Pregnancy and childbirth are usually considered a blessing in modern times. Off the grid, however, the family medic/midwife will be thrown back to the 19th century, when childbirth was associated with a much higher rate of complications than now.

Even if the group has no women of childbearing age at present, at one point or another the medic may be called upon to attend a delivery without the benefits of a modern medical system. This article will focus on a pregnancy at term, classically defined as one that has reached 37-42 weeks from the first day of the last menstrual period. More articles on pregnancy diagnosis, care, and complications can be found at doomandbloom.net.

(Note: I am an actively-licensed Life Fellow of the College of Ob/Gyn and my wife is an actively licensed Certified Nurse Midwife.)

As the woman approaches her due date, several things happen. The fetus begins to “drop”, assuming a position deep in the pelvis. The patient’s abdomen may look different, or the “fundus” (the top of the uterus) may appear lower. As the neck of the uterus (the cervix) relaxes, the patient may notice a mucus-like discharge mixed with a little blood. This is referred to as the “bloody show” and is usually a sign that labor will occur soon, anywhere from the next few hours to a week or so.

If you examine your patient vaginally by gently inserting two fingers of a gloved hand, you’ll notice the cervix is firm like your nose when it is not ripe, but becomes soft like your lips when the due date is approaching. This softening and thinning out of the cervix is called “effacement”

Effacement is measured in percentages. When 50% effaced, the cervix is half its normal thickness and length. At 100% effacement (“completely effaced”), the cervix is paper-thin. Effacement usually occurs before any significant opening of the cervix (also called “dilation”).

Contractions will start becoming more frequent. To identify a contraction, feel the skin on the soft area of your cheek, and then touch your forehead. A contraction will feel like your forehead. False labor, Braxton-Hicks contractions, will be irregular and will go away with bed rest (especially on the left side) and hydration. If contractions are coming faster and more furious even with bed rest and hydration, it’s likely the real thing!

A gush of watery fluid from the vagina will often signify “breaking the water”, and is also a sign of impending labor and delivery. The timing will be highly variable, however, and sometimes urine leakage may confuse the situation. A product called “nitrazine paper” will turn a bright blue when it touches amniotic fluid due to its high Ph. A bright blue result (nitrazine positive) usually verifies that the bag of water is broken. If you have a microscope in the hospital tent, a little amniotic fluid on a slide will reveal fern-like crystals. This is called “ferning” and is more solid proof of membrane rupture than nitrazine positive tests.

There are three stages of labor:

FIRST STAGE (LATENT PHASE)

The first stage is the longest part of labor: lasting up to 20 hours or more. It begins when your cervix starts to dilate and efface, and is separated into a latent phase and an active phase. The first stage is considered complete when the cervix reaches 10 centimeters and is so effaced that you can barely identify it.  

The latent phase is when labor begins. False labor has been ruled out and contractions are becoming stronger, more regularly, and in greater frequency. They may also last longer (60-90 seconds). The contractions cause your cervix to dilate and efface. In latent phase, dilation to about 4 centimeters or so often progresses slowly.

The mother should be given as much freedom to walk, sit, practice breathing techniques, or do other activities as she can handle. Keeping her occupied and moving is a good way to move the process along. A soak in a warm tub or shower is helpful if the water hasn’t broken. Oral hydration and small meals are also acceptable.

Once the cervix reaches 4 centimeters of dilation, a vaginal exam will allow you to place two (normal-sized) fingertips in the cervix. You’ll feel something firm; this is the baby’s head. In general, however, vaginal exams are invasive and shouldn’t be performed more often than, perhaps, every two hours.

FIRST STAGE (ACTIVE PHASE)

When the cervix reaches 5 centimeters or so of dilation, labor enters the active phase. Contractions get even stronger and spacing becomes closer. As the baby’s head descends, the mother may notice back pressure and bloody vaginal discharge. If the water membrane hasn’t ruptured, it will likely happen during this time.

Cervical dilation in active phase speeds up to about a centimeter an hour, although women who have had children may go much faster. Breathing techniques may be needed to manage discomfort during contractions (you won’t have epidural anesthesia or strong pain meds off the grid). Other strategies include:

-Changing positions. Some women prefer being on hands and knees to improve back pain.

-Walking between contractions with a helper.

-Emptying the bladder often.

-Gently massaging the mother’s back.

It may help to remind the mother that each contraction brings her closer to having a baby in her arms. Despite that, don’t encourage her to push until the cervix is completely dilated and the baby’s head has descended into the pelvis.

