- This is not a class in how to be a midwife. It is a class discussing normal labor and birth, how to assist a laboring mother and her newborn without causing problems, and, some ways to handle some emergencies in the event that trained medical assistance in not available.
- Childbirth is NOT the extremely dangerous “condition” we as a society and culture have been led to believe.
- Humans multiplied for centuries before the advent of modern medicine
- In nations where the practice of Obstetrics is limited to the truly complicated pregnancies, approximately 97% of ALL births are accomplished with NO intervention, and with significantly better percentages of both infant and maternal well-being than we have in the US.
- When labor proceeds too quickly for a woman to reach a hospital, there are rarely life threatening complications. See number 2 above.
Those points being made, a woman in labor needs to feel that both she and her baby are and will be safe. The emotion of fear, all by itself, triggers a hormonal cascade that increases risk in labor, especially for the baby. So, it is vital that anyone around a woman in labor be calm, and assured of the safety of the birth process. The mother-to-be should be reassured that birth is a normal and natural process, and that the likelihood of danger to either her or her baby is very, very small.
- Overview of normal labor and birth
1st stage – the period of time from the beginning of regular contractions to full dilation of the cervix and the beginning of the babies passage into the vagina or birth canal
Transition – not a true stage of labor, actually part of the 1st stage, but, the most difficult part of labor, and usually the shortest part
2nd stage – the period of time from full dilation of the cervix (10 cm) to the birth of the baby
3rd stage – the period of time from the birth of the baby to the complete expulsion of the placenta and membranes.
- How long does each stage take?
1st stage with a 1st baby may take 36-48 hours with no intervention. With 2nd and subsequent babies, it is usually much shorter. General rule of thumb (rules are meant to be broken!) is that labor gets shorter with each baby. Like I said though, rules are meant to be broken. Every pregnancy is different, every labor is different, every birth is different, every baby is different.
2nd stage with a 1st baby usually will take from 1-3 hours. Again, with 2nd and subsequent babies, it is usually significantly shorter.
3rd stage usually takes from 5-20 minutes, and should be carefully monitored as this is the most dangerous stage for the new mother.
- What is actually happening during each stage?
1st stage – the cervix, or uterine opening, is thinning out and opening to allow the baby to pass into the birth canal, or vagina
The baby is moving deeper into the pelvis, rotating slightly as it moves down
Usually the water breaks at some time during this stage
2nd stage – the baby is moving from the uterus to the outside world
3rd stage – the placenta separates from the side of the uterus and is expelled, usually with a contraction and a gush of blood
- What can I do to help a woman who is experiencing an unplanned out-of-hospital birth?
1st stage – help the mother become/remain calm and relaxed, emotional support and encouragement will be vital – the simple fact that she had not planned to give birth anywhere other than a hospital is going to result in significant stress. Stress increases risks for both mother and baby. This mother will often feel like everything is going all wrong, and will be probably be very fearful. Reassurance and calming are the best things you can do for her right now.
During this stage of labor, the mother simply has to relax and let her uterus do the work it was designed to do. She pretty much has to stay out of it’s way. The longer she is able to do anything other than focus on what her uterus is doing, the better. Sleep as much as possible. Walk around, eat light, easily digested food to keep energy up, drink lots to stay hydrated and keep energy up. Urinate frequently (every 30 minutes or so, even if she doesn’t feel the need) to keep the bladder empty so it doesn’t fill and impede the baby’s ability to move down into the pelvis. If she hasn’t had a bowel movement for more than 8 hours or so, this would be a good time to encourage one to help make room for the baby to descend.
As 1st stage progresses, the mother will usually need more quiet, and more subdued lighting, also more encouragement and reassurance as the realization that labor is really, really, really hard work takes over. The contractions become more and more intense, last longer, and the mother has less and less time between them. The laboring uterus totally consumes the mother’s energy and thoughts. Between contractions she will often appear to doze off. Let her rest! Keep the surroundings as quiet and peaceful as possible.
