the purpose of proper recovery after giving birth. Deeply rooted in Korean culture, sanhujori has similarly evolved with today’s society from being heavily reliant on the mothers’ family members to include services that encompass its principles, which is apparent with the over 500 sanhujori centers (maternity hotels) in operation around Korea.

Newborn Communication

Do newborns communicate? Certainly, they do. They do not, however, communicate with the use of language. Instead, they communicate their thoughts and needs with body posture (being relaxed or still), gestures, cries, and facial expressions. A person who spends adequate time with an infant can learn which cries indicate pain and which ones indicate hunger, discomfort, or frustration

Sensory Development

As infants and children grow, their senses play a vital role in encouraging and stimulating the mind and in helping them observe their surroundings. Two terms are important to understand when learning about the senses. The first is sensation, or the interaction of information with the sensory receptors. The second is perception, or the process of interpreting what is sensed. It is possible for someone to sense something without perceiving it. Gradually, infants become more adept at perceiving with their senses, making them more aware of their environment and presenting more affordances or opportunities to interact with objects.

Vision

What can young infants see, hear, and smell? Newborn infants’ sensory abilities are significant, but their senses are not yet fully developed. Many of a newborn’s innate preferences facilitate interaction with caregivers and other humans. The womb is a dark environment void of visual stimulation. Consequently, vision is the most poorly developed sense at birth. Newborns typically cannot see further than 8 to 16 inches away from their faces, have difficulty keeping a moving object within their gaze, and can detect contrast more than color differences. If you have ever seen a newborn struggle to see, you can appreciate the cognitive efforts being made to take in visual stimulation and build those neural pathways between the eye and the brain.

Although vision is their least developed sense, newborns already show a preference for faces. When you glance at a person, where do you look? Chances are you look into their eyes. If so, why? It is probably because there is more information there than in other parts of the face. Newborns do not scan objects this way; rather, they tend to look at the chin or another less detailed part of the face. However, by 2 or 3 months, they will seek more detail when visually exploring an object and begin showing preferences for unusual images over familiar ones, for patterns over solids, faces over patterns, and three-dimensional objects over flat images. Newborns have difficulty distinguishing between colors, but within a few months are able to discrimination between colors as well as adults. Infants can also sense depth as binocular vision develops at about 2 months of age. By 6 months, the infant can perceive depth perception in pictures as well (Sen, Yonas, & Knill, 2001). Infants who have experience crawling and exploring will pay greater attention to visual cues of depth and modify their actions accordingly (Berk, 2007).

Hearing

The infant’s sense of hearing is very keen at birth. If you remember from an earlier module, this ability to hear is evidenced as soon as the 5th month of prenatal development. In fact, an infant can distinguish between very similar sounds as early as one month after birth and can distinguish between a familiar and non-familiar voice even earlier. Babies who are just a few days old prefer human voices, they will listen to voices longer than sounds that do not involve speech (Vouloumanos & Werker, 2004), and they seem to prefer their mother’s voice over a stranger’s voice (Mills & Melhuish, 1974). In an interesting experiment, 3-week-old babies were given pacifiers that played a recording of the infant’s mother’s voice and of a stranger’s voice. When the infants heard their mother’s voice, they sucked more strongly at the pacifier (Mills & Melhuish, 1974). Some of this ability will be lost by 7 or 8 months as a child becomes familiar with the sounds of a particular language and less sensitive to sounds that are part of an unfamiliar language.

Pain and Touch

Immediately after birth, a newborn is sensitive to touch and temperature, and is also sensitive to pain, responding with crying and cardiovascular responses. Newborns who are circumcised (the surgical removal of the foreskin of the penis) without anesthesia experience pain, as demonstrated by increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones (United States National Library of Medicine, 2016). According to the American Academy of Pediatrics (AAP), there are medical benefits and risks to circumcision. They do not recommend routine circumcision, however, they stated that because of the possible benefits (including prevention from urinary tract infections, penile cancer, and some STDs) parents should have the option to circumcise their sons if they want to (AAP, 2012).