SECOND STAGE

The second stage of labor begins when the cervix is fully dilated and ends when the baby is born. This stage is usually completed within two hours, but is dependent on the strength and frequency of contractions. First-time mothers take longer than those who have had children.  Those who have delivered several children may proceed through this stage very quickly.

At this point, the mother will likely feel a strong urge to push. Encourage rest between contractions. When pushing, different positions may work for different mothers. Try squatting, lying on their side with a leg raised, or even hands and knees. The body should “curl into” the push as much as possible, almost exactly like have a bowel movement.

The delivery of a baby is best accomplished with the help of an experienced midwife or obstetrician, but those professionals will be hard to find in survival settings. If there is no chance of accessing modern medical care, you must prepare to perform the delivery.

NORMAL DELIVERY

Wash your hands and put gloves on. Then, place clean sheets so that there will be the least contamination possible. Tuck one under the mother’s buttocks if supine and spread it on your lap so that the baby, which comes out very slippery, will land on the sheet instead of the floor if you lose your grip on it. Place a towel on the mother’s belly; this is where the baby will go once it is delivered. It will be very important to dry the baby and wrap it in the towel, as newborns lose heat very quickly.

As the labor progresses, the baby’s head will move down the birth canal and the vagina will begin to bulge. When the baby’s head begins to become visible, it is called “crowning”. If the water has not yet broken (which can happen even at this late stage), the lining of the bag of water will appear as a slick gray surface. Some pressure on the membrane will rupture it, which is okay at this point (controversial to some). It might even help the process along.

To make space, place two gloved fingers along the edge of the vagina by the “perineum”. This is the area between the vagina and anus. Using gentle pressure, move your fingers from side to side. This will stretch the area somewhat to give the baby a little more room to come out. Although not advocated by all, “perineal massage” might decrease the risk of lacerations caused by the delivery of the baby.

With each contraction, the baby’s head will come out a little more. Don’t be concerned if it goes back in after the contraction. It should make steady progress and more and more of the head will become visible over time. Encourage the mother to help by taking a deep breath with each contraction and then pushing while slowly exhaling.

On occasion, a small cut is made in the bottom of the edge of the vagina to make room for the baby to be delivered. This is called an “episiotomy”. We discourage this if at all possible, as the cut has to be sutured afterward. The decision should be made as the head is crowning; You should only perform an episiotomy if you believe a very large, jagged tear will occur that would damage the anal sphincter or rectum.

As the baby’s head emerges, it will usually face straight down or up, and then turn to the side. The umbilical cord is sometimes wrapped around its neck. If this is the case, gently slip the cord over the baby’s head. In cases where the cord is very tight and is preventing delivery, you may choose to doubly clamp it and cut between. This will release the tension and make delivery easier. This is also a good time to suction the nose and mouth of the baby with a bulb syringe to remove amniotic fluid.

Next, place a hand on each side of the baby’s head and apply gentle traction straight down. This will help the top shoulder out of the birth canal. The second shoulder should then deliver with some gentle traction upward. Occasionally, steady gentle pressure on the top of the uterus during a contraction may be required. This is usually frowned upon, but may be needed if the mother is exhausted. Many times, however, little if any help will be needed for the baby to deliver, (especially in a woman who has had children before). Once the shoulders are out, the baby will deliver with one last push. The mother can now rest.

BREECH BIRTHS AND MULTIPLES

Multiple births like twins can be handled similarly to single deliveries if both are “cephalic”; that is, presenting head down. Each is delivered in turn, but the first placenta isn’t delivered until the second baby is out. Triplets or more are complicated, but rare. These occur (without fertility treatments) in about 1 in 8000 births. These usually deliver very prematurely, a bad thing for newborns as they are often unable to breath on their own. Indeed, it wasn’t until about 100 years ago that triplets and higher multiple births resulted in all surviving infancy.

Much more common than multiple births are breech births. Although the grand majority of babies present cephalically, breech babies comprise about three percent of all births. The survival medic or midwife can expect to eventually encounter one. Breech babies are “heads-up” and are routinely delivered surgically in modern times by cesarean section. This is because studies have shown that about 4% of vaginal breech deliveries end up with some bad outcome, compared to about 1.5% of breech babies delivered by C-section.

Why? The reason is often because the head, the largest-diameter part of the baby, comes last. Sometimes, it gets stuck and oxygen deprivation or other complications may occur. Most parents aren’t willing to accept any increased chance that their baby will come out with a problem.

Off the grid, however, C-section is not an option. Most breech babies delivered vaginally will come out without incident. The method is somewhat different. Instead of the head crowning, it’s the buttocks. This is called a “frank breech” and occurs 70% of the time. Although the legs may sometimes come first (a “footling” breech”), they usually deliver spontaneously a push or two after the butt. If they don’t, using the fingers to perform a sweeping motion (called the Pinard maneuver) may safely bring down the feet and legs.