During transition many women experience very strong, sometimes irrational, mood swings. There may be anger, fear, discouragement (I’ve even heard a couple of mothers say things along the lines of “I’m quitting this now. I’ll have this baby another day.”), exhaustion, “I’m going to die!” etc. The intensity of the contractions during this phase of labor is such that they can easily overwhelm a mother who is not prepared for them. This is the most common time for the water to break spontaneously. Be prepared for it!
Helping a mother through this phase requires that all around her remain calm, help her to relax and breathe slowly and deeply. Rapid and unnatural breathing patterns such as panting, alternating fast & slow or deep & shallow breaths are based on observations of animals that do not perspire but use breathing (panting) as a way to cool down. These breathing patterns increase the risk of hyperventilation which can cause complications for the unborn child and so, should be avoided in emergency childbirth. If a warm (not hot) tub or pool is available, it can help ease the perceived intensity of the contractions if the mother is able to simply relax & float in the warm water. Remind her as often as needed that this difficult period is the shortest phase of labor and that it means she will soon be able to hold her newborn in her arms. Some women find it very comforting to think of/picture their newborn, others prefer to simply concentrate on the moment. Take your cue from what seems to best help her focus & relax.
If this is a second or subsequent baby, gathering all of the materials needed for the birth, care of the newborn, and care of the mother immediately following birth should take place during first stage. This should be done quietly and in the background.
2nd stage – most women feel better when they can actually DO something! When this stage begins, the contractions become farther apart, giving the mother more time to rest between.
She feels an overwhelming urge to push as the baby’s head puts pressure on the rectum. If there is only a slight, or intermittent urge to push, it is best for the mother to keep relaxing and breathing, rather than holding her breath to push.
Pushing against a cervix that is not yet fulled dilated can cause it to swell, thus impeding the progress of labor. Much better to breathe through even 10 or 15 of these kinda-sorta-wanna-push contractions and allow the cervix to fully dilate and get out of the way than to have it swell and take several hours to get out of the way!
This is where you can also help the mother by encouraging her to keep breathing until her body simply won’t let her.
When the urge to push is fully overwhelming, help the mother into a position that will open the pelvic bones and allow gravity to aid in bringing the baby down.
Side – leg supported
Small sips of water and an occasional lick of honey or orange juice can really help the mother’s energy and outlook! Oh, and don’t forget that you need some too!
When you can see the baby’s head during contractions, you’ll need to watch two things;
see if the skin around the birth canal stays fairly pink, or, if it turns white, you can decrease the risk of the mother’s tissues tearing by applying very slight, gentle counter pressure above and below the baby’s head (between the head and mother’s pubic bone, and, between the head and the mother’s rectum)
If the baby’s head stretches the birth canal opening larger than about 1″ diameter, then disappears completely between contractions, there is a problem. Either the umbilical cord is wrapped around the neck several times, or, it is way too short. Either way, it is presenting a serious risk to the baby. Discussion of options will come shortly.
As the largest part of the baby’s head reaches the opening of the birth canal, GENTLE support of the mother’s tissues can help to prevent an “explosive” birth with associated tearing of the mother’s tissues.
When mother and baby are free of pain meds, and, there has not been an episiotomy performed, the muscles of the mother’s pelvic floor perform a very efficient Heimlich maneuver as the baby’s chest and abdomen are born, thus, there is no need for suctioning the baby’s airways.
Ideally, as the body emerges, the mother herself can reach down, take hold of her baby, and place it immediately on her chest, then, a warm blanket can be placed over both of them.
Usually the umbilical cord is long enough for the mother to comfortably hold the baby w/o cutting it. If this is not possible, try to have the baby lay across the mother’s abdomen. If the cord is still too short, lay the baby on something clean near the birth canal. Wherever the baby is, he/she needs to be kept warm!
Video of baby Heimlich over intact perineum
3rd stage – this is basically the delivery of the placenta, or afterbirth
This stage is actually the most dangerous for the mother, mostly due to the risk of excessive bleeding – hemorrhage – from the enlarged uterus.
