Why it matters: prenatal Development

People endure quite an incredible journey before they are born. Think about it—when the timing and conditions are just right, a tiny egg releases from ovulation and a single sperm out of hundreds of millions unite to begin the process of fertilization. Genetic material from the mother and father join together to form a completely new organism. This new organism has to continue to travel and implant in the uterine wall in order to continue to grow and thrive. It is not an easy feat. It still must grow and develop for approximately 268 days before it begins life outside of the womb.

Today we have more knowledge and technology than ever before that has an impact on this process. We are privy to tests that can give us a wealth of information even before we conceive. We have the ability to know the genetic make-up of an embryo before it is implanted in the womb. If you could choose all of the features of your future baby, would you? What would be the pros and cons of this? New parents also have the choice of the prenatal care that they receive and how they want to prepare for labor and delivery. As you can see, the choices that are made along the way and the unforeseen surprises make for a unique pregnancy and birth story.

Prenatal Development

Now we turn our attention to prenatal development which is divided into three periods: The germinal period, the embryonic period, and the fetal period. The following is an overview of some of the changes that take place during each period.

Period of the Zygote

The germinal period (about 14 days in length) lasts from conception to implantation of the fertilized egg in the lining of the uterus. At ejaculation millions of sperm are released into the vagina, but only a few reach the egg and typically only one fertilizes the egg. Once a single sperm has entered the wall of the egg, the wall becomes hard and prevents other sperm from entering. After the sperm has entered the egg, the tail of the sperm breaks off and the head of the sperm, containing the genetic information from the father, unites with the nucleus of the egg. It is typically fertilized in the top section of the fallopian tube and continues its journey to the uterus. As a result, a new cell is formed. This cell, containing the combined genetic information from both parents, is referred to as a zygote.

^{Sperm and ovum at conception. (Image is in the public domain)}

During this time, the organism begins cell division through mitosis. After five days of mitosis there are 100 cells, which is now called a blastocyst. The blastocyst consists of both an inner and 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 which nourishes the developing organism. This stage ends when the blastocyst fully implants into the uterine wall (U.S. National Library of Medicine, 2015, as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

^{The cycle of fertilization. (Image by Ttrue12 is licensed under CC BY-SA 3.0)}

Mitosis is a fragile process and fewer than one half of all zygotes survive beyond the first two weeks (Hall, 2004). Some of the reasons for this include: the egg and sperm do not join properly, thus their genetic material does not combine, there is too little or damaged genetic material, the zygote does not replicate, or the blastocyst does not implant into the uterine wall. The figure above illustrates the journey of the ova from its release to its fertilization, cell duplication, and implantation into the uterine lining (Lally & Valentine-French, 2019,p. 42-43).

The Embryonic Period

Starting the third week, the blastocyst has implanted in the uterine wall. Upon implantation this multi-cellular organism is called an 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). You will see that this pattern continues after birth.

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.

^{A human embryo. (Image by Anatomist90 is licensed under CC BY-SA 3.0)}

About 20 percent of organisms fail during the embryonic period, usually due to gross chromosomal abnormalities, often before the mother even knows that they are 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. Prospective 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 4 grams at the end of eight weeks. The embryo can move and respond to touch at this time. (Lally & Valentine-French, 2019, p. 43).

The Fetal Period

From the ninth week until birth (which is forty weeks for a full-term pregnancy), the organism is referred to as a 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. The fetus is about 3 inches long and weighs about 28 grams. In the following weeks, the fetus will develop hair, nails, teeth and the excretory and digestive systems will continue to develop.

^{A human fetus. (Image by lunar caustic is licensed under CC BY-SA 2.0)}

During the 4th – 6th months, the eyes become more sensitive to light and hearing develops. The respiratory system continues to develop, and reflexes such as sucking, swallowing and hiccupping, develop during the 5th month. Cycles of sleep and wakefulness are present at this time as well. The first chance of survival outside the womb, known as the age of viability is reached at about 24 weeks (Morgan, Goldenberg, & Schulkin, 2008, as cited in Paris, Ricardo, Raymond & Johnson, 2021). 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, as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

Between the 7th – 9th months, the fetus is primarily preparing for birth. It is exercising its muscles and its lungs begin to expand and contract. The fetus gains about 5 pounds and 7 inches during this last trimester of pregnancy, and during the 8th month a layer of fat develops under the skin. This layer of fat serves as insulation and helps the baby regulate body temperature after birth.

At around 36 weeks the fetus is almost ready for birth. It weighs about 6 pounds and is about 18.5 inches long. By week 37 all of the fetus’s organ systems are developed enough that it could survive outside the mother’s uterus without many of the risks associated with premature birth. The fetus continues to gain weight and grow in length until approximately 40 weeks. By then the fetus has very little room to move around and birth becomes imminent. The progression through the stages is shown in the following figure (Lally & Valentine-French, 2019, p. 44).

^{The development of a fetus. (Image by CNX Psychology is licensed under CC BY 4.0)}

Enivironmental Risks

Teratology

Good prenatal care is essential. The developing child is most at risk for some of the most severe problems during the first three months of development. Unfortunately, this is a time at which most mothers are unaware that they are pregnant. It is estimated that 10% of all birth defects are caused by a prenatal exposure or teratogen. Teratogens are factors that can contribute to birth defects which include some maternal diseases, drugs, alcohol, and stress. These exposures can also include environmental and occupational exposures. Today, we know many of the factors that can jeopardize the health of the developing child. Teratogen-caused birth defects are potentially preventable.

The study of factors that contribute to birth defects is called teratology. Teratogens are usually discovered after an increased prevalence of a particular birth defect. For example, in the early 1960’s, a drug known as thalidomide was used to treat morning sickness. Exposure of the fetus during this early stage of development resulted in cases of phocomelia, a congenital malformation in which the hands and feet are attached to abbreviated arms and legs.

A Look at Some Teratogens

Alcohol

One of the most commonly used teratogens is alcohol. 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 and when pregnant (Surgeon General’s Advisory on Alcohol Use During Pregnancy, 2005). Alcohol consumption, particularly during the second month of prenatal development, but at any point during pregnancy, may lead to neurocognitive and behavioural difficulties that can last a lifetime.

There is no acceptable safe limit for alcohol use during pregnancy, but binge drinking (5 or more drinks on a single occasion) or having 7 or more drinks during a single week places a child at particularly high risk. In extreme cases, alcohol consumption can lead to fetal death, but more frequently it can result in fetal alcohol spectrum disorders (FASD). This terminology is now used when looking at the effects of exposure and replaces the term fetal alcohol syndrome. It is preferred because it recognizes that symptoms occur on a spectrum and that all individuals do not have the same characteristics. Children with FASD share certain physical features such as flattened noses, small eye openings, small heads, intellectual developmental delays, and behavioural problems. Those with FASD are more at risk for lifelong problems such as criminal behaviour, psychiatric problems, and unemployment (CDC, 2006).

The terms alcohol-related neurological disorder (ARND) and alcohol-related birth defects (ARBD) have replaced the term Fetal Alcohol Effects to refer to those with less extreme symptoms of FASD. ARBD include kidney, bone and heart problems.

There is no acceptable safe limit for alcohol use during pregnancy, but binge drinking (5 or more drinks on a single occasion) or having 7 or more drinks during a single week places a child at particularly high risk. In extreme cases, alcohol consumption can lead to fetal death, but more frequently it can result in fetal alcohol spectrum disorders (FASD). This terminology is now used when looking at the effects of exposure and replaces the term fetal alcohol syndrome. It is preferred because it recognizes that symptoms occur on a spectrum and that all individuals do not have the same characteristics. Children with FASD share certain physical features such as flattened noses, small eye openings, small heads, intellectual developmental delays, and behavioural problems. Those with FASD are more at risk for lifelong problems such as criminal behaviour, psychiatric problems, and unemployment (CDC, 2006).

The terms alcohol-related neurological disorder (ARND) and alcohol-related birth defects (ARBD) have replaced the term Fetal Alcohol Effects to refer to those with less extreme symptoms of FASD. ARBD include kidney, bone and heart problems.

Tobacco

Smoking is also considered a teratogen because nicotine travels through the placenta to the fetus. When the mother smokes, the developing baby experiences a reduction in blood oxygen levels. Tobacco use during pregnancy has been associated with low birth weight, placenta previa, birth defects, preterm delivery, fetal growth restriction, and sudden infant death syndrome. Smoking in the month before getting pregnant and throughout pregnancy increases the chances of these risks. Quitting smoking before getting pregnant is best. However, for women who are already pregnant, quitting as early as possible can still help protect against some health problems for the mother and baby. (Centers for Disease Control and Prevention, n.d.)

Drugs

Prescription, over-the-counter, or recreational drugs can have serious teratogenic effects. In general, if medication is required, the lowest dose possible should be used. Combination drug therapies and first trimester exposures should be avoided. Almost three percent of pregnant women use illicit drugs such as marijuana, cocaine, Ecstasy and other amphetamines, and heroin. These drugs can cause low birth-weight, withdrawal symptoms, birth defects, or learning or behavioural problems. Babies born with a heroin addiction need heroin just like an adult addict. The child will need to be gradually weaned from the heroin under medical supervision; otherwise, the child could have seizures and die.

Environmental Chemicals

Environmental chemicals can include an exposure to a wide array of agents including pollution, organic mercury compounds, herbicides, and industrial solvents. Some environmental pollutants of major concern include lead poisoning, which is connected with low birth weight and slowed neurological development. Children who live in older housing in which lead-based paints have been used have been known to eat peeling paint chips thus being exposed to lead. The chemicals in certain herbicides are also potentially damaging. Radiation is another environmental hazard that a pregnant woman must be aware of. If a mother is exposed to radiation, particularly during the first three months of pregnancy, the child may suffer some congenital deformities. There is also an increased risk of miscarriage and stillbirth. Mercury leads to physical deformities and intellectual disabilities (Dietrich, 1999).

Sexually Transmitted Infections

Sexually transmitted infections (STIs) can complicate pregnancy and may have serious effects on both the mother and the developing baby. Most prenatal care today includes testing for STIs, and early detection is important. STIs, such as chlamydia, gonorrhea, syphilis, trichomoniasis and bacterial vaginosis can all be treated and cured with antibiotics that are safe to take during pregnancy. STIs that are caused by viruses, like genital herpes, hepatitis B, or HIV cannot be cured. However, in some cases these infections can be treated with antiviral medications or other preventive measures can be taken to reduce the risk of passing the infection to the baby. (Centers for Disease Control and Prevention, n.d.)

Maternal Diseases

Maternal illnesses increase the chance that a baby will be born with a birth defect or have a chronic health problem. Some of the diseases that are known to potentially have an adverse effect on the fetus include: diabetes, cytomegalovirus, toxoplasmosis, Rubella, varicella, hypothyroidism, and Strep B. If the mother contracts Rubella during the first three months of pregnancy, damage can occur in the eyes, ears, heart, or brain of the unborn child. On a positive note, Rubella has been nearly eliminated in the industrial world due to the vaccine created in 1969. Diagnosing these diseases early and receiving appropriate medical care can help improve the outcomes. Routine prenatal care now includes screening for gestational diabetes and Strep B. (Birth Defect Research for Children, n.d.)

Maternal Stress

Stress represents the effects of any factor able to threaten the homeostasis of an organism; these either real or perceived threats are referred to as the “stressors” and comprise a long list of potentially adverse factors, which can be emotional or physical. Because of a link in blood supply between a mother and fetus, it has been found that stress can leave lasting effects on a developing fetus, even before a child is born. The best-studied outcomes of fetal exposure to maternal prenatal stress are preterm birth and low birth weight. Maternal prenatal stress is also considered responsible for a variety of changes of the child’s brain, and a risk factor for conditions such as behavioural problems, learning disorders, high levels of anxiety, attention deficit hyperactivity disorder, autism, and schizophrenia. Furthermore, maternal prenatal stress has been associated with a higher risk for a variety of immune and metabolic changes in the child such as asthma, allergic disorders, cardiovascular diseases, hypertension, hyperlipidemia, diabetes, and obesity.(Douros et al., 2017)

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, as cited in as cited in Paris, Ricardo, Raymond, & Johnson, 2021), 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

Because are born with all of their eggs, environmental teratogens can affect the quality of the eggs as women get older. Also, a woman’s reproductive system ages which can adversely affect the pregnancy. Some women over 35 choose special prenatal screening tests, such as a maternal blood screening, to determine if there are any health risks for the baby.

Although there are medical concerns associated with having a child later in life, there are also many positive consequences to being a more mature parent. Older parents are more confident, less stressed, and typically married, providing family stability. Their children perform better on math and reading tests, and they are less prone to injuries or emotional troubles (Albert, 2013, as cited in as cited in Paris, Ricardo, Raymond, & Johnson, 2021). Women who delay pregnancy either by choice or because of challenges with conceiving are often better educated and have healthier lifestyles. According to Gregory (2007, as cited in as cited in Paris, Ricardo, Raymond, & Johnson, 2021), older women are more stable, demonstrate a stronger family focus, possess greater self-confidence, and have more money. Having a child later in one’s career equals overall higher wages. In fact, for every year a woman delays motherhood, she makes 9% more in lifetime earnings. Lastly, women who delay having children actually live longer.

Paternal Factors

The age of fathers at the time of conception is also an important factor in health risks for children. According to Nippoldt (2015, as cited in Paris, Ricardo, Raymond, & Johnson, 2021), 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, as cited in Paris, Ricardo, Raymond, & Johnson, 2021). However, like older women, the overall risks are small.

In addition, men are more likely than women to work in occupations where hazardous chemicals, many of which have teratogenic effects or may cause genetic mutations, are used (Cordier, 2008, as cited in Paris, Ricardo, Raymond, & Johnson, 2021). These may include petrochemicals, lead, and pesticides that can cause abnormal sperm and lead to miscarriages or diseases. Men are also more likely to be a source of second hand smoke for their developing offspring. As noted earlier, smoking by either the mother or around the mother can hinder prenatal development (Lally & Valentine-French, 2019. p.52).

Gestational diabetes

Gestational diabetes can occur if the body cannot produce enough insulin to adapt to the effects of a growing fetus and changing hormone levels. The cells become resistant to the action of insulin and, in turn, the pancreas cannot secrete enough insulin to counterbalance the effect of these hormones.

In Canada, between 3% and 20% of pregnant women develop gestational diabetes, depending on their risk factors. While the rate for all pregnancies is roughly 2%-4%, the rate in First Nations women has been reported to be between 8% and 18% (Diabetes Canada, 2022). Research by Dyck et al. (2002, as cited in First Nations Centre, National Aboriginal Health Organization, 2009)  concluded that First Nations ancestry is an independent risk factor; that is, even when a woman has none of the other risk factors for developing gestational diabetes, if she is of First Nations ancestry, she is more likely to develop gestational diabetes. The researchers concluded that the reasons for this were unclear.

 ^{A gestational diabetes kit. (Image by Jessica Merz is licensed under CC BY 2.0)}

Most pregnant women have their glucose level tested between 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. In addition to women with First Nation ancestry, African-American, Native American, Hispanic, Asian, or Pacific Islander have a higher risk. Eating healthy, exercising regularly and maintaining a healthy weight during pregnancy can reduce the chance of developing gestational diabetes. If these actions are unsuccessful at controlling blood sugar levels, insulin may be required. 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.

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, 2004). 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.
• Genetics: Genetic make-up also plays a role on the impact a particular teratogen might have on the child. This is suggested by fraternal twin studies who are exposed to the same prenatal environment, yet 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.

^{Critical Periods of Prenatal Development. This image summarizes the three developmental periods in prenatal development. The blue images indicate where major development is happening and the aqua indicate where refinement is happening. As shown, the majority of organs are particularly susceptible during the embryonic period. The central nervous system still continues to develop in major ways through the fetal period as well.}

Prenatal Assessment

A number of assessments are suggested to women as part of their routine prenatal care to find conditions that may increase the risk of complications for the mother and fetus (Eisenberg, Murkoff, & Hathaway, 1996, as cited in Paris, Ricardo, Raymond, & Johnson, 2021). These can include blood and urine analyses and screening and diagnostic tests for birth defects.

^{Figure 2.18: A woman receiving an ultrasound. (Creator: Keith Brofsky | Credit: Getty Images)}

Ultrasound

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 in the uterus, and number of fetuses. Most women have at least one ultrasound during pregnancy, but if problems are noted, additional ultrasounds may be recommended.

When diagnosis of a birth defect is necessary, ultrasounds help guide the more invasive diagnostic tests of amniocentesis and chorionic villus sampling. 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.

^{Amniocentesis. (Image by BruceBlaus is licensed under CC BY-SA 4.0)}

Chorionic Villus Sampling

Chorionic Villus Sampling is a procedure in which a small sample of cells is taken from the placenta and tested. This test is typically performed during the first trimester and can identify chromosomal abnormalities. Both amniocentesis and chorionic villus sampling have a risk of miscarriage, and consequently they are not done routinely (Lally & Valentine-French, 2019).

birth and the newborn

Prepared childbirth refers to being not only in good physical condition to help provide a healthy environment for the baby to develop, but also helping individuals to prepare to accept their new roles as parents. Additionally, parents can receive information and training that will assist them in delivery and life with the baby. The more future parents can learn about childbirth and the newborn, the better prepared they will be for the adjustment they must make to a new life.

Approaches to Childbirth

The vast majority of births occur in a hospital setting. However, approximately 1% of births in Canada in 2019 were in locations other than a hospital (Statistics Canada, 2020). Live births and fetal deaths (stillbirths), by place of birth (hospital or non-hospital) 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 midwives. In 1994, Ontario became the first province in Canada to regulate midwifery. “Midwifery is a health care profession distinct from nursing. Midwives specialize in providing primary care to women during pregnancy, labour, birth and postpartum in relation to low risk prenatal, intrapartum and postnatal care.” (Mah, 2013).

^{Figure 3.1: Expectant parents in a childbirth preparation class. (Image by liz.schrenk is licensed under CC BY-NC-ND 2.0)}

Childbirth Classes

Prenatal education helps families learn important information on childbirth so they can feel prepared and make good decisions. Through classes and guidance from various health professionals, elders and knowledge keepers, parents learn:

• how to stay healthy
• what to expect during labour
• how to manage pain
• how to care for a baby

Mom & Kids Health Saskatchewan is a great resource for families who will are preparing for a newborn.

Nurse Midwives

Historically, 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.

In Saskatchewan, the Saskatchewan College of Midwives is a regulating body which protects public interest by ensuring only registered, qualified and competent midwives provide care to Saskatchewan women and families. (Saskatchewan College of Midwives, n.d.)

Doula

Doulas are not regulated in Canada. They are trained to provide professional support and education to the birthing woman and her family through their pregnancy but are non-clinical in nature. Doulas can be an important support role through one’s pregnancy, but they are not authorized to perform duties reserved to midwives, physicians or other regulated professionals. (Saskatchewan College of Midwives, n.d.)

Process of Delivery

Onset of Labour

Childbirth typically occurs within a week of a woman’s due date, unless the woman is pregnant with more than one fetus, which usually causes an early labour early. As a pregnancy progresses into its final weeks, several physiological changes occur in response to hormones that trigger labour.

A common sign that labour is beginning is the so-called “bloody show.” During pregnancy, a plug of mucus accumulates in the cervical canal, blocking the entrance to the uterus. Approximately 1–2 days prior to the onset of true labor, this plug loosens and is expelled, along with a small amount of blood.

As labour nears, the mothers’ pituitary gland produces oxytocin. This begins to stimulate stronger, more painful uterine contractions, which—in a positive feedback loop—stimulate the secretion of prostaglandins from fetal membranes. Like oxytocin, prostaglandins also enhance uterine contractile strength. The fetal pituitary gland also secretes oxytocin, which increases prostaglandins even further.

And the stretching of the cervix by a full-term fetus in the head-down position is regarded as a stimulant to uterine contractions. Combined, these stimulate true labor (Biga, Dawson, Harwell, Hopkins, Kaufmann, LeMaster, Matern, Morrison-Graham, Quick, & Runyeon, n.d., as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

The First Stage of Labour – Uterine contractions signify that the first stage of labour has begun. These contractions 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 and midwives advise that they be called when contractions are coming about every 5 minutes. Some women experience false labour 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 labour pains or contractions tend to increase with walking. In one out of 8 pregnancies, the amniotic sac or water in which the fetus is suspended may break before labour begins. In such cases, the physician or midwife may induce labour with the use of medication if it does not begin on its own within twenty-four hours in order to reduce the risk of infection. Normally this sac does not rupture until the later stages of labour.

The first stage of labour is typically the longest. 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 is during this stage that strategies learned in childbirth classes such as breathing techniques and finding visual focal points can be of great benefit to the labour process. Labor may also begin with a discharge of blood or amniotic fluid.

^{Early Cervical dilation. (Image by OpenStax is licensed under CC BY 3.0)}

The Second Stage – The passage of the baby through the birth canal is the second stage of labour. This stage takes about 10-40 minutes. Contractions usually come about every 2-3 minutes. The mother pushes and relaxes as coached by the birthing team. Typically, 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, as cited in Lally & Valentine French, 2019). The baby’s mouth and nose are suctioned out. The umbilical cord is clamped and cut (Lally & Valentine French, 2019, p.60, as cited in Paris, Ricardo, Raymond, & Johnson, 2021)

^{Full dilation and expulsion of the newborn.(Image by OpenStax is licensed under CC BY 3.0)}

The Third Stage – The third and final stage of labour 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 (Lally & Valentine French, 2019, as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

^{Delivery of the placenta and associated fetal membranes. (Image by OpenStax is licensed under CC BY 3.0)}

Caesarian Section

Sometimes women cannot go into labour on their own and/or deliver vaginally. Let’s look at induction of labour and cesarean sections.

Sometimes a baby’s arrival may need to be induced before labor begins naturally. Induction of labour may be recommended for a variety of reasons when there is a concern for the health of the mother or baby. For example:

• The mother is approaching two weeks beyond the due date and labour 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 them or the baby at risk, such as high blood pressure or diabetes (Mayo Clinic, 2014, as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

A caesarean section (C-section) is surgery to deliver the baby by being removed through the mother’s abdomen. In Canada, caesarean births have risen from 17.6% in 1995/96 to 27.9% in 2015/16 (Public Health Agency of Canada, 2018). 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 or a transverse lie, where the baby may be sideways.

^{A woman receiving a C-section. (Image by Tammra M is licensed under CC BY 2.0)}

^{A baby being delivered by C-section. (Image by Patricia Prudente on Unsplash)}

C-sections are also more common among women carrying more than one baby. Although the surgery is relatively safe for mother and baby, it is considered major surgery and carries health risks. Additionally, it also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. In the past, doctors were hesitant to allow a vaginal birth after a C-section. However, now more than half of women who have a C-section go on to have a vaginal birth later (Lally & Valentine-French, 2019, p. 61). This is referred to as a Vaginal Birth After Cesarean (VBAC).

Complications of the Newborn

The Apgar assessment 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: Heart rate, respiration, muscle tone (assessed by touching the baby’s palm), reflex response (the Babinski reflex is tested), and colour. 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 (Lally & Valentine-French, 2019, p. 63). Keep in mind a higher score does not guarantee full health.

^{The Apgar assessment. (Image by Event Medicine Group)}

Another way to assess the condition of the newborn is the Neonatal Behavioral Assessment Scale (NBAS). The baby’s motor development, muscle tone, and stress response are assessed. This tool has been used around the world to further assess the newborn, especially those with low Apgar scores, and to make comparisons of infants in different cultures (Brazelton & Nugent, 1995, as cited in Paris, Ricardo, Raymond, & Johnson, 2021).

Newborns are also routinely screened for different conditions. Within the first 24 to 48 hours after birth, babies born in hospitals undergo a simple heel stick and a few drops of blood are collected on a special paper card. Providers test those dried blood spots for a variety of different congenital disorders, or conditions that are present when the baby is born.

^{A medical professional performing the heel stick test. (Image by the U.S. Air Force is in the public domain) Newborns are also screened for hearing disorders and certain serious heart problems using methods other than dried blood spots.Newborn Screening is in the public domain ; Newborn Screening Program (NBS) by the California Department of Public Health is in the public domain}

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

A child is considered low birth weight if they weigh less than 2500 grams (5.5lbs). In 2017, 6.5% of babies born in Canada weighed less than 2500 grams. There are regional differences in this statistic. For example, in the Northwest Territories, 5.9% of babies were low birth weight. Ontario was slightly above the national figure at 6.7%. In Nunavut, 7.8% of babies were low birth weight (Statistics Canada, 2018a).

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.

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.

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, 2015, as cited in Paris, Ricardo, Raymond, & Johnson, 2021). 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. A significant consequence of preterm birth includes respiratory distress syndrome, which is characterized by weak and irregular breathing (see the image below). Premature babies often cannot yet regulate their own temperature or feed by nursing or bottle. They may struggle to regulate their heart rate effectively and may experience jaundice. They often require care in the Neonatal Intensive Care Unit (NICU) until they are as healthy as a full-term baby.

^{A premature baby on CPAP (continuous positive airway pressure)in the NICU. (Photo by Jennifer Paris used with permission)}

Small-for-date

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 (see image below), 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, as cited in Paris, Ricardo, Raymond, & Johnson, 2021) found that small-for-date infants died at rates more than four times higher than other infants.

^{This baby was born at 32 weeks and only weighed 2 pounds and 15 ounces. (Photo by Jennifer Paris used with permission)}

Postmature

When babies are not born by 42 weeks gestation, or two weeks after their due date, they are considered overdue or postmature. There are some concerns about how long the placenta can function and most doctors will consider induction for overdue babies.

Stillborn

When a fetus (unborn baby) dies while still inside the mother (after 20-24 weeks gestation) or dies during delivery (childbirth), it is said that the delivered baby is stillborn. The causes of many stillbirths are unknown, even when special tests are done to learn the cause. Possible causes include: nicotine, alcohol, or drugs taken by the mother during pregnancy, physical trauma, radiation poisoning, Rh disease, and umbilical cord problems.

In 2019, there were 3,191 stillbirths in Canada. This is a fetal death rate of 8.6 per 1,000 total births (Statistics Canada, 2020). 

The Newborn

The average newborn in Canada weighs 3.5 kg or 7.5 pounds and is 50cm or 20in. in length.  (HealthLink BC, n.d.)

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.

^{A newborn being weighed. (Image by Trei Brundrett is licensed under CC BY-SA 2.0)}

The head initially makes up about 50 percent of our entire length when we are developing in the womb. At birth, the head makes up about 25 percent of our length (think about how much of your length would be head if the proportions were still the same!).

 ^{Body proportions from infancy to adulthood.(Image is in the public domain)}

During labor and birth, the infant’s skull changes shape to fit through the birth canal, sometimes causing the child to be born with a misshapen or elongated head. It will usually return to normal on its own within a few days or weeks.

Some newborns have a fine, downy body hair called lanugo. It may be particularly noticeable on the back, shoulders, forehead, ears and face of premature infants. Lanugo disappears within a few weeks. Likewise, not all infants are born with lush heads of hair. Some may be nearly bald while others may have very fine, almost invisible hair. Some babies are even born with a full head of hair. Amongst fair-skinned parents, this fine hair may be blond, even if the parents are not.

Immediately after birth, a newborn’s skin is often grayish to dusky blue in colour. As soon as the newborn begins to breathe, usually within a minute or two, the skin’s colour returns to its normal tone. Newborns are wet, covered in streaks of blood, and coated with a white substance known as vernix, which is thought to act as an antibacterial barrier.

The scalp may also be temporarily bruised or swollen, especially in hairless newborns, and the area around the eyes may be puffy.

The newborn may also have congenital dermal melanocytosis (sometimes referred to as “Mongolian spots”) (blue or blue black birthmark on the lower back), various other birthmarks, or peeling skin, particularly on the wrists, hands, ankles, and feet (as cited in Paris, Ricardo, Raymond, & Johnson, 2021). 

In a typical day 24 hour period a newborn will eat and have periods of wakefulness and sleep. For many reasons this varies greatly between infants. It can take some time for an infant to fall into a somewhat recognizable and predictable schedule. A number of factors can influence this. The child’s temperament, their capacity to manage stressors, whether they are bottle fed or nursed, the environment, the experience of their families.

A newborn typically sleeps approximately 16.5 hours per 24-hour period. The infant sleeps in several periods throughout the day and night, which means they wake often throughout the day and night (Salkind, 2005, as cited in Lally & Valentine-French, 2019).

^{An older newborn baby. (Image by brytny.com on Unsplash)}

Postpartum Depression

There is no doubt that becoming a parent is a life changing event and can be challenging even for those individuals who are knowledgeable about child development and have experience with children! Hormones play a critical role in pregnancy, childbirth, postpartum and lactation. The hormonal changes, the physical, emotional and psychological recovery from childbirth and delivery are experienced by the mother. In addition, the mother and baby may be figuring out nursing. According to Statistics Canada (2019), one in three women report feelings consistent with postpartum depression or an anxiety disorder. Postpartum psychosis is rarer and is experienced in about 1 in 1000 women.

In the first few days and weeks after birth the family are tasked with getting to know this brand-new human being who is unique and unlike anyone else who has ever existed…even unlike a twin sibling, if they have one! In turn the infant is learning how to live in this world…to breathe air, regulate their body temperature, communicate their needs and process information to name a few.

For a variety of reasons in Canada 30% of women giving birth are considered a lone parent. Being a lone parent can be challenging no matter the age or experience of the parent. Caring for an infant is a twenty-four hour, seven day a week job. Hopefully, the mother can access support from family members and community agencies.

The mother’s partner can play a significant role in parenting, especially during this period of adjustment. The support may involve sharing in home and child care responsibilities and accepting help from friends and family. (Canadian Mental Health Association, 2021) It is important to ensure that the mother’s basic needs are met. In the early days, some mothers may not even know what support they need while others will articulate their needs. They may want to shower, take a nap or eat a meal without holding the baby. When safe to do so, some mothers may wish to exercise by going for a run, to a gym class or yoga. This supports their overall well being. The partner can offer emotional support and respect the wishes of the mother. It is important to nurture the partnership during this adjustment period. Couples need protected time to share their feelings as they take on the new role of being a parent. Some couples protect time for ‘date nights’ to reconnect as a couple.

All of these factors mean that new families benefit from intentional and responsive support as they navigate their new roles and responsibilities. In the past much of this support was provided through extended families, where it was not uncommon for members of different generations to live in one household. While this still occurs in some communities and cultures, in many jurisdictions this post-partum care is now offered through health care providers and community agencies. Local health units may offer resources and services.

New parents in all populations frequently report being sleep deprived and feeling like their lives have been turned upside down. As educators it is important to show empathy and understanding to families. Recognizing the signs that a family may be struggling is an opportunity to share community resources and agencies that can offer support.

In Saskatchewan, HealthLine 811 can be called to to access a Maternal Wellness Program.

References

Berger, K. S. (2004). The developing person through childhood and adolescence. New York, NY: Worth Publishers

Canadian Mental Health Association. (2021) Post-partum depression. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/postpartum-depression

Centers for Disease Control and Prevention. (n.d.). Birth defects research and tracking. https://www.cdc.gov/ncbddd/birthdefects/research.html

Diabetes Canada. (2022). Gestational diabetes. Retrieved from https://www.diabetes.ca/about-diabetes/gestational

Dietrich, J. C. (1999). Psychological development during pregnancy. In R. J. Bibace, J. Laird, & J. Valsiner (Eds.), Developmental psychology and social change (pp. 123–140). Routledge.

Exner-Pirot, H., Norbye, B. & Butler, L. (Eds). (2018). Northern and indigenous health and health care. Retrieved from http://openpress.usask.ca/northernhealthcare

HealthLink BC. (n.d.). Physical growth in newborns. https://www.healthlinkbc.ca/healthwise/physical-growth-newborns

Lally, M. & Valentine-French, S. (2019). Lifespan development: A psychological perspective (2nd Ed). Retrieved from http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf

Government of Ontario, (2021). Infant hearing program. Retrieved from https://www.ontario.ca/page/infant-hearing-program

Mah, C. (2013). Midwifery in Canada. Retrieved from https://www.lawnow.org/midwifery-canada/

Paris, J., Ricardo, A., Rymond, D., & Johnson, A. (2019). Child growth and development. College of the Canyons.

Public Health Agency of Canada. (2018). Care and labour during birth. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/maternity-newborn-care/maternity-newborn-care-guidelines-chapter-4-eng.pdf

Shanker, S. (2016). Self-reg: How to help your child (and you) break the stress cycle and successfully engage with life. Toronto, ON: Viking, an imprint of Penguin Canada.

Statistics Canada. (2020). Live births by marital status of the mother. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310041901

Statistics Canada. (2019). Maternal mental health in Canada. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/190624/dq190624b-eng.htm

World Health Organization. (2018, February). Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality