An announcement of a pregnancy is a cause for joy in modern times, but in olden times was also a cause for concern. Indeed, before we had knowledge of infection prevention, a woman could expect a 1-2% death rate per pregnancy. As the average woman might be pregnant 10 times or more in a life, there was a cumulative 10-20% death rate among our pioneers. In areas where modern medical care is unavailable, there is still a risk of maternal death due to pregnancy, childbirth, and after-delivery (“postpartum“) complications.
Luckily, most pregnancies end in a normal and happy outcome for both mother and baby. This article will outline how to monitor a labor and conduct a normal delivery. Other articles on our website cover pregnancy care in austere settings, so please be sure to check them out. Here’s one:
I should mention that there are many variations of what you will read below. As one of the first doctors to incorporate midwives in the state of Florida, I had different practitioners (including Nurse Amy) with their own special way of birthing that baby!
Pregnancy at Term
As the woman approaches her due date, several things will happen. The fetus will begin to “drop” lower in the pelvis. The patient’s abdomen may look different, or the top of the womb (the “fundus”) may appear lower. As the neck of the uterus (the cervix) relaxes, the patient may notice a mucus-like discharge, sometimes with a bloody component. This is referred to as the “bloody show” and is usually a sign that things will be happening soon.
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 and soft like your lips when the due date is approaching. As labor progresses, the cervical walls will thin out until they are as thin as paper. This is called “effacement“.
Dilation of the cervical opening (the “os“) will be slow at first (latent phase), and speed up once you reach about 4 cm. At this level of dilation, you will be able to place two (normal-sized) fingertips in the cervix and feel something firm; this is the baby’s head. Frequent vaginal exams are invasive, however, and not necessary in most cases.
Contractions will start becoming more frequent and the cervix dilates more rapidly (active phase). To identify a contraction, feel the skin on the soft area of your cheek, and then touch your forehead. A contraction will feel firm like your forehead. False labor contractions will be irregular and will usually 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 is probably 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, however, will be highly variable.
To prepare for delivery, wash your hands and then put gloves on. Set up clean sheets so that there will be the least contamination possible. Tuck a sheet under the mother’s buttocks and spread it on your lap so that the baby, which comes out very slippery, will land onto the sheet instead of the floor if you lose your grip. Place a towel on the mother’s belly; this is where the baby will go once it is delivered. Delivery kits are available online with everything you need, including drapes, clamps, bulb syringes, etc. To prevent infection, avoid touching anything but mother and baby if you can.
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 but not absolutely necessary at this point. It might 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. Perineal massage works better on some patients than others; some practitioners recommend that the mother perform it herself in the last weeks of a pregnancy.
With each contraction, the baby’s head will come out a little more. Don’t be concerned if it goes back after the contraction. It will make steady progress and more and more of the head will become visible. Encourage the mother to help by taking a deep breath with each contraction and then pushing while slowly exhaling.
As the baby’s head emerges, it will usually face straight down or up, and then turn to the side. The cord might appear to be 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.
Next, gently hold each side of the baby’s head and apply gentle traction straight down. Usually 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.
Put the baby immediately on the mother’s belly and clean out its nose and mouth with a bulb syringe. It will usually begin crying, which is a good sign that it is a vigorous infant. If it doesn’t, stimulate it by rubbing the baby’s back (spanking its bottom is more a cliché than anything else).
Dry the baby and wrap it up in a small towel or blanket. 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 no hurry to perform this procedure.
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. Pulling on the umbilical cord to force the placenta out is usually a bad idea. Breaking the cord due to excessive traction will require 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 (a potentially life-threatening situation) if the placenta is stubborn. 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. If a portion of the placenta remains inside, you may have to extract it manually.
The uterus (the top of which is now around the level of the belly button) contracts to control bleeding naturally. In a long labor, the uterus may be as tired as the mother after delivery and may be slow to contract. This may cause excessive bleeding. Gentle massage of the top of the uterus (the “fundus”) will make it firm again and thus 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.
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, a factor in decreasing blood loss.
It should be noted that there are different schools of thought regarding some of the above. Remember that your goal is to have an end result of a healthy mother and baby, both physically and emotionally. Feel free to mention your tips for a successful delivery in the comments section below.
Joe Alton, M.D.
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