Usually, 5-10 minutes after birth, the uterus will contract again, causing the placenta to separate and slide out of the birth canal. However, that is simply an average time! I’ve seen placentas come right on the baby’s heels, and, I’ve seen them take up to 30 minutes to separate.
Watch for a lengthening of the umbilical cord, and a gush of blood. You can also watch the mother’s abdomen for a slight rise above the pubic bone indicating that the uterus is contracting again, or, keep one hand laying gently on her abdomen just above the pubic bone so you can feel the uterus contract. If you do this RESIST THE URGE TO MASSAGE THE UTERUS UNTIL AFTER THE PLACENTA HAS DELIVERED! Doing so can cause the placenta to partially separate, resulting in hemorrhage for the mother, or, can cause the uterus to prolapse, which is an extreme and life-threatening medical emergency. Often, the mother is concentrating too hard on her newborn to notice the contraction, but, not always.
Have a large, clean, pan of some kind handy, ready to catch the placenta and the accompanying blood, otherwise, you will have a much larger mess to clean up than you already have.
Since the cervix and birth canal are already dilated and enlarged from the baby’s birth, the placenta will normally slide out very easily.
DO NOT PULL ON THE UMBILICAL CORD TO EITHER HASTEN OR “ASSIST” WITH THE DELIVERY OF THE PLACENTA! Doing so can cause the mother’s uterus to prolapse, or come out. This is an extreme, life-threatening medical emergency.
If the placenta comes, but the membranes are not fully released from the uterus, grasp the placenta with both hands and gently twist in one direction until they separate from the uterus also.
The placenta, membranes, and umbilical cord should be checked by an experienced doctor or midwife as soon as possible.
Once the placenta has delivered, the mother’s uterus needs to stay contracted. Having the baby nurse as soon as possible after birth will help this to happen. Also, it is now safe to massage the uterus if it is not contracting on it’s own. It should feel rather like a large grapefruit just above the mother’s pubic bone. If it doesn’t, you may have to dig fairly deep into the mother’s abdomen to find it & get it to start contracting. This process is decidedly uncomfortable for the mother, but, necessary to prevent hemorrhage.
The mother needs to be monitored for at least two hours following birth to make sure the uterus stays contracted.
Care of the Newborn
Keep the baby warm, most heat loss is through the head, so, a knitted cap is ideal.
Skin to skin contact with the mother is ideal both for warmth, as well as to stimulate the baby’s breathing, and, the mother’s uterine contractions.
The umbilical cord ideally should not be cut until all blood flow through it has spontaneously stopped.
As long as the cord still has blood pulsing through it, the baby is receiving Oxygen and does not have to be breathing all on his/her own.
The cord must not be cut, clamped, or tied with anything that is not absolutely sterile.
String, dental floss, and twine are not acceptable for use in tying off the cord. They can actually cut through the cord and result in a fatal hemorrhage for the baby.
If you don’t have to cut the cord, don’t! Some cultures keep the baby and the placenta together until the cord drops off naturally.
If you do have to cut the cord, make sure that you go out at least 5″ from the baby’s abdomen to put the first clamp. Go out another inch further for the second clamp. Cut between the two clamps. This will be a hard cut! Be careful not to cut the baby, the mother, or yourself.
Rate how well the baby is doing by remembering APGAR
Appearance (color) – pink/red = 2 points bluish = 1 point white = 0
Pulse – over 110 bpm = 2 points below 100 weak/slow = 1 absent = 0
Grimace (reaction to mouth/nose stimulation) strong = 2 weak = 1 absent = 0
Activity level – kicking/crying/nursing = 2 weak = 1 absent = 0
Respiration – strong & regular = 2 weak/irregular = 1 absent = 0
The higher the score, the better, the lower the score, the more closely the baby needs to be monitored
Emergency Birth Kit
What’s in an EBK and why….
Emergency Childbirth – it IS a complication for a woman who was planning to have her baby in a hospital or clinic to suddenly be in the position of giving birth without the medical staff and accouterments (probably including medication) that she was planning on having.
