When birth is imminent
and medical help is unavailable, it is important to understand the
normal course of labor and childbirth. The mother and anyone who
is helping can make the birth easier and safer by knowing exactly
what is happening and how best to help.
Labor is Divided into Three
Stages
First Stage
- the womb contracts by itself to open and bring the baby down to
the birth canal.
Second Stage -
the mother pushes (bears down) with the contractions of the womb
to help the baby through the birth canal and out into the world.
Third Stage
- the afterbirth is expelled.
First Stage
In this early part of labor it is often helpful
for the mother to keep occupied as long as she does not get too
tired. She should be patient and calm, relaxing as the contractions
come and go and breathing slowly and deeply during the contractions
as they become strong. Emptying the bowels and frequent urination
will help to relieve discomfort. The mother will know she is in
true labor if she has regular contractions of the womb which are
prolonged and become strong and closer together. When she knows
the baby is on the way, she should choose a place to have the baby
that will be clean and peaceful. She should be able to lie down
or sit in a leaning position (with her back well supported).
The following events occur as part of the first
stage of labor and delivery.
- The state of dilation: the first signs may
be noticeable only to the mother, low-backache and irregular cramping
pains (contractions) in the lower abdomen.
- As labor progresses, the contractions become
stronger, last longer, and become more regular. When the contractions
recur at regular 3-4 minute intervals and last from 50-60 seconds,
the mother is in the latter part of the first stage.
- The contractions will get stronger and more
frequent. The mother will often make an involuntary, deep grunting,
moan with each contraction. The delivery of the baby is now imminent.
What To Do During the First
Stage
Those helping the mother should know how to
time the contractions. This information will give them an idea as
to how far into labor the mother is and how much time remains until
the baby comes.
Place a hand on the mother’s abdomen just
above the umbilicus. As contractions begin you will feel a hardening
ball. Time the interval from the moment the uterus begins to harden
until it completely relaxes.
Time the intervals in minutes between the start
of one contraction and the start of the next contraction. As labor
progresses this time will decrease.
Walking or standing tends to shorten labor,
so if that feels comfortable to the mother, let her. Also, if she
becomes hungry or thirsty, let her eat or drink small amounts of
food, fruit juice, or suck on ice chips.
Don’t Leave the Mother
Alone
Make no attempt to wipe away vaginal secretions,
as this may contaminate the birth canal. The bag of water may rupture
during this stage of labor and blood tinged mucous may appear.
At the end of the first stage, the mother may
feel tired, discouraged and irritable. This is often referred to
as "transition" and is the most uncomfortable part of
labor and such feelings are perfectly normal. The mother may have
a backache, may vomit, may feel either hot or cold (or both at the
same time), she may tremble, feel panicky or scared, cry or get
very cross with her husband and birthing attendants. She may even
announce that she has changed her mind and is not going through
with it. At this time she needs plenty of encouragement and assurance
that things are proceeding normally and that her feelings are normal.
Birth attendants, the husband, and others present
at the labor and birth should have a cheerful, calm appearance.
Nervousness, panic, or distressing remarks can have an inhibiting
effect on a laboring woman. Comments on how long the labor is lasting,
how pale or tired the woman looks can have a terrible effect on
her morale. Even talking quietly can irritate a woman having an
intense contraction because it is hard to concentrate on relaxing
when there is noise in the room.
Relaxation is very important. A woman’s
husband or labor coach should instruct her to go limp like a rag
doll and breath deeply, making her tummy rise and fall. This is
called abdominal breathing. Begin each contraction with a deep breath
to keep the tissues (of both mom and baby) oxygenated. Observe the
kind of breathing you do when you are nearly asleep and try to simulate
it. Help her to relax her hands, face, legs etc. if you see that
they are tense. Tenseness in the body fights the contractions and
intensifies the sensations of "pain." Relaxation helps
a woman to handle the contractions easier and have a faster labor.
Sometimes a woman will breathe too fast and get tingling sensations
in her hands and feet. She needs to be coached to slow down her
breathing. You can have her follow your breathing until the tingling
goes away.
Firm hand pressure on the lower back by those
attending the mother may help to relieve the back ache. Alternately,
the mother may prefer to lean her back against a firm surface. Deep
rhythmical breathing helps to relieve annoying symptoms. The discomfort
seldom lasts for more than a dozen contractions.