Once the legs and buttocks are out, you’ll use both hands to grasp the hips of the baby, thumbs on the sacroiliac and fingers in front on the iliac crests. With each push, the abdomen and cord will descend and then deliver. You’ll use your grip on the hips to help guide one shoulder, (the topmost one) by gently pulling down and slightly out. If the arm doesn’t deliver on its own, a sweeping motion with a finger may be performed to move an extended arm across the chest, down, and out. Then, deliver the posterior second shoulder by holding the feet with both hands and exerting gentle upward traction.

At this point, the entire body is delivered except for the head. Now you’ll move your hands to the baby’s chest and back. Avoid squeezing the neck with your fingers. You want to keep the head flexed, which can be done by having an assistant place some pressure downward just above the pubic bone of the mother. The midwife may also place a finger in the baby’s mouth, not to apply any pressure whatsoever, but to keep the head flexed so it will deliver easily. Using only the hand on the back, traction is exerted downward and outward. In most cases, the head will deliver without an issue.

The description above is just part of the process; there are a lot of nuances that help decrease the chance of complications. You’ll find the whole process described in detail in Varney’s Midwifery, an essential resource for those medics that may be responsible for off-grid labor and delivery. In the end, however, there’s no substitute for experience.

THIRD STAGE

The third stage of labor begins after the baby is born and ends when the placenta (the “afterbirth”) separates from the wall of the uterus and is passed through the vagina. This stage is the shortest, lasting from a few minutes up to 20-30 minutes.

Once delivered, the baby’s nose and mouth are suctioned out again to remove amniotic fluid. Then, place the newborn on the mother’s chest. It will usually begin crying, which is a good sign that it is a vigorous infant. Spanking the baby’s bottom to get it to cry is rarely needed, and is more of a cliché than anything else. A better way to stimulate a baby to cry is to rub the baby’s back while drying it with a towel.

Once dry, wrap the newborn up in a towel or blanket. The head (but not the face) should be covered to avoid heat loss. At this point, you may clamp the cord twice (2 inches apart) with Kelly or Umbilical clamps, and cut in between with a scissors. There is usually no special hurry to perform this procedure. The items needed are available in commercially-produced delivery kits.

Once the baby has delivered, it’s the placenta’s turn. Be patient: In most cases, the placenta will deliver by itself in a few minutes. Avoid pulling on the umbilical cord to force the placenta out. Breaking the cord due to excessive traction will require your placing your hand deep in the uterus to extract it. This is traumatic and can introduce infection. You can ask the mother to give a push when it’s clear the placenta is almost out.

If traction is necessary for some reason, place your fingers above the pubic bone and press as you apply mild traction. This will prevent the uterus being turned inside out and hemorrhaging (a potentially life-threatening situation). A moderate amount of bleeding is not unusual after delivery of the afterbirth.

Once the placenta is out, examine it. The “fetal” surface is grey and shiny; turn it inside out and you will see the “maternal” surface, which look like a rough version of liver. The fetal surface is separated into sections called “cotyledons”. If one of the cotyledons remains inside, you may have to extract it manually.

The uterus after delivery naturally contracts to control bleeding. The top is now felt around the level of the belly button. In a long labor, the uterus may be as tired as the mother after delivery, and may be slow to contract. As a result, this may cause excessive bleeding. Although drugs like oxytocin are given in modern times to firm up the uterus, massage of the top of the uterus should also work to limit blood loss. You may have to do this from time to time during the first 24 hours or so after delivery.

Monitor the mother closely for excessive bleeding over the next few days. In normal situations, the bleeding will become more and more watery as time progresses. This is normal. Also, keep an eye out for evidence of fever, foul discharge or other issues.

It would be wise to place the baby on the mother’s breast soon after delivery. This will begin the secretion of “colostrum”, a clear yellow liquid rich in substances that will increase the baby’s resistance to infection. Suckling also causes the uterus to contract, which decreases blood loss. It’s also important to recognize the bonding element between mother and baby when breastfeeding.

It should be noted that there are different schools of thought regarding some of the above, many of which are equally valid. Remember that your goal is to end up with a healthy mother and baby, both physically and emotionally.

Joe Alton MD

Learn more about pregnancy, labor, delivery and 100 other topics in austere scenarios with a copy of The Survival Medicine Handbook. Also check out midwife Nurse Amy’s OB kit and her entire line at store.doomandbloom.net.