Fear = lower oxygen to uterus, slows labor; lower oxygen to baby; muscles tense fighting birth = longer more painful labor
Probable issues with privacy increase fear
Probable issues with sanitation increase infection risk for mother & baby
Premature labor – this is often a tough one and you may have no clue why it’s happening, the mother needs to stay quiet, remove as many stressors as possible, sometimes there is an imbalance of calcium/magnesium/phosphorus, sometimes a cervical infection/irritation, dietary problems (fish oil sometimes causes a calcium/magnesium imbalance), and the list goes on, and on, and on, and on. If rest, relaxation, and hydration don’t help, and no medical assistance is available, be prepared for a premature birth. Some of these will be fine, others won’t.
Labor seems to stop & start repeatedly – this usually means that the mother is either very uncomfortable (psychologically) with the circumstances & her fears are interfering with labor, or, she may simply be exhausted. If it’s the later, hydrate, easily digested foods, sleep. If it’s the former, prayer, Priesthood blessing, and talk with her, or, perhaps, give her more solitude.
Breech birth – baby is coming bottom or feet first –
if it’s one or both feet, mom needs to be in either a side position or on her knees with her hips higher than her head. The danger here is that the body can slip through the partially dilated cervix while the head then becomes trapped, pinches off the circulation in the umbilical cord, and the baby suffocates. The goal is to prevent gravity from doing anything to assist in bringing the baby down the birth canal until the cervix is fully dilated.
if it’s bottom first, positions as above, but, the risk is pretty well gone when the urge to push becomes unstoppable, at that time, have someone support the mother in a standing position for birth to get maximum assistance from gravity for the birth to occur as quickly as possible, catch the baby, but don’t pull on it.
Make sure the baby’s back is toward one of the mother’s legs, not toward her back. If it is toward her back, gently but firmly grasp the body and slowly turn it so the baby is facing (preferably) more toward the mother’s right leg.
Once the baby is born to the point of the umbilicus, birth needs to be completed fairly quickly. Often, the arms will be up along side the head & a bit of assistance at this point can be very helpful. Run a gloved finger up the baby’s back to the level of the shoulder, follow the shoulder to the arm and then gently but firmly coax the arm down in front of the face, then out. Repeat for the other arm. The head should now follow immediately, if it does not, bring the baby’s body toward it’s face.
Umbilical cord around the neck – when the head appears, slide a finger down the back of the head to the neck, if you can feel the cord, try to catch hold of it with your finger & loop it up over the baby’s head, if that doesn’t work, be prepared to help baby do a “jack-knife” maneuver as he/she is born, keeping the head right next to the birth canal while the body comes toward you, then unwrap the cord ASAP
Baby not breathing – if all other signs in the APGAR are good, this one is not much of a concern, otherwise, stimulate the baby to breathe on his/her own by rubbing vigorously, flicking the soles of the feet, or rubbing a drop or two of cayenne tincture on the baby’s back. If none of these work within a minute to a minute, begin artificial respiration, and CPR as needed. Once baby begins breathing, monitor closely for the next 24 hours.
Helping New Mother & Baby Feel Better
New mother needs water and or juice to replenish fluids lost during labor & birth, and, to give her a renewal of energy.
If mother is shaking, try some warm blankets – but keep a close watch for bleeding, and watch for other symptoms of shock. Other things that can help with shakes include conscious, guided relaxation techniques, warm herb tea (chamomile and catnip are my two favorites) with a tablespoon of honey or sugar added, a warm bath, being held by husband (hopefully will help her relax)
Things I like to put into the bath for mom & baby if available (use cheesecloth or similar to keep “floaties” out of the water) (helps prevent infection and soothe traumatized tissue)
½ cup salt (sea salt or Epsom salt work best)
3 cloves of crushed garlic
2-3 tablespoons powdered golden seal
1 cup of chopped fresh comfrey or 1/4 cup dried comfrey