When the womb is almost fully opened the baby
will soon enter the birth canal, and there will be a vocalized catch
in the mother’s breathing when she has a contraction. The will
signal the onset of the second stage.
Second Stage
The contractions of the second stage are often
of a different kind. They may come further apart and the mother
usually fells inclined to bear down (push) with them. When she gets
this feeling she should take a deep breath as each contraction comes,
hold her breath and gently push. There is no hurry here. The mother
should feel no need to exert great force as she pushes. She may
want to push with several breaths during each contraction. After
it passes, a deep sigh will help her recover her breath. She should
then rest until the next contraction. She may even sleep between
contractions.
Some general instructions for the second stage
of labor:
- Be calm! Reassure the mother and be prepared
to administer first aid to both the mother and baby. (Possible
respiratory and cardiac resuscitation for the baby and hemorrhage
control and prevention of shock for the mother may be needed).
- Discourage onlookers from crowding around
the mother.
- Use sterile materials or the cleanest materials
available. Clean towels or parts of the mother's clothing can
be used. Place newspaper under the mother if nothing else is available.
If she must lie on the ground, place a blanket or other covering
under her.
- In order to prevent infection, refrain from
direct contact with the vagina.
- Prepare for the delivery by assisting the
mother to lie on her back with the knees bent and separated as
far apart as possible. Remove any constricting clothing or push
it above her waist.
- When the baby's head reaches the outlet of
the birth canal, the top of the head will first be seen during
contractions but will then become visible all the time. The mother
will now feel a stretching, burning sensation. She must now no
longer push during the contractions, and to avoid this, should
pant (like a dog on a hot day). This will allow the baby's head
to slide gently and painlessly out of the canal. If possible allow
the head to emerge between contractions. This will prevent the
mother's skin from tearing and will minimize trauma to the baby's
head. It is important that the mother pant instead of pushing
until both of the baby's shoulders have emerged.
Delivery of the Baby
As the baby is coming down the birth canal,
keep the perineum red or pink by massaging with warm olive oil (if
none is available simply massage the area with your hand). Any place
that gets white will tear more easily so keep massaging and keep
all areas red. Use olive oil on the inside too and pay special attention
to the area at the bottom, as that is the most common place to tear.
Do this massage during a contraction when it will not be noticed
or it may irritate some women.
You can support under the perineum with your
hand on top of a sterile gauze pad or washcloth. Do not hold it
together, just support it so the baby's head can ease out. The other
hand can gently press with the fingers around the baby's head so
it won't pop out too fast causing tearing. As the baby's head is
born, support it with your hand so the face doesn't sit in a puddle
of amniotic fluid. Gently wipe the face with a clean or sterile
washcloth. Check quickly around the neck for the cord. If you feel
it, just hook it with your finger and pull it around the baby's
head. Check again. Some are wrapped more than once. If the cord
is so tight it cannot be slipped over the baby's head, just wait
until the baby is born to untangle it. Most cords are long enough
to permit this. IF the cord is too short to permit the baby to be
born, it has to be cut and clamped and the baby delivered rapidly.
In this situation the baby may be in distress because the oxygen
supply was cut off prematurely. With the next contraction, one of
the shoulders comes and then the whole body slips quickly out. IF
several contractions have passed without a shoulder coming, you
may have to slip two fingers in and try to find an armpit. With
one or two fingers hooked under the armpit, try to rotate the shoulder
counterclockwise while pulling out. Usually this does it.
As the baby's head emerges, it is usually face
down. It then turns, so that the nose is turned towards he mother's
thigh. Support the baby's head by cradling it in your hands. Do
not pull or exert any pressure. Help the shoulders out. For the
lower shoulder, support the head in an upward position. As the shoulders
emerge, be prepared for the rest of the body to come quickly. Use
the cleanest cloth or item available to receive the baby.
Make a record of the time and approximate location
of the birth of the baby.
With one hand, grasp the baby at the ankles,
slipping a finger between the ankles. With the other hand, support
the shoulders with the thumb and middle finger around its neck and
the forefinger on the head. (Support but do not choke). Do not pull
on the umbilical cord when picking the baby up. Raise the baby's
body slightly higher than the head in order to allow mucous and
other fluid to drain from its nose and mouth. Be
Very Careful as newborn babies are very slippery.
The baby will probably breathe and cry almost
immediately.
If the baby doesn't breathe spontaneously, very
gently clear the mouth of mucous with your finger. Stimulate crying
by gently rubbing its back. IF all this fails, give extremely gentle
mouth-to-mouth resuscitation. Gently pull the lower jaw back and
breathe gently with small puffs--20 puffs a minute. If there seems
to be excess mucous, use your finger to gently clear the baby's
mouth.
The mother will probably want to hold the baby.
This is desirable. If the umbilical cord is long enough, let her
hold the baby in her arms. If the cord is short, support the baby
on the mother's abdomen and help her hold it there.
It is of benefit to the baby and makes the afterbirth
come with less bleeding if the baby can be allowed to suckle at
the breast as soon as it is born. The cord should not be cut until
the afterbirth has completely emerged.
Third Stage
The placenta delivery or afterbirth is expelled
by the womb in a period of a few minutes to several hours after
the baby is born. No attempt should be made to pull it out using
the cord. Immediately following the afterbirth, there may be additional
bleeding and a few blood clots. The womb should feel like a firm
grapefruit just below the mother's navel. If it is soft, the baby
should be encouraged to nurse, and the mother may be encouraged
to gently massage the womb. These actions will cause it to contract
and lessen the chances of bleeding.
If hemorrhaging occurs,
do the following:
- The uterus should be gently massaged to keep
it hard.
- The woman should lie flat, and the bottom
of the bed should be elevated.
- Put a cold pack (such as a small towel dipped
in cold water and wrung out) on the lower tummy to irritate the
uterus to contract.
- Put pressure on the perineum with several
sanitary napkins and the pressure of your hand.
- Most importantly, have the baby nurse. Sucking
stimulates the uterus to contract.
Another problem to be alert for is shock. Symptoms
of shock are vacant eyes, dilated pupils, pale and cold or clammy
skin, faint and rapid pulse, shallow and irregular breathing, dizziness
and vomiting. If you notice any of these symptoms, keep the woman
warm, slightly elevate her feet and legs, use soft lights, and talk
softly and calmly to her.
The baby has some danger of getting an infection
through the cut cord, so it should not be cut until sterile conditions
are available. If there is a possibility of getting medical help
within a few hours, do not cut the cord but leave it and the afterbirth
attached to the baby. If there will be no medical help, wait until
the afterbirth is out, or at least until the cord is whitened and
empty of blood. The cord should not be cut until it quits pulsating
so the baby can have a transition time before he absolutely has
to breathe on his own. As long as the cord is pulsating, the baby
is still receiving oxygen from his mother.
If the cord is long enough, the baby can be
put on his mother's tummy so she can hold him and talk to him. IF
not, the father should touch him and talk to him. After the cord
has stopped pulsating and has become limp it can be clamped or tied
about one inch from the baby's tummy with a cord or sterile cloth
and then cut.
As the placenta separates from the uterus, the
cord will appear longer. Wait for the delivery of the placenta.
It will usually be about 10 minutes or longer before the placenta
is delivered.
Never pull on the cord. When the placenta appears,
grasp gently and rotate it clockwise. Then tie the cord in two places--about
six inches from the baby--using strips of material that has been
boiled or held in a hot flame.
The placenta and attached membranes must be
saved for a doctor's inspection. Leaving the cord and placenta attached
to the baby is messy but safe. Save all soiled sheets, blankets,
cloths, etc., for a doctor's examination. Check the amount of vaginal
bleeding; a small amount (1 to 2 cups) is expected. Place sanitary
pads or other sanitary material around birth areas. Then cover mother
and baby but do not allow them to overheat. Continue to check the
baby's color and respiration. The baby should not appear blue or
yellowish. When necessary, gently flick your fingers on the soles
of the baby's feet; this will encourage it to cry vigorously.
The mother will probably need light nourishment
and will wish to rest and watch her baby. She should keep her hand
away from the area surrounding the birth outlet. If uncontaminated
water is available, she may wish to wash off her thighs. She may
get up and go to he bathroom or seek better shelter. All care should
be taken to avoid introducing infection into the birth canal. The
mother can expect some vaginal discharge for several days. This
is usually reddish for the first day or so but lightens and becomes
less profuse within a few days.
Stay with the mother until relieved by competent
personnel. This is a relatively dangerous period for the mother,
as hemorrhage and shock may occur. Almost all emergency births are
normal. The babies typically thrive and the mothers recover quickly.
It is very important when assisting with an emergency delivery that
you continually reassure the mother and attempt to keep her calm.