The sense of touch is acute in infants and is essential to a baby’s growth of physical abilities, language and cognitive skills, and socio-emotional competency. Touch not only impacts short-term development during infancy and early childhood but also has long-term effects, suggesting the power of positive gentle touch from birth. Through touch, infants learn about their world, bond with their caregiver, and communicate their needs and wants. Research emphasizes the great benefits of touch for premature babies, but the presence of such contact has been shown to benefit all children (Stack, D. M. (2010). In an extreme example, some children in Romania were reared in orphanages in which a single care worker may have had as many as 10 infants to care for at one time. These infants were not often helped or given toys with which to play. As a result, many of them were developmentally delayed (Nelson, Fox, & Zeanah, 2014). When we discuss emotional and social development later in this module, you will also see the important role that touch plays in helping infants feel safe and protected, which builds trust and secure attachments between the child and their caregiver.

Taste and Smell

Not only are infants sensitive to touch, but newborns can also distinguish between sour, bitter, sweet, and salty flavors and show a preference for sweet flavors. They can distinguish between their mother’s scent and that of others, and prefer the smell of their mothers. A newborn placed on the mother’s chest will inch up to the mother’s breast, as it is a potent source of the maternal odor. Even on the first day of life, infants orient to their mother’s odor and are soothed, when crying, by their mother’s odor (Sullivan et al., 2011).

Bringing Baby Home

Benefits of Breastfeeding

Breast milk is considered the ideal diet for newborns due to the nutrition makeup of colostrum and subsequent breastmilk production. Colostrum, the milk produced during pregnancy and just after birth, has been described as “liquid gold. Colostrum is packed with nutrients and other important substances that help the infant build up his or her immune system. Most babies will get all the nutrition they need through colostrum during the first few days of life (CDC, 2018).Breast milk  changes by the third to fifth day after birth, becoming much thinner, but containing just the right amount of fat, sugar, water, and proteins to support overall physical and neurological development. It provides a source of iron more easily absorbed in the body than the iron found in dietary supplements, it provides resistance against many diseases, it is more easily digested by infants than formula, and it helps babies make a transition to solid foods more easily than if bottle-fed.

The reason infants need such a high fat content is the process of myelination which requires fat to insulate the neurons. Therefore, there has been some research, including meta-analyses, to show that breastfeeding is connected to advantages with cognitive development (Anderson, Johnstone, & Remley, 1999)Low birth weight infants had the greatest benefits from breastfeeding than did normal-weight infants in a meta-analysis that of twenty controlled studies examining the overall impact of breastfeeding (Anderson et al., 1999). This meta-analysis showed that breastfeeding may provide nutrients required for rapid development of the immature brain and be connected to more rapid or better development of neurologic function. The studies also showed that a longer duration of breastfeeding was accompanied by greater differences in cognitive development between breastfed and formula-fed children. Whereas normal-weight infants showed a 2.66-point difference, low-birth-weight infants showed a 5.18-point difference in IQ compared with weight-matched, formula-fed infants (Anderson et al, 1999). These studies suggest that nutrients present in breast milk may have a significant effect on neurologic development in both premature and full-term infants.

For most babies, breast milk is also easier to digest than formula. Formula-fed infants experience more diarrhea and upset stomachs. The absence of antibodies in formula often results in a higher rate of ear infections and respiratory infections. Children who are breastfed have lower rates of childhood leukemia, asthma, obesity, type 1 and 2 diabetes, and a lower risk of SIDS. For all of these reasons, it is recommended that mothers breastfeed their infants until at least 6 months of age and that breast milk be used in the diet throughout the first year (U.S. Department of Health and Human Services, 2004a in Berk, 2007).

Several recent studies have reported that it is not just babies that benefit from breastfeeding. Breastfeeding stimulates contractions in the uterus to help it regain its normal size, and women who breastfeed are more likely to space their pregnancies farther apart. Mothers who breastfeed are at lower risk of developing breast cancer, especially among higher-risk racial and ethnic groups (Islami et al., 2015). Other studies suggest that women who breastfeed have lower rates of ovarian cancer (Titus-Ernstoff, Rees, Terry, & Cramer, 2010), and reduced risk for developing Type 2 diabetes (Gunderson, et al., 2015).

Most mothers who breastfeed in the United States stop breastfeeding at about 6-8 weeks, often in order to return to work outside the home (United States Department of Health and Human Services (USDHHS), 2011). Mothers can certainly continue to provide breast milk to their babies by expressing and freezing the milk to be bottle fed at a later time or by being available to their infants at feeding time, but some mothers find that after the initial encouragement they receive in the hospital to breastfeed, the outside world is less supportive of such efforts. Some workplaces support breastfeeding mothers by providing flexible schedules and welcoming infants, but many do not. And the public support of breastfeeding is sometimes lacking. Women in Canada are more likely to breastfeed than are those in the United States, and the Canadian health recommendation is for breastfeeding to continue until 2 years of age. Facilities in public places in Canada such as malls, ferries, and workplaces provide more support and comfort for the breastfeeding mother and child than found in the United States.

In addition to the nutritional and health benefits of breastfeeding, breast milk is free! Anyone who has priced formula recently can appreciate this added incentive to breastfeeding. Prices for a month’s worth of formula can easily range from $130-$200. Prices for a year’s worth of formula and feeding supplies can cost well over $1,500 (USDHHS, 2011).

When Breastfeeding Doesn’t Work

There are occasions where mothers may be unable to breastfeed babies, often for a variety of health, social, and emotional reasons. For example, breastfeeding generally does not work: 

• when the baby is adopted 
• when the biological mother has a transmissible disease such as tuberculosis or HIV
• when the mother is addicted to drugs or taking any medication that may be harmful to the baby (including some types of birth control)
• when the infant was born to (or adopted by) a family with two fathers and the surrogate mother is not available to breastfeed
• when there are attachment issues between mother and baby
• when the mother or the baby is in the Intensive Care Unit (ICU) after the delivery process
• when the baby and mother are attached but the mother does not produce enough breast-milk

One early argument given to promote the practice of breastfeeding (when health issues are not the case) is that it promotes bonding and healthy emotional development for infants. However, this does not seem to be a unique case. Breastfed and bottle-fed infants adjust equally well emotionally (Ferguson & Woodward, 1999). This is good news for mothers who may be unable to breastfeed for a variety of reasons and for fathers who might feel left out as a result.

Global Considerations and Malnutrition

In the 1960s, formula companies led campaigns in developing countries to encourage mothers to feed their babies on infant formula. Many mothers felt that formula would be superior to breast milk and began using formula. The use of formula can certainly be healthy under conditions in which there is adequate, clean water with which to mix the formula and adequate means to sanitize bottles and nipples. However, in many of these countries, such conditions were not available and babies often were given diluted, contaminated formula which made them become sick with diarrhea and become dehydrated. These conditions continue today and now many hospitals prohibit the distribution of formula samples to new mothers in efforts to get them to rely on breastfeeding. Many of these mothers do not understand the benefits of breastfeeding and have to be encouraged and supported in order to promote this practice.

The World Health Organization (2018) recommends:

• initiation of breastfeeding within one hour of birth
• exclusive breastfeeding for the first six months of life
• introduction of solid foods at six months together with continued breastfeeding up to two years of age or beyond

Sleep and Health

Infant Sleep

Infants 0 to 2 years of age sleep an average of 12.8 hours a day, although this changes and develops gradually throughout an infant’s life. For the first three months, newborns sleep between 14 and 17 hours a day, then they become increasingly alert for longer periods of time. About one-half of an infant’s sleep is rapid eye movement (REM) sleep, and infants often begin their sleep cycle with REM rather than non-REM sleep. They also move through the sleep cycle more quickly than adults. Parents spend a significant amount of time worrying about and losing even more sleep over their infant’s sleep schedule when there remains a great deal of variation in sleep patterns and habits for individual children. A 2018 study showed that at 6 months of age, 62% of infants slept at least six hours during the night, 43% of infants slept at least 8 hours through the night, and 38% of infants were not sleeping at least six continual hours through the night. At 12 months, 28% of children were still not sleeping at least 6 uninterrupted hours through the night, while 78% were sleeping at least 6 hours, and 56% were sleeping at least 8 hours.

The most common infant sleep-related problem reported by parents is nighttime waking. Studies of new parents and sleep patterns show that parents lose the most sleep during the first three months with a new baby, with mothers losing about an hour of sleep each night, and fathers losing a disproportionate 13 minutes. This decline in sleep quality and quantity for adults persists until the child is about six years old.

While this shows there is no precise science as to when and how an infant will sleep, there are general trends in sleep patterns. Around six months, babies typically sleep between 14-15 hours a day, with 3-4 of those hours happening during daytime naps. As they get older, these naps decrease from several to typically two naps a day between ages 9-18 months. Often, periods of rapid weight gain or changes in developmental abilities such as crawling or walking will cause changes to sleep habits as well. Infants generally move towards one 2-4 hour nap a day by around 18 months, and many children will continue to nap until around four or five years old.

Sudden Unexpected Infant Deaths (SUID)

Each year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (SUID). These deaths occur among infants less than one-year-old and have no immediately obvious cause (CDC, 2015). The three commonly reported types of SUID are:

• Sudden Infant Death Syndrome (SIDS): SIDS is identified when the death of a healthy infant occurs suddenly and unexpectedly, and medical and forensic investigation findings (including an autopsy) are inconclusive. SIDS is the leading cause of death in infants up to 12 months old, and approximately 1,500 infants died of SIDS in 2013 (CDC, 2015). The risk of SIDS is highest at 4 to 6 weeks of age. Because SIDS is diagnosed when no other cause of death can be determined, possible causes of SIDS are regularly researched. One leading hypothesis suggests that infants who die from SIDS have abnormalities in the area of the brainstem responsible for regulating breathing (Weekes-Shackelford & Shackelford, 2005). Although the exact cause is unknown, doctors have identified the following risk factors for SIDS:
  • low birth weight
  • siblings who have had SIDS
  • sleep apnea
  • of African-American or Eskimo decent
  • low socioeconomic status (SES)
  • smoking in the home
• Unknown Cause: The sudden death of an infant less than one year of age that cannot be explained because a thorough investigation was not conducted and the cause of death could not be determined.
• Accidental Suffocation and Strangulation in Bed: Reasons for accidental suffocation include the following: Suffocation by soft bedding, another person rolling on top of or against the infant while sleeping, an infant being wedged between two objects such as a mattress and wall, and strangulation such as when an infant’s head and neck become caught between crib railings.

The combined SUID rate declined considerably following the release of the American Academy of Pediatrics safe sleep recommendations in 1992, which advocated that infants be placed on their backs for sleep (non-prone position). These recommendations were followed by a major Back to Sleep Campaign in 1994. According to the CDC, the SIDS death rate is now less than one-fourth of what is was (130 per 100,000 live birth in 1990 versus 40 in 2015). However, accidental suffocation and strangulation in bed mortality rates remained unchanged until the late 1990s. Some parents were still putting newborns to sleep on their stomachs partly because of past tradition. Most SIDS victims experience several risks, an interaction of biological and social circumstances. But thanks to research, the major risk, stomach sleeping, has been highly publicized. Other causes of death during infancy include congenital birth defects and homicide.

Co-Sleeping

The location of sleep depends primarily on the baby’s age and culture. Bed-sharing (in the parents’ bed) or co-sleeping (in the parents’ room) is the norm in some cultures, but not in others (Esposito et al., 2015). Colvin, Collie-Akers, Schunn, and Moon (2014) analyzed a total of 8,207 deaths from 24 states during 2004–2012. The deaths were documented in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The results indicated that younger victims (0-3 months) were more likely to die by bed-sharing and sleeping in an adult’s bed or on a person. A higher percentage of older victims (4 months to 364 days) rolled into objects in the sleep environment and changed position from side/back to prone. Carpenter et al. (2013) compared infants who died of SIDS with a matched control and found that infants younger than three months old who slept in bed with a parent were five times more likely to die of SIDS compared to babies who slept separately from the parents, but were still in the same room. They concluded that bed-sharing, even when the parents do not smoke or take alcohol or drugs, increases the risk of SIDS. However, when combined with parental smoking and maternal alcohol consumption and/or drug use, the risks associated with bed-sharing greatly increased.

Despite the risks noted above, the controversy about where babies should sleep has been ongoing. Co-sleeping has been recommended for those who advocate attachment parenting (Sears & Sears, 2001), and other research suggests that bed-sharing and co-sleeping is becoming more popular in the United States (Colson et al., 2013). So, what are the latest recommendations?

The American Academy of Pediatrics (AAP) actually updated their recommendations for a Safe Infant Sleeping Environment in 2016. The most recent AAP recommendations on creating a safe sleep environment include:

• Back to sleep for every sleep. Always place the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
• Avoid the use of soft bedding, including crib bumpers, blankets, pillows, and soft toys. The crib should be bare.
• Breastfeeding is recommended.
• Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
• Avoid baby’s exposure to smoke, alcohol, and illicit drugs.

As you can see, there is a recommendation to now “share a bedroom with parents,” but not the same sleeping surface. Breastfeeding is also recommended as adding protection against SIDS, but after feeding, the AAP encourages parents to move the baby to his or her separate sleeping space, preferably a crib or bassinet in the parents’ bedroom. Finally, the report included new evidence that supports skin-to-skin care for newborn infants.

Temperament

Perhaps you have spent time with a number of infants. How were they alike? How did they differ? Or compare yourself with your siblings or other children you have known well. You may have noticed that some seemed to be in a better mood than others and that some were more sensitive to noise or more easily distracted than others. These differences may be attributed to temperament. Temperament is an inborn quality noticeable soon after birth. Temperament is not the same as personality but may lead to personality differences. Generally, personality traits are learned, whereas temperament is genetic. Of course, for every trait, nature and nurture interact.

According to Chess and Thomas (1996), children vary on nine dimensions of temperament. These include activity level, regularity (or predictability), sensitivity thresholds, mood, persistence or distractibility, among others. These categories include the following:[foodnote]Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel[/footnote].

1. Activity level. Does the child display mostly active or inactive states?
2. Rhythmicity or Regularity. Is the child predictable or unpredictable regarding sleeping, eating, and elimination patterns?
3. Approach-Withdrawal. Does the child react or respond positively or negatively to a newly encountered situation?
4. Adaptability. Does the child adjust to unfamiliar circumstances easily or with difficulty
5. Responsiveness. Does it take a small or large amount of stimulation to elicit a response (e.g., laughter, fear, pain) from the child?
6. Reaction Intensity. Does the child show low or high energy when reacting to stimuli?
7. Mood Quality. Is the child normally happy and pleasant, or unhappy and unpleasant?
8. Distractibility. Is the child’s attention easily diverted from a task by external stimuli?
9. Persistence and Attention Span. Persistence – How long will the child continue at an activity despite difficulty or interruptions? Attention span – For how long a period of time can the child maintain interest in an activity?

The New York Longitudinal Study was a long term study of infants, on these dimensions, which began in the 1950s. Most children do not have their temperament clinically measured, but categories of temperament have been developed and are seen as useful in understanding and working with children. Based on this study, babies can be described according to one of several profiles: easy or flexible (40%), slow to warm up or cautious (15%), difficult or feisty (10%), and undifferentiated, or those who can’t easily be categorized (35%).

Easy babies (40% of infants) have a positive disposition. Their body functions operate regularly and they are adaptable. They are generally positive, showing curiosity about new situations and their emotions are moderate or low in intensity. Difficult babies (10% of infants) have more negative moods and are slow to adapt to new situations. When confronted with a new situation, they tend to withdraw. Slow-to-warm babies (15% of infants) are inactive, showing relatively calm reactions to their environment. Their moods are generally negative, and they withdraw from new situations, adapting slowly. The undifferentiated (35%) could not be consistently categorized. These children show a variety of combinations of characteristics. For example, an infant may have an overall positive mood but react negatively to new situations.

No single type of temperament is invariably good or bad, however, infants with difficult temperaments are more likely than other babies to develop emotional problems, especially if their mothers were depressed or anxious caregivers (Garthus-Niegel et al., 2017). Children’s long-term adjustment actually depends on the goodness-of-fit of their particular temperament to the nature and demands of the environment in which they find themselves. Therefore, what appears to be more important than child temperament is how caregivers respond to it.

Think about how you might approach each type of child in order to improve your interactions with them. An easy or flexible child will not need much extra attention unless you want to find out whether they are having difficulties that have gone unmentioned. A slow to warm up child may need to be given advance warning if new people or situations are going to be introduced. A difficult or feisty child may need to be given extra time to burn off their energy. A caregiver’s ability to accurately read and work well with the child will enjoy this goodness-of-fit, meaning their styles match and communication and interaction can flow. The temperamentally active children can do well with parents who support their curiosity but could have problems in a more rigid family.

It is this goodness-of-fit between child temperament and parental demands and expectations that can cause struggles. Rather than believing that discipline alone will bring about improvements in children’s behavior, our knowledge of temperament may help a parent, teacher or other caregiver gain insight to work more effectively with a child. Viewing temperamental differences as varying styles that can be responded to accordingly, as opposed to ‘good’ or ‘bad’ behavior. For example, a persistent child may be difficult to distract from forbidden things such as electrical cords, but this persistence may serve her well in other areas such as problem-solving.  Positive traits can be enhanced and negative traits can be subdued. The child’s style of reaction, however, is unlikely to change. Temperament doesn’t change dramatically as we grow up, but we may learn how to work around and manage our temperamental qualities. Temperament may be one of the things about us that stays the same throughout development.

Psychosocial Development

Theory of Psychosexual Development

Freud believed that personality develops during early childhood and that childhood experiences shape our personalities as well as our behavior as adults. He asserted that we develop via a series of stages during childhood. Each of us must pass through these childhood stages, and if we do not have the proper nurturing and parenting during a stage, we will be stuck, or fixated, in that stage even as adults.

In each psychosexual stage of development, the child’s pleasure-seeking urges, coming from the id, are focused on a different area of the body, called an erogenous zone. The stages are oral, anal, phallic, latency, and genital (Table 1).

For about the first year of life, the infant is in the oral stage of psychosexual development. The infant meets needs primarily through oral gratification. A baby wishes to suck or chew on any object that comes close to the mouth. Babies explore the world through the mouth and find comfort and stimulation as well. Psychologically, the infant is all id. The infant seeks immediate gratification of needs such as comfort, warmth, food, and stimulation. If the caregiver meets oral needs consistently, the child will move away from this stage and progress further. However, if the caregiver is inconsistent or neglectful, the person may stay stuck in the oral stage. As an adult, the person might not feel good unless involved in some oral activity such as eating, drinking, smoking, nail-biting, or compulsive talking. These actions bring comfort and security when the person feels insecure, afraid, or bored.

Assessing the Psychodynamic Perspective

Originating in the work of Sigmund Freud, the psychodynamic perspective emphasizes unconscious psychological processes (for example, wishes and fears of which we’re not fully aware), and contends that childhood experiences are crucial in shaping adult personality. When reading Freud’s theories, it is important to remember that he was a medical doctor, not a psychologist. There was no such thing as a degree in psychology at the time that he received his education, which can help us understand some of the controversies over his theories today. However, Freud was the first to systematically study and theorize the workings of the unconscious mind in the manner that we associate with modern psychology. The psychodynamic perspective has evolved considerably since Freud’s time, encompassing all the theories in psychology that see human functioning based upon the interaction of conscious and unconscious drives and forces within the person, and between the different structures of the personality (id, ego, superego).

Freud’s theory has been heavily criticized for several reasons. One is that it is very difficult to test scientifically. How can parenting in infancy be traced to personality in adulthood? Are there other variables that might better explain development? Because psychodynamic theories are difficult to prove wrong, evaluating those theories, in general, is difficult in that we cannot make definite predictions about a given individual’s behavior using the theories. The theory is also considered to be sexist in suggesting that women who do not accept an inferior position in society are somehow psychologically flawed. Freud focused on the darker side of human nature and suggested that much of what determines our actions is unknown to us. Others make the criticism that the psychodynamic approach is too deterministic, relating to the idea that all events, including human action, are ultimately determined by causes regarded as external to the will, thereby leaving little room for the idea of free will.

Freud’s work has been extremely influential, and its impact extends far beyond psychology (several years ago Time magazine selected Freud as one of the most important thinkers of the 20th century). Freud’s work has been not only influential but quite controversial as well. As you might imagine, when Freud suggested in 1900 that much of our behavior is determined by psychological forces of which we’re largely unaware—that we literally don’t know what’s going on in our own minds—people were (to put it mildly) displeased (Freud, 1900/1953a). When he suggested in 1905 that we humans have strong sexual feelings from a very early age and that some of these sexual feelings are directed toward our parents, people were more than displeased—they were outraged (Freud, 1905/1953b). Few theories in psychology have evoked such strong reactions from other professionals and members of the public.

Freud’s psychosexual development theory is quite controversial. To understand the origins of the theory, it is helpful to be familiar with the political, social, and cultural influences of Freud’s day in Vienna at the turn of the 20th century. During this era, a climate of sexual repression, combined with limited understanding and education surrounding human sexuality heavily influenced Freud’s perspective. Given that sex was a taboo topic, Freud assumed that negative emotional states (neuroses) stemmed from the suppression of unconscious sexual and aggressive urges. For Freud, his own recollections and interpretations of patients’ experiences and dreams were sufficient proof that psychosexual stages were universal events in early childhood.

So why do we study Freud? As mentioned above, despite the criticisms, Freud’s assumptions about the importance of early childhood experiences in shaping our psychological selves have found their way into child development, education, and parenting practices. Freud’s theory has heuristic value in providing a framework from which to elaborate and modify subsequent theories of development. Many later theories, particularly behaviorism and humanism, were challenges to Freud’s views. Controversy notwithstanding, no competent psychologist, or student of psychology, can ignore psychodynamic theory. It is simply too important for psychological science and practice and continues to play an important role in a wide variety of disciplines within and outside psychology (for example, developmental psychology, social psychology, sociology, and neuroscience; see Bornstein, 2005, 2006; Solms & Turnbull, 2011).

Psychosocial Theory

Erikson’s Psychosocial Theory

Now, let’s turn to a less controversial psychodynamic theorist, the father of developmental psychology, Erik Erikson (1902-1994). Erikson was a student of Freud’s and expanded on his theory of psychosexual development by emphasizing the importance of culture in parenting practices and motivations and adding three stages of adult development (Erikson, 1950; 1968).

Background

As an art school dropout with an uncertain future, young Erik Erikson met Freud’s daughter, Anna Freud, while he was tutoring the children of an American couple undergoing psychoanalysis in Vienna. It was Anna Freud who encouraged Erikson to study psychoanalysis. Erikson received his diploma from the Vienna Psychoanalytic Institute in 1933, and as Nazism spread across Europe, he fled the country and immigrated to the United States that same year. Erikson later proposed a psychosocial theory of development, suggesting that an individual’s personality develops throughout the lifespan—a departure from Freud’s view that personality is fixed in early life. In his theory, Erikson emphasized the social relationships that are important at each stage of personality development, in contrast to Freud’s emphasis on erogenous zones. Erikson identified eight stages, each of which includes a conflict or developmental task. The development of a healthy personality and a sense of competence depend on the successful completion of each task.

Psychosocial Stages of Development

Erikson believed that we are aware of what motivates us throughout life and that the ego has greater importance in guiding our actions than does the id. We make conscious choices in life, and these choices focus on meeting certain social and cultural needs rather than purely biological ones. Humans are motivated, for instance, by the need to feel that the world is a trustworthy place, that we are capable individuals, that we can make a contribution to society, and that we have lived a meaningful life. These are all psychosocial problems.

Erikson’s theory is based on what he calls the epigenetic principle, encompassing the notion that we develop through an unfolding of our personality in predetermined stages, and that our environment and surrounding culture influence how we progress through these stages. This biological unfolding in relation to our socio-cultural settings is done in stages of psychosocial development, where “progress through each stage is in part determined by our success, or lack of success, in all the previous stages.”

Erikson described eight stages, each with a major psychosocial task to accomplish or crisis to overcome. Erikson believed that our personality continues to take shape throughout our life span as we face these challenges. We will discuss each of these stages in greater detail when we discuss each of these life stages throughout the course. Here is an overview of each stage: